The Theory and Practice of Group Psychotherapy (49 page)

Thus, clients with problems in intimacy represent at the same time a specific indication and contraindication for group therapy. The problem, of course, is how to identify and screen out those who will be overwhelmed in the group. If only we could accurately quantify this critical cutoff point! The prediction of group behavior from pretherapy screening sessions is a complex task that I will discuss in detail in the next chapter.

Individuals with severe character and narcissistic pathology and a pervasive dread of self-disclosure may be unfavorable candidates for interactional group therapy. But if such individuals are dissatisfied with their interpersonal styles, express a strong motivation for change, and manifest curiosity about their inner lives, then they stand a better chance of benefiting from a therapy group. The group interaction may cause these individuals intense anxiety about losing their sense of self and autonomy. They crave connectedness yet fear losing themselves in that very process. Interpersonal defenses against these vulnerabilities, such as withdrawal, devaluation, or self-aggrandizement, may push the group member into a deviant group role.
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Mildly or moderately schizoid clients and individuals with avoidant personality disorder, on the other hand, are excellent candidates for group therapy and rarely fail to benefit from it.

Greater caution should be exercised when the therapist is seeking a replacement member for an already established, fast-moving group. Often, combining individual and group therapy may be necessary to launch or sustain vulnerable clients in the group. The added support and containment provided by the individual therapist may diminish the sense of risk for the client.
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Fear of Emotional Contagion.
Several clients who dropped out of group therapy reported being adversely affected by hearing the problems of the other group members. One man stated that during his three weeks in the group, he was very upset by the others’ problems, dreamed about them every night, and relived their problems during the day. Other clients reported being upset by one particularly disturbed client in each of their groups. They were all frightened by seeing aspects of the other client in themselves and feared that they might become as mentally ill as the severely disturbed client or that continued exposure to that member would evoke a personal regression. Another client in this category who bolted from the first group meeting thirty minutes early and never returned described a severe revulsion toward the other group members: “I couldn’t stand the people in the group. They were repulsive. I got upset seeing them trying to heap their problems on top of mine. I didn’t want to hear their problems. I felt no sympathy for them and couldn’t bear to look at them. They were all ugly, fat, and unattractive.” This client had a lifelong history of being upset by other people’s illnesses and avoiding sick people. Once when her mother fainted, she “stepped over her” to get away rather than trying to help. Other clinicians have noted that clients in this category have a long-term proclivity to avoid sick people, and, if they had been present at an accident were the first to leave or tended to look the other way.
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Such concern about contagion has many possible dynamics. Many clients with borderline personality disorder report such fears (it is a common phenomenon in inpatient group therapy), and it is often regarded as a sign of permeable ego boundaries and an inability to differentiate oneself from significant others in one’s environment.

A fear of emotional contagion, unless it is extremely marked and clearly manifest in the pretherapy screening procedure, is not a particularly useful index for selection or exclusion for a group. Generally, it is difficult to predict this behavior from screening interviews. Furthermore, fear of emotional contagion is not in itself sufficient cause for failure. Therapists who are sensitive to the problem can deal with it effectively in the therapeutic process. Occasionally, clients must gradually desensitize themselves: I have known individuals who dropped out of several therapy groups but who persevered until they were finally able to remain in one. These attitudes by no means rule out group therapy. The therapist may help by clarifying for the client the crippling effects of his or her attitudes toward others’ distress. How can one develop friendships if one cannot bear to hear of another’s difficulties? If the discomfort can be contained, the group may well offer the ideal therapeutic format for such a client.

Other Reasons.
The other reasons for group therapy dropouts—inability to share the therapist, complications of concurrent individual and group therapy, early provocateurs, problems in orientation to therapy, and complications arising from subgrouping—were generally a result less of faulty selection than of faulty therapeutic technique; they will be discussed in later chapters. None of these categories, though, belongs solely under the rubric of selection or therapy technique. For example, some clients terminated because of an inability to share the therapist. They never relinquished the notion that progress in therapy was dependent solely on the amount of goods (time, attention, and so on) they received from the group therapist.

