The Theory and Practice of Group Psychotherapy (93 page)

Now that you have come this far in this text, now that you are familiar with the fundamental principles and techniques of the prototypical therapy group, you are ready for the next step
: the adaptation of basic group therapy principles to any specialized clinical situation.
That step is the goal of this chapter. First I describe the basic principles that allow the group therapy fundamentals to be adapted to different clinical situations, and then I present two distinct clinical illustrations—the adaptation of group therapy for the acute psychiatric inpatient ward, and the widespread use of groups for clients coping with medical illness. The chapter ends with a discussion of important developments in group therapy: the structured group therapies, self-help groups, and online groups.

MODIFICATION OF TRADITIONAL GROUP THERAPY FOR SPECIALIZED CLINICAL SITUATIONS: BASIC STEPS

To design a specialized therapy group, I suggest the following three steps: (1) assess the clinical situation; (2) formulate appropriate clinical goals; and (3) modify traditional technique to be responsive to these two steps—the new clinical situation and the new set of clinical goals.

Assessment of the Clinical Situation

It is important to examine carefully all the clinical facts of life that will bear on the therapy group. Take care to differentiate the
intrinsic
limiting factors from the
extrinsic
factors. The
intrinsic
factors (for example, mandatory attendance for clients on legal probation, prescribed duration of group treatment in an HMO clinic, or frequent absences because of medical hospitalizations in an ambulatory cancer support group) are built into the clinical situation and cannot be changed.

Then there are
extrinsic
limiting factors (factors that have become tradition or policy), which are arbitrary and within the power of the therapist to change—for example, an inpatient ward that has a policy of rotating the group leadership so that each group meeting has a different leader, or an incest group that traditionally opens with a long “check-in” (which may consume most of the meeting) in which each member recounts the important events of the week.

In a sense, the AA serenity prayer is pertinent here: therapists must accept that which they cannot change (intrinsic factors), change that which can be changed (extrinsic factors) and be wise enough to know the difference. Keep in mind, though, that as therapists gain experience, they often find that more and more of the intrinsic factors are actually extrinsic and hence mutable. For example, by educating the program’s or institution’s decision makers about the rationale and effectiveness of group therapy, it is possible to create a more favorable atmosphere for the therapy group.
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Formulation of Goals

When you have a clear view of the clinical facts of life—number of clients, length of therapy, duration and frequency of group meetings, type and severity of pathology, availability of co-leadership—your next step is to construct a reasonable set of clinical goals.

You may not like the clinical situation, you may feel hampered by the many intrinsic restraints that prevent you from leading the ideal group, but do not wear yourself out by protesting an immutable situation. (Better to light a candle than to curse the darkness.) With proper modification of goals and technique, you will always be able to offer some form of help.

I cannot overemphasize the importance of setting clear and appropriate goals: it may be the most important step you take in your therapeutic work. Nothing will so inevitably ensure failure as inappropriate goals. The goals of the long-term outpatient group I describe in this book are ambitious: to offer symptomatic relief and to change character structure. If you attempt to apply these same goals to, say, an aftercare group of clients with chronic schizophrenia you will rapidly become a therapeutic nihilist and stamp yourself and group therapy as hopelessly ineffective.

It is imperative that you shape a set of goals that is
appropriate to the clinical situation and achievable in the available time frame.
The goals must be clear not only to the therapists but to participants as well. In my discussion of group preparation in chapter 10, I emphasized the importance of enlisting the client as a full collaborator in treatment. You facilitate collaboration by making the goals and the group task explicit and by linking the two: that is, by clarifying for the members how the procedure of the therapy group will help them attain those goals.

In time-limited specialized groups, the goals must be focused, achievable, and tailored to the capacity and potential of the group members. It is important that the group be a success experience: clients enter therapy often feeling defeated and demoralized; the last thing they need is another failure. In the discussion of the inpatient group in this chapter, I shall give a detailed example of this process of goal setting.

Modification of Technique

When you are clear about the clinical conditions and have formulated appropriate, realizable goals, you must next consider the implication these conditions and goals have for your therapeutic technique. In this step, it is important to consider the therapeutic factors and to determine which will play the greatest role in the achievement of the goals. It is a phase of disciplined experimentation in which you alter technique, style, and, if necessary, the basic form of the group to adapt to the clinical situation and to the new goals of therapy.

To provide a brief hypothetical example, suppose you are asked to lead a group for which there is relatively little precedent—say a suicide-prevention center asks you to lead a twenty-session group of older, hemiparetic, suicidal clients. Your primary and overriding goal, of course, is to prevent suicide, and all technical modifications must first address that goal. A suicide during the life of the group would not only be an individual tragedy, it would also be catastrophic for the successful development of the group.

During your screening interviews, you develop some additional goals: you may discover that many clients are negligent about taking medication and that all the clients suffer from severe social isolation, from a pervasive sense of hopelessness and meaninglessness. So, given the additional goals of working on these issues as well, how do you modify standard group techniques to achieve them most efficiently?

