The Theory and Practice of Group Psychotherapy (106 page)

Regardless of the format used, the group members must be fully informed about the presence of observers and their purpose. I remind clients that observation is necessary for training, that I was trained in that fashion, and that their willingness to permit observers will ultimately be beneficial to clients the student observers will treat in the future. I add another point: the observations of the students offered to me in our postgroup discussion are frequently of value to the process of therapy. There are formats (to be described shortly) in which clients attend the postgroup observer-therapist discussion and generally profit considerably from the discussion.

The total length of students’ observation time is generally determined by service and training rotations. If there is sufficient program flexibility, I would suggest that observation continue for at least six to ten sessions, which generally provides a sufficient period of time for changes to occur in group development, in interactional patterns, and in perceivable intrapersonal growth. If their schedules preclude regular and consistent attendance, I distribute a detailed summary of the group to the students before the next meeting (see chapter 14).

A postmeeting discussion is an absolute necessity in training, and there is no better time for the group leader/teacher to meet with student observers than immediately after the meeting. I prefer to meet for thirty to forty-five minutes, and I use the time in a variety of ways: obtaining the students’ observations, answering their questions about underlying reasons for my interventions, and using the clinical material as a springboard for discussion of fundamental principles of group therapy. Other instructors prefer to delay the discussion and assign the students the task of writing a description of the meeting, focusing primarily on process (that is, the interpersonal relationships among the members of the group and group dynamics). The students may be asked to exchange their summaries and meet later in the week for an analysis of the meeting.
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Although some introductory didactic sessions are useful, I find that much of the material presented in this book can be best discussed with students around appropriate clinical material that arises over several sessions of an observed group.
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Theory becomes so much more alive when it is immediately relevant.

The relationship between observers, the group, and the group therapists is important. There will be times when an inordinate amount of carping (“Why didn’t you . . . ?”) creates discomfort for the therapists and impairs their efficiency. Not infrequently, observers complain of boredom, and therapists may feel some pressure to increase the group’s entertainment quotient. My experience is that, in general,
boredom is inversely related to experience
; as students gain in experience and sophistication, they come increasingly to appreciate the many subtle, fascinating layers underlying every transaction. The observation group has a process of its own as well. Observers may identify with the therapist, or with certain characteristics of the clients, which, if explored in the debriefing session, may provide an opportunity to explore empathy, countertransference, and projective identification. At times, observers may express the wish that they were in the group as participants and develop strong attachments to group members. In every instance, observers should be held to the same standard of professionalism regarding confidentiality and ethical conduct as are the therapists.
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Group members respond differently to being observed by students. Like any group event, the different responses are grist for the therapeutic mill. If all members face the same situation (that is, being observed by students), why do some respond with anger, others with suspicion, and still others with pleasure, even exhilaration? Why such different responses to a common stimulus? The answer, of course, is that
each member has a different inner world
, and the differing responses facilitation examination of each inner world.

Nonetheless, for the majority of clients, traditional observation is an intrusion. Sometimes the observers may serve as a lightning rod for anxiety arising from other concerns. For example, one group that had been regularly observed suddenly became preoccupied with the observers and grew convinced that they were mocking and ridiculing the members. One group member reported encountering a person in the washroom before the group, whom he was convinced was an observer, and this person smirked at him. The group members demanded that the observers be brought into the group room to account for themselves. The power of the group’s reaction was intense and caused me to wonder if there had been some breach of trust. As we continued to examine where this heat was coming from, it became more apparent that the group was in fact projecting onto the observers their apprehension about impending changes in the group—two senior members of the group had left and two new additions to the group were imminent. The real issue for the group was whether the new additions would value the group or deride the process and the members.

Though the most a leader can generally expect from clients is a grudging acceptance and dimming awareness of the observers’ presence, there are methods of turning the students’ observation to therapeutic advantage. I remind the group that the observers’ perspectives are valuable to me as the leader and, if appropriate, I cite some helpful comments observers made after the previous meeting. I also let the group know that I often incorporate some of the observers’ comments into the written summary.

Another, more daring, strategy is to invite the group members to be present at the observers’ postmeeting discussion. In chapter 15, I discussed a model of an inpatient group that regularly included a ten-minute observers’ discussion that the group members observed.
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I have used a similar format for outpatient groups: I invite members and observers to switch rooms at the end of a meeting so that the clients observe through the one-way mirror the observers’ and co-therapists’ postgroup discussion. My only proviso is that the entire group elect to attend: if only some members attend, the process may be divisive and retard the development of cohesiveness. A significant time commitment is required: forty-five minutes of postgroup discussion after a ninety-minute group therapy session make for a long afternoon or evening.

This format has interesting implications for teaching. It teaches students how to be constructively transparent, and it conveys a sense of respect for the client as a full ally in the therapeutic process. It also demystifies therapy: it is a statement that therapy is a potent, rational, collaborative process requiring no part of Dostoevsky’s Grand Inquisitor’s triumvirate—magic, mystery, and authority.

