The Theory and Practice of Group Psychotherapy (50 page)

Melnick and Rose, in a project involving forty-five encounter group members, determined at the start of the group each member’s risk-taking propensity and expectations about the quality of interpersonal behavior to be experienced in the group. They then measured each member’s actual behavior in the group (including self-disclosure, feedback given, risk taking, verbal activity, depth of involvement, attraction to the group).
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They found that both high-risk propensity and more favorable expectations correlated with therapeutically favorable behavior in the group.

The finding that a positive expectational set is predictive of favorable outcome has substantial research support:
the more a client expects therapy—either group or individual
—
to be useful, the more useful will it be
.†
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The role of prior therapy is important in this regard: experienced clients have more positive and more realistic expectations of therapy. Agreement between therapist and client about therapy expectations strengthens the therapeutic alliance, which also predicts better therapy outcome.
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This relationship between positive expectational set and positive outcome has important implications not only for the selection process but also for the preparation of clients for therapy. As I will discuss in chapter 10, it is possible, through proper preparation, to create a favorable expectational set.

The Client’s Effect on Other Group Members

Other inclusion criteria become evident when we consider the other members of a group into which the client may be placed. Thus far, for pedagogical clarity, I have oversimplified the problem by attempting to identify only absolute criteria for inclusion or exclusion. Unlike individual therapy recruitment, where we need consider only whether the client will profit from therapy and whether he or she and a specific therapist can establish a working relationship, recruitment for group therapy cannot, in practice, ignore the other group members.

It is conceivable, for example, that a depressed suicidal client or a compulsive talker might derive some benefit from a group, but also that such a client’s presence would render the group less effective for several other members. Group therapists not only commit themselves to the treatment of everyone they bring into the group, they also commit all of their other members to that individual. For example, Grant, the client described earlier in this chapter, elicited very powerful reactions from the women in the early phases of his group therapy. At one point a female member of the group responded to one of a series of Grant’s angry attacks with, “I am trying to understand where Grant is coming from, but how much longer must I sacrifice myself and my progress for his therapy?”

Conversely, there may be clients who would do well in a variety of treatment modalities but are placed in a group to meet some specific group needs. For example, some groups at times seem to need an aggressive member, or a strong male, or a soft feminine member. While clients with borderline personality disorder often have a stormy course of therapy, some group therapists intentionally introduce them into a group because of their beneficial influence on the group therapy process. Generally, such individuals are more aware of their unconscious, less inhibited, and less dedicated to social formality, and they may lead the group into a more candid and intimate culture. Considerable caution must be exercised, however, in including a member whose ego strength is significantly less than that of the other members. If these clients have socially desirable behavioral traits and are valued by the other members because of their openness and deep perceptivity, they will generally do very well. If, however, their behavior alienates others, and if the group is so fast moving or threatening that they retard the group rather than lead it, then they will be driven into a deviant role and their experience is likely to be countertherapeutic.

The Therapist’s Feeling Toward the Client

One final, and important, criterion for inclusion is the therapist’s personal feeling toward the client. Regardless of the source, the therapist who strongly dislikes or is disinterested in a client (and cannot understand or alter that reaction) should refer that person elsewhere. This caveat is obviously relative, and you must establish for yourself which feelings would preclude effective therapy.

It is my impression that this issue is somewhat more manageable for group therapists than for individual therapists. With the consensual validation available in the group from other members and from the co-therapist, many therapists find that they are more often able to work through initial negative feelings toward clients in group therapy than in individual therapy. Nonetheless there is evidence that therapist hostility often results in premature termination in group therapy.
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As therapists gain experience and self-knowledge, they usually develop greater generosity and tolerance and find themselves actively disliking fewer and fewer clients. Often the antipathy the therapist experiences reflects the client’s characteristic impact on others and thus constitutes useful data for therapy.†

AN OVERVIEW OF THE SELECTION PROCEDURE

The material I have presented thus far about selection of clients may seem disjunctive. I can introduce some order by applying to this material a central organizing principle—a simple punishment-reward system. Clients are likely to terminate membership in a therapy group prematurely—and hence are poor candidates—
when the punishments or disadvantages of group membership outweigh the rewards or the anticipated rewards
. By “punishments” and “disadvantages,” I mean the price the client must pay for group membership, including an investment of time, money, and energy as well as a variety of uncomfortable feelings arising from the group experience, including anxiety, frustration, discouragement, and rejection.

The client should play an important role in the selection process. It is preferable that one deselect oneself before entering the group rather than undergo the discomfort of dropping out of the group. However, the client can make a judicious decision only if provided with sufficient information: for example, the nature of the group experience, the anticipated duration of therapy, and what is expected of him or her in the group (see chapter 10).

The rewards of membership in a therapy group consist of the various satisfactions members obtain from the group. Let us consider those rewards, or determinants of group cohesiveness, that are relevant to the selection of clients for group therapy.
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Members are satisfied with their groups (attracted to their groups and likely to continue membership in them) if:

1. They view the group as meeting their personal needs—that is, their goals in therapy.

2. They derive satisfaction from their relationships with the other members.

3. They derive satisfaction from their participation in the group task.

4. They derive satisfaction from group membership vis-à-vis the outside world.

These are important factors. Each, if absent or of negative value, may outweigh the positive value of the others and result in premature termination. Let us consider each in turn.

