The Theory and Practice of Group Psychotherapy (107 page)

Once this basic skeleton is in place, I fill in the other vital data: the transition between themes; each member’s contribution to each of the themes; my interventions and feelings about the meeting as a whole and toward each of the members. Other supervisors suggest that students pay special attention to choice points—a series of critical points in the meeting where action is required of the therapist.
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Still others make use of clients’ feedback obtained from questionnaires distributed at the end of a group session.
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A ninety-minute group session provides a wealth of material. If trainees present a narrative of the meeting, discuss each member’s verbal and nonverbal contribution as well as their own participation, and explore in depth their countertransference and realistically based feelings toward each of the members and toward their co-therapist, there should be more than enough important material to occupy the supervisory hour. If not, if the trainee quickly runs out of material, if the supervisor has to scratch hard to learn the events of the meeting, something has gone seriously wrong in the supervisory process. At such times supervisors would do well to examine their relationship with the trainee(s). Are the students guarded, distrustful, or fearful of exposing themselves to scrutiny? Are they cautious lest the supervisor pressure them to operate in the group in a manner that feels alien or beyond them?

The supervisory session is no less a microcosm than is the therapy group, and the supervisor should be able to obtain much information about the therapist’s behavior in a therapy group by attending to the therapist’s behavior in supervision. (Sometimes this phenomenon is referred to as the “parallel process” in supervision.)
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If students lead groups as co-therapy teams (and, as chapter 14 explains, I recommend that format for neophyte therapists), a process focus in the supervisory hour is particularly rich. It is likely that the relationship of the two co-therapists in the supervisory hour parallels their relationship during the therapy group meetings. Supervisors should attend to such issues as the degree of openness and trust during the supervisory hour. Who reports the events of the meeting? Who defers to whom? Do the co-leaders report two bewilderingly different views of the group? Is there much competition for the supervisor’s attention?

The relationship between co-therapists is of crucial importance for the therapy group, and the supervisor may often be maximally effective by focusing attention on this relationship. For example, I recall supervising two residents whose personal relationship was strained. In the supervisory session, each vied for my attention; there was a dysrhythmic quality to the hour, since neither pursued the other’s lead but instead brought up different material, or the same material from an entirely different aspect. Supervision was a microcosm of the group: in the therapy sessions they competed intensely with each other to make star interpretations and to enlist members onto their respective teams. They never complemented each other’s work by pursuing a theme the other had brought up; instead, each remained silent, waiting for an opportunity to introduce a different line of inquiry. The group paid the price for the therapists’ poor working relationship: no good work was done, absenteeism was high, and demoralization evident.

Supervision in this instance focused almost entirely on the co-therapy relationship and took on many of the characteristics of couples therapy, as we examined the therapists’ competition and their wish to impress me. One had just transferred from another residency and felt strongly pressed to prove her competence. The other felt that he had made a great mistake in blindly accepting a co-therapist and felt trapped in a dysfunctional relationship. We considered a “divorce”—dissolving the co-therapy team—but decided that such a move would be countertherapeutic. What chance do we have of persuading our clients to work on their relationships if we therapists refuse to do the same? If co-therapists can successfully work on their relationship, there is a double payoff: therapy is served (the group works better with an improved inter-leader relationship), and training is served (trainees learn firsthand some of the basic principles of conflict resolution).

In the ongoing work the supervisor must explore the student’s verbal and nonverbal interventions and check that they help establish useful group norms. At the same time, the supervisor must avoid making the student so self-conscious that spontaneity is stunted. Groups are not so fragile that a single statement markedly influences their direction; it is the therapist’s overall posture that counts.

Most supervisors will at times tell a supervisee what they themselves would have said at some juncture of the group. It is not uncommon, however, for student therapists to mimic the supervisor’s comments at an inappropriate spot in the following group meeting and then begin the next supervisory session with: “I did what you said, but . . .” Thus, when I tell a student what I might have said, I preface my comments: “Don’t say this at the next meeting, but here’s one way you might have responded . . .” Here too, a delicate balance needs to be maintained. Supervision should rarely be prescriptive and never heavy-handed. But there are times when suggesting a particular approach or intervention is essential and much welcomed.

Many teachers have, to good effect, expanded the supervisory hour into a continuous case seminar for several student therapists, with the group leaders taking turns presenting their group to the entire supervision group. Since it takes time to assimilate data about all the members of a group, I prefer that one group be presented for several weeks before moving on to another. In this format, three to four groups can be followed throughout the year.

There are several benefits to providing group therapy supervision in a group format. For one thing, it may be possible for a skillful supervisor to focus on the interaction and the group dynamics of the supervisory group. The learning opportunities may be further enhanced by asking supervisees to describe and record their experiences in the supervision group. Another benefit of group supervision is the presence of peer support. Furthermore, accounts of colleagues’ experiences, conceptualizations, and techniques exposes trainees to a greater range of group therapy phenomena and broadens their empathic awareness. Trainees also have the opportunity to think like a supervisor or consultant, a skill that will be useful at other points in their career.
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Feedback about one’s clinical work is often a delicate process. Supervision groups demand and model metacommunication—ways to communicate authentically, respectfully, and empathically.

A group supervision format may also encourage subsequent participation in a peer supervision group by demonstrating the value of peer supervision, consultation, and support.
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The supervision group should not, however, transform itself into a personal growth or therapy group—that group experience comes with a substantially different set of norms and expectations.