First, it is clear that the risk is so high that you must assiduously monitor the intensity of and fluctuations in suicidality. You might, for example, require conjoint individual therapy and/or ask members to fill in a brief depression scale each week. Or you could begin each meeting with a
brief
check-in focused on suicidal feelings. Because of the high risk of suicide and the extent of social isolation, you may wish to
encourage
rather than discourage extragroup contact among the members, perhaps even mandating a certain number of phone calls or e-mail messages from clients to therapists and between clients each week. You may decide to encourage an additional coffee hour after the meeting or between meetings. Or you may address both the isolation and the sense of uselessness by tapping the therapeutic factor of altruism—for example, by experimenting with a “buddy system” in which new members are assigned to one of the experienced members. The experienced member would check in with the new member during the week to make sure the client is taking his or her medication and to “sponsor” that individual in the meeting—that is, to make sure the new member gets sufficient time and attention during the meeting.

There is no better antidote to isolation than deep therapeutic engagement in the group, and thus you must strive to create positive here-and-now interactions in each meeting. Since instillation of hope is so important, you may decide to include some recovered clients in the group—clients who are no longer suicidal and have discovered ways to adapt to their hemiparesis. Shame about physical disability is also an isolating force. The therapist might wish to counteract shame through physical contact—for example, asking group members to touch or hold each others’ paralyzed hands and arms, or asking members to join hands at the end of meetings for a brief guided meditation. In an ideal situation, you may launch a support group that will evolve, after the group therapy ends, into a freestanding self-help group for which you act as consultant.

It is clear from this example that therapists must know a good deal about the special problems of the clients who will be in their group. And that is true for each clinical population—there is no all-purpose formula. Therapists must do their homework in order to understand the unique problems and dynamics likely to develop during the course of the group.

Thus, therapists leading long-term
groups of alcoholics
must expect to deal with issues surrounding sobriety, AA attendance, sneak drinking, conning, orality, dependency, deficiencies in the ability to bind anxiety, and a proneness to act out.

Bereavement groups
must often focus on guilt (for not having done more, loved more, been a better spouse), on loneliness, on major life decisions, on life regrets, on adapting to a new, unpalatable life role, on feeling like a “fifth wheel” with old friends, on the pain and the need to “let go” of the dead spouse. Many widows and widowers feel that building a new life would signify insufficient love and constitute a betrayal of their dead spouse. Groups must also focus on dating (and the ensuing guilt) and the formation of new relationships, and, if the therapist is skillful, on personal growth.

Retirement groups
must address such themes as recurrent losses, increased dependency, loss of social role, need for new sources to validate sense of self-worth, diminished income and expectancies, relinquishment of a sense of continued ascendancy, and shifts in spousal relationship as a result of more time shared together.
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Groups for
burdened family caregivers
of people with Alzheimer’s disease often focus on the experience of loss, on the horrific experience of caring for spouses or parents who are but a shell of their former self, unable to acknowledge the caregiver’s effort or even to identify the caregiver by name. They focus also on isolation, on understanding the causes of dementia and elaborating strategies for coping with the consuming burden, on guilt about wishing for or achieving some emancipation from the burden.
⁴

Groups of
incest survivors
are likely to display considerable shame, fear, rage toward male authorities (and male therapists), and concerns about being believed.

Groups for psychological trauma
would likely address a range of concerns, perhaps in a sequence of different group interventions. Safety, trust, and security would be important at first. Being together with others who have experienced a similar trauma and receiving psychoeducation about the impact of trauma on the mind and body can serve to reduce feelings of isolation and confusion. Later these groups might use structured behavioral interventions to treat specific trauma symptoms. Next the groups might address how trauma has altered members’ basic beliefs and assumptions about the world. These groups would ideally be homogeneous for the earlier work and later a heterogeneous, mixed-gender group may be necessary to complete the process of the client’s reentry into the posttrauma world.
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In summary, to develop a specialized therapy group I recommend the following steps:

1.
Assessment of the clinical setting.
Determine the immutable clinical restraints.

2.
Formulation of goals
. Develop goals that are appropriate and achievable within the existing clinical restraints.

3.
Modification of traditional technique
. Retain the basic principles and therapeutic factors of group therapy but alter techniques to achieve the specified goals: therapists must adapt to the clinical situation and the dynamics of the special clinical population.

Be mindful that all groups, even the most structured ones, also have a
group process
that may impact the group. You may determine that it is outside of the scope of the group to explore directly that process in depth, but you must be able to recognize its presence and how best to utilize, manage, or contain it.†

These steps are clear but too aseptic to be of immediate clinical usefulness. I shall now proceed to illustrate the entire sequence in detail by describing in depth the development of a therapy group for the acute psychiatric inpatient ward.

I have chosen the acute inpatient therapy group for two reasons. First, it offers a particularly clear opportunity to demonstrate many principles of strategic and technical adaptation. The clinical challenge is severe: as I shall discuss,
the acute inpatient setting is so inhospitable to group therapy that radical modifications of technique are required.
Second, this particular example may have intrinsic value to many readers since the inpatient group is the
most common specialized group
: therapy groups are led on most acute psychiatric wards in the country and, as a comprehensive survey documents, over 50 percent of clients admitted to acute psychiatric units nationwide participate in group psychotherapy.
⁶
For many, it is their first group exposure, hence it behooves us to make it a constructive experience.

THE ACUTE INPATIENT THERAPY GROUP

The Clinical Setting

The outpatient group that I describe throughout this book is freestanding: all important negotiations occur between the group therapist(s) and the seven or eight group members. Not so for the inpatient group! When you lead an inpatient group, the first clinical fact of life you must face is that your group is never an independent, freestanding entity. It always has a complex relationship to the larger group: the inpatient ward in which it is ensconced.†
⁷
What unfolds between members in the
small
therapy group reverberates unavoidably with what transpires within the
large
group of the institution.