Does the Group Satisfy Personal Needs?

The explicit personal needs of group members are at first expressed in their chief complaint, their purpose for seeking therapy. These personal needs are usually couched in terms of relief from suffering or, less frequently, in terms of self-understanding or personal growth. Several factors are important here: there must be significant personal need; the group must be viewed as an agent with the potential of meeting that need; and the group must be seen, in time, as making progress toward meeting that need.

Clients must, of course, have some discomfort in their lives to provide the required motivation for change. The relationship between discomfort and suitability for group therapy is not
linear but curvilinear
. Clients with
too little discomfort
(coupled with only a modest amount of curiosity about groups or themselves) are usually unwilling to pay the price for group membership.

Clients with
moderately high discomfort
may, on the other hand, be willing to pay a high price, provided they have faith or evidence that the group can and will help. From where does this faith arise? There are several possible sources:

• Endorsement of group therapy by the mass media, by friends who have had a successful group therapy experience, or by a previous individual therapist, referring agency, or physician

• Explicit preparation by the group therapist (see chapter 10)

• Belief in the omniscience of authority figures

• Observing or being told about improvement of other group members

• Observing changes in oneself occurring early in group therapy

Clients with
exceedingly high discomfort
stemming from extraordinary environmental stress, internal conflicts, inadequate ego strength, or some combination of these may be so overwhelmed with anxiety that many of the activities of the long-term dynamic group seem utterly irrelevant. Initially groups are unable to meet highly pressing personal needs. Dynamic, interactional group therapy is not effective or efficient in management of intense crisis and acute psychological distress.

Greatly disturbed clients may be unable to tolerate the frustration that occurs as the group gradually evolves into an effective therapeutic instrument. They may demand instant relief, which the group cannot supply—it is not designed to do so. Or they may develop anxiety-binding defenses that are so interpersonally maladaptive (for example, extreme projection or somatization) as to make the group socially nonviable for them. Again,
it is not group therapy per se that is contraindicated for clients with exceedingly high discomfort, but longer-term dynamic group therapy.
These acutely disturbed clients may be excellent candidates for a crisis group or for a specialized problem-oriented group—for example, a cognitive-behavioral group for clients with depression or panic disorder.† There too, however, they will need to participate in the group work; the difference is in the nature and focus of the work.
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Some clients facing an urgent major decision like divorce, abortion, or relinquishing custody of a child may not be good candidates for a dynamic group. But later, after the decision has been made, they may benefit from group therapy in dealing with the psychological and social ramifications of their choice.

Individuals variously described as non–psychologically minded, nonintrospective, high deniers, psychological illiterates, psychologically insensitive, and alexithymic may be unable to perceive the group as meeting their personal needs. In fact, they may perceive an incompatibility between their personal needs and the group goals. Psychological-mindedness is a particularly important variable, because it helps individuals engage in the “work” of therapy
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that produces positive outcomes. Without it, clients may reason, “How can looking at my relations with the group members help me with my bad nerves?”

Satisfaction from Relationships with Other Members

Group members derive satisfaction from their relationships with other group members, and often this source of attraction to the group may dwarf the others. The importance of relationships among members both as a source of cohesiveness and as a therapeutic factor was fully discussed in chapter 3, and I need pause here only to reflect that it is rare for a client to continue membership in the prolonged absence of interpersonal satisfaction.

The development of interpersonal satisfaction may be a slow process. Psychotherapy clients are often contemptuous of themselves and are therefore likely to be initially contemptuous of their fellow group members. They have had, for the most part, few gratifying interpersonal relationships in the past and have little trust or expectation of gaining anything from close relationships with the other group members. Often they may use the therapist transitionally: by relating positively to the therapist at first, they may more easily grow closer to one another.
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Satisfaction from Participation in Group Activities

The satisfaction that clients derive from participation in the group task is largely inseparable from the satisfaction they derive from relationships with the other members. The group task—to achieve a group culture of intimacy, acceptance, introspection, understanding, and interpersonal honesty—is fundamentally interpersonal, and research with a wide variety of groups has demonstrated that participation in the group task is an important source of satisfaction for the group members.
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Clients who cannot introspect, reveal themselves, care for others, or manifest their feelings will derive little gratification from participation in group activities. Such clients include many of the types discussed earlier: for example, the schizoid personality, clients with other types of overriding intimacy problems, the deniers, the somatizers, the organically impaired, and the mentally retarded. These individuals are better treated in a homogeneous, problem-specific group that has a group task consonant with their abilities.

Satisfaction from Pride in Group Membership

Members of many kinds of groups derive satisfaction from membership because the outside world regards their group as highly valued or prestigious. Not so for therapy groups because of members’ share. Therapy group members will, however, usually develop some pride in their group: for example, they will defend it if it is attacked by new members. They may feel superior to outsiders—to those “in denial,” to individuals who are as troubled as they but lack the good sense to join a therapy group. If clients manifest extraordinary shame at membership and are reluctant to reveal their membership to intimate friends or even to spouses, then their membership will appear to them dissonant with the values of other important anchor groups. It is not likely that such clients will become deeply attracted to the group. Occasionally, outside groups (family, military, or, more recently, industry) will exert pressure on the individual to join a therapy group.
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Groups held together only by such coercion are tenuous at first, but the evolving group process may generate other sources of cohesiveness.