The Theory and Practice of Group Psychotherapy (55 page)

The Homogeneous Mode of Composition

The cohesiveness theory
, underlying the homogeneous approach to group composition, postulates, quite simply, that
attraction to the group is the intervening variable critical to outcome and that the paramount aim should be to assemble a cohesive, compatible group.

Summary

How can we reconcile or decide between these two approaches? First, note that no group therapy research supports the dissonance model. There is great clinical consensus (my own included) that group therapy clients should be exposed to a variety of conflict areas, coping methods, and conflicting interpersonal styles, and that conflict in general is essential to the therapeutic process. However, there is no empirical evidence that
deliberately composed heterogeneous groups
facilitate therapy, and I have just cited modest evidence to the contrary.

On the other hand, a large body of small-group research supports the cohesiveness concept. Interpersonally compatible therapy groups will develop greater cohesiveness. Members of cohesive groups have better attendance, are more able to express and tolerate hostility, are more apt to attempt to influence others, and are themselves more readily influenced. Members with greater attraction to their group have better therapeutic outcome; members who are less compatible with the other members tend to drop out of the group. Members with the greatest interpersonal compatibility become the most popular group members, and group popularity is highly correlated with successful outcome.

The fear that a homogeneous group will be unproductive, constricted, or conflict free or that it will deal with a only narrow range of interpersonal concerns is unfounded, for several reasons. First, there are few individuals whose pathology is indeed monolithic—that is, who, despite their chief conflict area, do not also encounter conflicts in intimacy or authority, for example. Second, the group developmental process may demand that clients deal with certain conflict areas. For example, the laws of group development (see chapter 11) demand that the group ultimately deal with issues of control, authority, and the hierarchy of dominance. In a group with several controlconflicted individuals, this phase may appear early or very sharply. In a group lacking such individuals, other members who are less conflicted or whose conflicts are less overt in the area of dependency and authority may be forced nonetheless to deal with it as the group inevitably moves into this stage of development. If certain developmentally required roles are not filled in the group, most leaders, consciously or unconsciously, alter their behavior to fill the void.
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Furthermore—and this is an important point—no therapy group with proper leadership can be too comfortable or fail to provide dissonance for its members, because the members must invariably clash with the group task. To develop trust, to disclose oneself, to develop intimacy, to examine oneself, to confront others—
are all discordant tasks
to individuals who have significant problems in interpersonal relationships.

Many problem-specific brief groups can easily be transformed into a productive interactional group with proper guidance from the leader. For example, two rigorous studies compared homogeneous groups of clients with bulimia who were randomly assigned to behavioral group therapy, cognitive-behavioral group therapy, or interactional group therapy (therapy that did not explicitly address eating behavior but instead focused entirely on interpersonal interaction). Not only did these homogeneous interactional groups function effectively, but their outcome was in every way equal to the cognitive-behavioral groups, including their positive effect on the eating disorder.
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On the basis of our current knowledge, therefore, I propose that
cohesiveness be the primary guideline in the composition of therapy groups.
The hoped-for dissonance will unfold in the group, provided the therapist functions effectively in the pretherapy orientation of clients and during the early group meetings. Group integrity should be given highest priority, and group therapists must select clients with the lowest likelihood of premature termination. Individuals with a high likelihood of being irreconcilably incompatible with the prevailing group ethos and culture, or with at least one other member, should not be included in the group. It bears repeating that
group cohesiveness is not synonymous with group comfort or ease
. Quite the contrary: it is only in a cohesive group that conflict can be tolerated and transformed into productive work.

A FINAL CAVEAT

Admittedly, the idea of crafting an ideal group is seductive. It is a siren’s wail that has lured many researchers and generated a large body of research, little of which, alas, has proved substantial, replicable, or clinically relevant. Not only that, but, in many ways, the topic of group composition is out of touch with the current everyday realities of clinical practice. As noted earlier, contemporary pressures on the practice of group therapy discourage the therapist’s attention to group composition as a relevant concern.

Many contemporary group clinicians in private practice and in public clinics are more concerned with group integrity and survival. Generally, these clinicians have difficulty accumulating enough clients to form and maintain groups. (And I have no doubt that this difficulty will grow with each passing year because of the rapid increase in numbers of practicing psychotherapists from ever more professional disciplines.) The more therapists available, the more professional competition for clients, the harder it is to begin and maintain therapy groups in private practice. Therapists prefer to fill their individual hours and are reluctant to risk losing a client through referral to a therapy group. If clinicians attempt to put some group candidates on hold while awaiting the perfect blend of group participants—assuming that we know the formula of the blend (which we do not)—they will never form a group. Referrals accumulate so slowly that the first prospective members interviewed may tire of waiting and find suitable therapy elsewhere.

Thus contemporary clinicians, myself included, generally form groups by accepting, within limits, the first suitable seven or eight candidates screened and deemed to be good group therapy candidates. Only the crudest principles of group composition are employed, such as having an equal number of men and women or a wide range of age, activity, or interactional style. For example, if two males already selected for the group are particularly passive, it is desirable to create balance by adding more active men.

Other excellent options exist in practice, however. First, the clinician may compose a group from clients in his individual practice. As I shall discuss in chapter 15, concurrent therapy is a highly effective format. Second, clinicians who are in a collaborative practice, often sharing a suite of offices, may coordinate referrals and fill one group at a time. In many communities, group therapists have successfully created a specialty practice by marketing themselves through speaking engagements and advertising.

