The Theory and Practice of Group Psychotherapy (46 page)

An overly restricted definition of the role of group therapist—whether based on transparency or any other criterion—may cause the leader to lose sight of the individuality of each client’s needs. Despite your group orientation, you must retain some individual focus; not all clients need the same thing. Some, perhaps most, clients need to relax controls; they need to learn how to express their affect—anger, love, tenderness, hatred. Others, however, need the opposite: they need to gain impulse control because their lifestyles are already characterized by labile, immediately acted-upon affect.

One final consequence of more or less unlimited therapist transparency is that the cognitive aspects of therapy may be completely neglected. As I noted earlier,
mere catharsis is not in itself a corrective experience
. Cognitive learning or restructuring (much of which is provided by the therapist) seems necessary for the client to be able to generalize group experiences to outside life; without this transfer or carryover, we have succeeded only in creating better, more gracious therapy group members. Without the acquisition of some knowledge about general patterns in interpersonal relationships, the client may, in effect, have to rediscover the wheel in each subsequent interpersonal transaction.

Chapter 8

THE SELECTION OF CLIENTS

G
ood group therapy begins with good client selection. Clients improperly assigned to a therapy group are unlikely to benefit from their therapy experience. Furthermore, an improperly composed group may end up stillborn, never having developed into a viable treatment mode for any of its members. It is therefore understandable that contemporary psychotherapy researchers are actively examining the effects of matching clients to psychotherapies according to specific characteristics and attributes.
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In this chapter I consider both the research evidence bearing on selection and the clinical method of determining whether a given individual is a suitable candidate for group therapy. In chapter 9, on group composition, I will examine a different question: once it has been decided that a client is a suitable group therapy candidate, into which specific group should he or she go? These two chapters focus particularly on a specific type of group therapy: the heterogeneous outpatient group with the ambitious goals of symptomatic relief and characterological change. However, as I shall discuss shortly, many of these general principles have relevance to other types of groups, including the shorter-term problem-oriented group. Here, as elsewhere in this book, I employ the pedagogic strategy of providing the reader with fundamental group therapy principles plus strategies for adapting these principles to a variety of clinical situations. † There is no other reasonable educative strategy. Such a vast number of problem-specific groups exist (see also chapter 15) that one cannot focus separately on selection strategy for each specific one—nor would a teacher wish to. That would result in too narrow and too rigid an education. The graduate of such a curriculum would be unable to adapt to the forms that group therapy may take in future years. Once students are grounded in the prototypical psychotherapy group they will have the base which will permit them to modify technique to fit diverse clinical populations and settings.

Effectiveness of group therapy.
Let us begin with the most fundamental question in client selection: Should the client—indeed, any client—be sent to group therapy? In other words,
how effective is group therapy?
This question, often asked by individual therapists and
always
asked by third-party payers, must be addressed before considering more subtle questions of client selection. The answer is unequivocal.
Group therapy is a potent modality producing significant benefit to its participants
.
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A great deal of research has also attempted to determine the relative efficacy of group versus individual therapy, and the results are clear:
there is considerable evidence that group therapy is at least as efficacious as individual therapy
. An excellent, early review of the thirty-two existing well-controlled experimental studies that compared individual and group therapy
^s
indicates that group therapy
was more effective than individual therapy in 25 percent of the studies
. In the other 75 percent, there were
no significant differences
between group and individual therapy.
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In no study was individual therapy more effective. A more recent review using a rigorous meta-analysis
^t
demonstrated similar findings.
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Other reviews, some including a greater number of studies (but less rigorously controlled), have reached similar conclusions and underscore that group therapy is also more efficient than individual therapy (from the standpoint of therapist resources) by a factor of two to one and perhaps as much as four to one.
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Research indicates further that group therapy has specific benefits: It is for example superior to individual therapy in the provision of social learning, developing social support, and improving social networks, factors of great importance in reducing relapse for clients with substance use disorders.
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It is more effective than individual approaches for obesity
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(an effect achieved in part through reducing stigma), and for clients with medical illness—clients learn to enhance self-efficacy better from peers than from individual therapy.
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Adding group therapy to the treatment of women who are survivors of childhood sexual abuse provides benefits beyond individual therapy: it results in greater empowerment and psychological well-being.
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The evidence for the effectiveness of group therapy is so persuasive that some experts advocate that group therapy be utilized as the primary model of contemporary psychotherapy.
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Individual therapy, however, may be preferable for clients who require active clinical management, or when relationship issues are less important and personal insight and understanding are particularly important.
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So far, so good! We can be confident (and each of us should convey this confidence to sources of referral and to third-party payers) that group therapy is an effective treatment modality.

One might reasonably expect the research literature to yield useful answers to the question of which clients do best in group therapy and which are better referred to another form of therapy. After all, here’s all that needs to be done: Describe and measure a panoply of clinical and demographic characteristics before clients are randomly assigned to group therapy or to other modalities and then correlate these characteristics with appropriate dependent variables, such as therapy outcome, or perhaps some intervening variable, such as attendance, mode of interaction, or cohesiveness.