Some recent supervision innovations have made good use of the Internet to offer supervision to practitioners living in isolated or distant locales. Students and supervisor may begin with a few face-to-face meetings and then continue contact through an electronic bulletin board or a facilitated online supervision group.
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A GROUP EXPERIENCE FOR TRAINEES

A personal group experience has become widely accepted as an integral part of training and continuing professional development. Such an experience may offer many types of learning not available elsewhere. You are able to learn at an emotional level what you may previously have known only intellectually. You experience the power of the group—power both to wound and to heal. You learn how important it is to be accepted by the group; what self-disclosure really entails; how difficult it is to reveal your secret world, your fantasies, feelings of vulnerability, hostility, and tenderness. You learn to appreciate your own strengths as well as your weaknesses. You learn about your own preferred role in the group, about your habitual countertransference responses and about group-as-a-whole and system issues that lurk in the background of the meetings. Perhaps most striking of all, you learn about the role of the leader by becoming aware of your own dependency and your own, often unrealistic, appraisal of the leader’s power and knowledge.

Even experienced practitioners who are being trained in a new model of group therapy profit greatly when an experiential affective component is added to their didactic training. Personal participation is the most vital way to teach and to learn group process.
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Surveys indicate that one-half to two-thirds of group therapy training programs offer some type of personal group experience.
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Some programs offer a simulated group in which one or two trainees are appointed co-therapists and the rest role-play the group members. The most common model (which will be discussed in detail shortly) is a group composed of other trainees and referred to by any number of terms (T-group, support group, process group, experiential training group, and so on). This group may be short-term, lasting maybe a dozen sessions, or it may consist of an intensive one- or two-day experience; but the model I prefer is a weekly process group that meets for sixty to ninety minutes throughout the entire year.

I have led groups of psychology interns and psychiatric residents for over thirty years and, without exception, have found the use of such groups to be a highly valuable teaching technique. Indeed, many psychotherapy students, when reviewing their entire training program, have rated their group as the single most valuable experience in their curriculum. A group experience with one’s peers has a great deal to recommend it: not only do the members reap the benefits of a group experience but also, if the group is led properly, members may improve relationships and communication within the trainee class and, thus, enrich the entire educational experience. Students always learn a great deal from their peers, and any efforts that potentiate that process increase the value of the program.

Are there also disadvantages to a group experience? One often hears storm warnings about the possible destructive effects of staff or trainee experiential groups. These warnings are, I believe, based on irrational premises: for example, that enormous amounts of destructive hostility would ensue once a group unlocks suppressive floodgates, or that a group would constitute an enormous invasion of privacy as forced confessionals are wrung one by one from each of the hapless trainees. We know now that responsibly led groups that are clear about norms and boundaries facilitate communication and constructive working relationships.

Should Training Groups Be Voluntary?

An experiential group is always more effective if the participants engage voluntarily and view it not only as a training exercise but as an opportunity for personal growth. Indeed, I prefer that trainees begin such a group with an explicit formulation of what they want to obtain from the experience personally as well as professionally. To this end, it is important that the group be introduced and described to the trainees in such a way that they consider it to be consonant with their personal and professional goals. I prefer to frame the group within the students’ training career by asking them to project themselves into the field of the future. It is, after all, highly probable that mental health practitioners will spend an increasing amount of their time in groups—as members and leaders of treatment teams. To be effective in this role, clinicians of the future will simply have to know their way around groups. They will have to learn how groups work and how they themselves work in groups.

Once an experiential group is introduced as a regular part of a training program, and once the faculty develops confidence in the group as a valuable training adjunct, there is little difficulty in selling it to incoming trainees. Still, programs differ on whether to make the group optional or mandatory. My experience is that if a group is presented properly, the trainees not only look forward to it with anticipation but experience strong disappointment if for some reason the opportunity for a group experience is withheld.

If a student steadfastly refuses to enter the training group or any other type of experiential group, it is my opinion that some investigation of such resistance is warranted. Occasionally, such a refusal stems from misconceptions about groups in general or is a reflection of some respected senior faculty member’s negative bias toward groups. But if the refusal is based on a pervasive dread or distrust of group situations, and if the student does not have the flexibility to work on this resistance in individual therapy, in a supportive training group, or in a bona fide therapy group, I believe it may well be unwise for that student to pursue the career of psychotherapist.

Who Should Lead Student Experiential Groups?

Directors of training programs should select the leader with great care. For one thing, the group experience is an extraordinarily influential event in the students’ training career; the leader will often serve as an important role model for the trainees and therefore should have extensive clinical and group experience and the highest possible professional standards. The overriding criteria are, of course, the personal qualities and the skill of the leader: a secondary consideration is the leader’s professional discipline (whether it be, for example, in counseling, clinical psychology, social work, or psychiatry).

I believe that a training group model led by a leader skilled in the interactional group therapy model provides the best educational experience.
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Supporting this view is a study of 434 professionals who participated in two-day American Group Psychotherapy Association training groups. Process-oriented groups that emphasized here-and-now interaction resulted in significantly greater learning about leadership and peer relations than groups that were more didactic or structured. The members felt they profited most from an atmosphere in which leaders supported participants, demonstrated techniques, and facilitated an atmosphere in which members supported one another, revealed personal feelings, took risks, and enjoyed the group.
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