If clients do observe the postgroup discussion, then there must be an additional teaching seminar just after the observation period or later, perhaps just before the next group meeting. Additional teaching time is required, because the postmeeting discussions that the clients observe differ from the typical postgroup rehash. The postgroup discussion becomes part of the therapy itself as the observers’ and therapists’ comments evoke feelings from the group members. Hence, in this format less time is available for formal instruction of basic theory or strategic principles. Furthermore, the students tend to be inhibited in their questions and comments, and there is less free-ranging discussion of transference and countertransference. A benefit is that boredom in the observation room absolutely vanishes: students, knowing they will later take part in the meeting, become more engaged in the process.

A useful adjunct teaching tool may be a group videotape especially designed to illustrate important aspects of leader technique and group dynamics. I have produced two videotape programs—one for outpatient groups and one for inpatients—around which group therapy courses may be constructed.
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SUPERVISION

A supervised clinical experience is a sine qua non in the education of the group therapist. This book posits a general approach to therapy, delineates broad principles of technique, and, especially when discussing the opening and closing stages of therapy, suggests specific tactics. But the laborious working-through process that constitutes the bulk of therapy cannot be thoroughly depicted in a text. An infinite number of situations arise, each of which may require a rich, imaginative approach. It is precisely at these points that a supervisor makes a valuable and unique contribution to a student therapist’s education. Because of its central importance in training, supervision has become a major focus of attention in the psychotherapy literature, although there is a paucity of empirical research on the subject.
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What are the characteristics of effective supervision? Supervision first requires the establishment of a
supervisory alliance
that conveys to the student the ambiance and value of the
therapeutic alliance.
Supervision not only conveys technical expertise and theoretical knowledge, it also models the profession’s values and ethics. Accordingly, supervisors must strive for congruence: they should treat their students with the same respect and care that the student should provide to clients. If we want our trainees to treat their clients with respect, compassion, and dignity, that is how we must treat our trainees.
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The supervisor should focus on the professional and clinical development of the trainee and be alert to any blocks—either from lack of knowledge or from countertransference—that the trainee encounters. A fine balance must be maintained between training and therapy. Alonso suggests that the supervisor should listen like a clinician but speak like a teacher.
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The most effective supervisors are able to tune in to the trainee, track the trainee’s central concerns, capture the essence of the trainee’s narrative, guide the trainee through clinical dilemmas, and demonstrate personal concern and support. Supervision that is unduly critical, shaming, or closed to the trainee’s principal concerns will not only fail educationally, it will also dispirit the trainee.
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How personal and transparent should the supervisor be? Probably the more the better! By revealing their own experiences and clinical challenges, supervisors reduce the power hierarchy and help the trainee see that there is no shame in not having all the answers. What’s more, such a revealing and nondefensive stance will influence the type of clinical material the trainee will bring to supervision.
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The neophyte therapist’s first group is a highly threatening experience. Even conducting psychoeducational groups, with their clear content and structure, can be inordinately challenging to the neophyte.
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In a study of neophyte trainees, researchers compared trainees who had positive and those who had negative group therapy training experiences. Both groups reported high degrees of apprehension and frankly unpleasant emotional reactions early in the work. One variable distinguished the two groups: the quality of the supervision. Those with high-quality supervision were far more likely to feel positive about group therapy.
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In another study, my colleagues and I examined twelve nonprofessionally trained leaders who led groups in a psychiatric hospital. Half received ongoing supervision as well as an intensive training course in group leadership; the others received neither. Observers who did not know which therapists received supervision rated the therapists at the beginning of their groups and again six months later. The results indicated that not only did the trained therapists improve but the untrained therapists, at the end of six months,
were less skilled than at the beginning
.
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Sheer experience, apparently, is not enough. Without ongoing supervision and evaluation,
original errors may be reinforced by simple repetition
. Supervision may be even more important for the neophyte group therapist than the budding individual therapist because of the inherent stress in the group leader role: I have had many trainees report anxiety dreams filled with images about being out of control or confronting some threatening group situation just before commencing their first group experience.

In many ways, group therapy supervision is more taxing than individual therapy supervision. For one thing, mastering the cast of characters is in itself a formidable task. Furthermore, there is such an abundance of data that both student and supervisor must often be highly selective in their focus.

A few practical recommendations may be helpful. First, supervision should be well established before the first group, both to attend to the selection and preparation tasks of group leadership and to address therapist apprehension about starting the group.
One supervisory hour per group therapy session
is, in my experience, the optimal ratio. It is wise to hold the supervisory session soon after the group session, preferably the following day. Some supervisors observe the last thirty minutes of each meeting and hold the supervisory session immediately thereafter. At the very least, the supervisor must observe one or two sessions at the beginning of supervision and, if possible, an occasional session throughout the year: it permits the supervisor to affix names to faces and also to sample the affective climate of the group. Videotapes may serve this purpose also (audiotapes, too, though far less satisfactorily).

If much time elapses between the group meeting and the supervisory session, the events of the group fade; in this case students are well advised to make detailed postgroup notes. Therapists develop their own style of note taking. My preference is to record the major themes of each session—generally, from one to three: for example: (1) John’s distress at losing his job and the group’s efforts to offer support; (2) Sharon’s anger at the men in the group; (3) Annabelle’s feeling inferior and unaccepted by the group.