The therapist’s paramount task is to create a group that coheres. Time and energy spent on delicately casting and balancing a group cannot be justified, given the current state of our knowledge and clinical practice. I believe that therapists do better to invest their time and energy in careful selection of clients for group therapy and in pretherapy preparation (to be discussed in the next chapter). There is no question that composition radically affects the group’s character, but if the group holds together and if you appreciate the therapeutic factors and are flexible in your role, you can make therapeutic use of any conditions (other than lack of motivation) that arise in the group.

Chapter 10

CREATION OF THE GROUP: PLACE, TIME, SIZE, PREPARATION

PRELIMINARY CONSIDERATIONS

Before convening a group, therapists must secure an appropriate meeting place and make a number of practical decisions about the structure of the therapy: namely, the size and the life span of the group, the admission of new members, the frequency of meetings, and the duration of each session. In addition, the contemporary practitioner often must negotiate a relationship with a third-party payer, HMO, or managed care organization.
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The tension between therapeutic priorities and the economic priorities of managed care regarding the scope and duration of treatment must also be addressed.
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Dissonance between therapists and third-party administrators may have a deleterious impact on the client-therapist relationship. † The entire practice of therapy, including therapists’ morale, will benefit from greater partnership and less polarization.

Today clinicians have an ethical responsibility to advocate for effective therapy. They must educate the public, destigmatize group therapy, build strong clinical practice organizations with well-trained and properly credentialed clinicians, and urge third-party payers to attend to the robust empirical research supporting group therapy’s effectiveness.†

The Physical Setting

Group meetings may be held in any room that affords privacy and freedom from distractions. In institutional settings, the therapist must negotiate with the administration to establish inviolate time and space for therapy groups. The first step of a meeting is to form a circle so that members can all see one another. For that reason, a seating arrangement around a long, rectangular table or the use of sofas that seat three or four people is unsatisfactory. If members are absent, most therapists prefer to remove the empty chairs and form a tighter circle.

If the group session is to be videotaped or observed through a one-way mirror by trainees, the group members’ permission must be obtained in advance and ample opportunity provided for discussion of the procedure. Written consent is essential if any audiovisual recording is planned. A group that is observed usually seems to forget about the viewing window after a few weeks, but often when working through authority issues with the leader, members again become concerned about it. If only one or two students are regular observers, it is best to seat them in the room but outside of the group circle. This avoids the intrusion of the mirror and allows the students to sample more of the group affect, which inexplicably is often filtered out by the mirror. Observers should be cautioned to remain silent and to resist any attempts of the group members to engage them in the discussion. (See chapter 17 for further discussion about group observation.)

Open and Closed Groups

At its inception, a group is designated by its leader as open or closed. A closed group, once begun, shuts its gates, accepts no new members except within the first 2 or 3 sessions and meets for a predetermined length of time. An open group, by contrast, maintains a consistent size by replacing members as they leave the group. An open group may have a predetermined life span—for example, groups in a university student health service may plan to meet only for the nine-month academic year. Many open groups continue indefinitely even though every couple of years there may be a complete turnover of group membership and even of leadership. I have known of therapy groups in psychotherapy training centers that have endured for twenty years, being bequeathed every year or two by a graduating therapist to an incoming student. Open groups tolerate changes in membership better if there is some consistency in leadership. One way to achieve this in the training setting is for the group to have two co-therapists; when the senior co-therapist leaves, the other one continues as senior group leader, and a new co-therapist joins.
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Most closed groups are brief therapy groups that meet weekly for six months or less. A longer closed group may have difficulty maintaining stability of membership. Invariably, members drop out, move away, or face some unexpected scheduling incompatibility. Groups do not function well if they become too small, and new members must be added lest the group perish from attrition. A long-term closed-group format is feasible in a setting that assures considerable stability, such as a prison, a military base, a long-term psychiatric hospital, and occasionally an ambulatory group in which all members are concurrently in individual psychotherapy with the group leader. Some therapists lead a closed group for six months, at which time members evaluate their progress and decide whether to commit themselves to another six months.

Some intensive partial hospitalization programs begin with an intensive phase with closed group therapy, which is followed by an extended, less intensive open group therapy aftercare maintenance phase. The closed phase emphasizes common concerns and fundamental skills that are best acquired if the whole group can move in concert. The open phase, which aims to reduce relapse, reinforces the gains made during the intensive phase and helps clients apply their gains more broadly in their own social environments. This model has worked well in the treatment of substance abuse, trauma, and depression.
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DURATION AND FREQUENCY OF MEETINGS

Until the mid-1960s, the length of a psychotherapy session seemed fixed: the fifty-minute individual hour and the eighty- to ninety-minute group therapy session were part of the entrenched wisdom of the field. Most group therapists agree that, even in well-established groups, at least sixty minutes is required for the warm-up interval and for the unfolding and working through of the major themes of the session. There is also some consensus among therapists that after about two hours, the session reaches a point of diminishing returns: the group becomes weary, repetitious, and inefficient. Many therapists appear to function best in segments of eighty to ninety minutes; with longer sessions therapists often become fatigued, which renders them less effective in subsequent therapy sessions on the same day.