But the matter turns out to be far more complex. The methodological problems are severe, not least because a true measure of psychotherapy outcome is elusive. The client variables used to predict therapy outcome are affected by a host of other group, leader, and comember variables that confound the research enterprise.†
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Clients drop out of therapy; many obtain ancillary individual therapy; group therapists vary in competence and technique; and initial diagnostic technique is unreliable and often idiosyncratic. An enormous number of clients are needed to obtain enough therapy groups for the results to be statistically significant. Although standardized therapies are required to ensure that each of the treatment modalities is delivering proper therapy, still each person and each group is exquisitely complex and cannot simplify itself in order to be precisely measured. Hence in this chapter I draw on relevant research but also rely heavily on clinical experience—my own and that of others.

CRITERIA FOR EXCLUSION

Question: How do group clinicians select clients for group psychotherapy? Answer: The great majority of clinicians do not select for group therapy. Instead, they
deselect
. Given a pool of clients, experienced group therapists determine that certain ones cannot possibly work in a therapy group and should be excluded.
And then they proceed to accept all the other clients.

That approach seems crude. We would all prefer the selection process to be more elegant, more finely tuned. But, in practice, it is far easier to specify exclusion than inclusion criteria; one characteristic is sufficient to exclude an individual, whereas a more complex profile must be delineated to justify inclusion.

Keep in mind that there are many group therapies, and exclusion criteria apply only for the type of group under consideration. Almost all clients (there are exceptions) will fit into
some
group. A characteristic that excludes someone from one group may be the exact feature that secures entry into another group. A secretive, non–psychologically minded client with anorexia nervosa, for example, is generally a poor candidate for a long-term interactional group, but may be ideal for a homogeneous, cognitive-behavioral eating-disorders group.†

There is considerable clinical consensus that clients are poor candidates for a heterogeneous outpatient therapy group if they are brain-damaged,
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paranoid,
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hypochondriacal,
¹⁵
addicted to drugs or alcohol,
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acutely psychotic,
¹⁷
or sociopathic.† But such dry lists are of less value than identifying underlying principles. Here is the major guideline:
clients will fail in group therapy if they are unable to participate in the primary task of the group
,
be it for logistical, intellectual, psychological, or interpersonal reasons
. This consideration is even more compelling for brief, time-limited groups, which are particularly unforgiving of poor client selection.†

What traits must a client possess to participate in the primary task of the dynamic, interactional therapy group? They must have a capacity and willingness to examine their interpersonal behaviors, to self-disclose, and to give and receive feedback. Unsuitable clients tend to construct an interpersonal role that proves detrimental to themselves as well as to the group. In such instances the group becomes a venue for re-creating and reconfirming maladaptive patterns without the possibility of learning or change.

Consider sociopathic clients, for example, who are exceptionally poor candidates for outpatient interactional group therapy. Characteristically, these individuals are destructive in the group. Although early in therapy they may become important and active members, they will eventually manifest their basic inability to relate, often with considerable dramatic and destructive impact, as the following clinical example illustrates.

• Felix, a highly intelligent thirty-five-year-old man with a history of alcoholism, transiency, and impoverished interpersonal relationships, was added with two other new clients to an ongoing group, which had been reduced to three by the recent graduation of members. The group had shrunk so much that it seemed in danger of collapsing, and the therapists were anxious to reestablish its size. They realized that Felix was not an ideal candidate, but they had few applicants and decided to take the risk. In addition, they were somewhat intrigued by his stated determination to change his lifestyle. (Many sociopathic individuals are forever “reaching a turning point in life.”)

By the third meeting, Felix had become the social and emotional leader of the group, seemingly able to feel more acutely and suffer more deeply than the other members. He presented the group, as he had the therapists, with a largely fabricated account of his background and current life situation. By the fourth meeting, as the therapists learned later, he had seduced one of the female members and, in the fifth meeting, he spearheaded a discussion of the group’s dissatisfaction with the brevity of the meetings. He proposed that the group, with or without the permission of the therapist, meet more often, perhaps at one of the members’ homes, without the therapist. By the sixth meeting, Felix had vanished, without notifying the group. The therapists learned later that he had suddenly decided to take a 2,000-mile bicycle trip, hoping to sell an article about it to a magazine.

This extreme example illustrates many of the reasons why the inclusion of a sociopathic individual in a heterogeneous ambulatory group is ill advised: his social front is deceptive; he often consumes such an inordinate amount of group energy that his departure leaves the group bereft, puzzled, and discouraged; he rarely assimilates the group therapeutic norms and instead often exploits other members and the group as a whole for his immediate gratification.
Let me emphasize that I do not mean that group therapy per se is contraindicated for sociopathic clients.
In fact, a specialized form of group therapy with a more homogeneous population and a wise use of strong group and institutional pressure may well be the treatment of choice.
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Most clinicians agree that clients in the midst of some acute situational crisis are not good candidates for group therapy; they are far better treated in crisis-intervention therapy in an individual, family, or social network format.
¹⁹
Deeply depressed suicidal clients are best not admitted to an interactionally focused heterogeneous therapy group either. It is difficult for the group to give them the specialized attention they require (except at enormous expense of time and energy to the other members); furthermore, the threat of suicide is too taxing, too anxiety provoking, for the other group members to manage.
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Again, that does not mean that group therapy per se (or group therapy in combination with individual therapy) should be ruled out. A structured homogeneous group for chronic suicidality has been reported to be effective.
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