Although it may have been true that these clients tended to be excessively dependent and authority oriented, it was also true that they had been incorrectly referred to group therapy. They had all been in individual therapy, and the group was considered a method of therapy weaning. Obviously, group therapy is not a modality to be used to facilitate the termination phase of individual therapy, and the therapist, in pretherapy screening, should be alert to inappropriate client referrals. Sometimes clients’ strong reluctance to relinquish individual therapy will prevent them engaging in group therapy.†

As we saw in earlier chapters, there is compelling evidence that the strength of the therapeutic alliance predicts therapy outcome. Conversely, problems with the alliance, such as client-therapist disagreement about the goals, tasks, or therapy relationship, are associated with premature terminations and failure. A study of ten dropouts noted that several clients had been inadequately prepared for the group.
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The therapist had been unclear about the reasons for placing them in a group. No clear set of goals had been formulated, and some clients were suspicious of the therapists’ motives—questioning whether they had been placed in the group simply because the group needed a warm body. Some were wounded by being placed in a group with significantly dysfunctional members. They took this as a statement of the therapist’s judgment of their condition. Some were wounded simply by being referred to a group, as though they were being reduced from a state of specialness to a state of ordinariness. Still others left the group because of a perceived imbalance in the giving-receiving process. They felt that they gave far more than they received in the group.

CRITERIA FOR INCLUSION

The most important clinical criterion for inclusion is the most obvious one: motivation.
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The client must be highly motivated for therapy in general and for group therapy in particular. It will not do to start group therapy because one has been sent—whether by spouse, probation officer, individual therapist, or any individual or agency outside oneself. Many erroneous prejudgments of the group may be corrected in the preparation procedure (see chapter 10), but if you discern a deeply rooted unwillingness to accept responsibility for treatment or deeply entrenched unwillingness to enter the group, you should not accept that person as a group therapy member.

Most clinicians agree that an important criterion for inclusion is whether a client has obvious problems in the interpersonal domain: for example, loneliness, shyness and social withdrawal, inability to be intimate or to love, excessive competitiveness, aggressivity, abrasiveness, argumentativeness, suspiciousness, problems with authority, narcissism, an inability to share, to empathize, to accept criticism, a continuous need for admiration, feelings of unlovability, fears of assertiveness, obsequiousness, and dependency. In addition, of course, clients must be willing to take some responsibility for these problems or, at the very least, acknowledge them and entertain a desire for change.

Some clinicians suggest group therapy for clients who do not work well in individual therapy as a result of their limited ability to report on events in their life (because of blind spots or because of ego syntonic character pathology.)
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Impulsive individuals who find it difficult to control the need to act immediately on their feelings usually work better in groups than in individual therapy.
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The therapist working with these clients in individual therapy often finds it difficult to remain both participant and observer, whereas in the group these two roles are divided among the members: some members may, for example, rush to battle with the impulsive client, while others egg them on (“Let’s you and him fight”), and others act as disinterested, reliable witnesses whose testimony the impulsive client is often far more willing to trust than the therapist’s.

In cases where interpersonal problems are not paramount (or not obvious to the client), group therapy may still be the treatment of choice. For example, clients who are extremely intellectualized may do better with the affective stimuli available in a group. Other clients fare poorly in individual therapy because of severe problems in the transference: they may not be able to tolerate the intimacy of the dyadic situation, either so distorting the therapeutic relationship or becoming so deeply involved with (or oppositional to) the therapist that they need the reality testing offered by other group members to make therapy possible. Others are best treated in a group because they characteristically elicit strong negative counter-transference from an individual therapist.
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• Grant, a thirty-eight-year-old man referred to group therapy by his female individual therapist, struggled with anger and a near-phobic avoidance of tenderness or dependence that he believed was related to physical abuse he suffered at the hands of his brutal father. When his young son’s physical playfulness became frightening to him, he sought individual therapy because of his concern that he would be an inadequate or abusive father.

At first the individual therapy progressed well, but soon the therapist became uneasy with Grant’s aggressive and crude sexual feelings toward her. She became particularly concerned when Grant suggested that he could best express his gratitude to her through sexual means. Stymied in working this through, yet reluctant to end the therapy because of Grant’s gains, the therapist referred him to a therapy group, hoping that the concurrent group and individual format would dilute the intensity of the transference and countertransference. The group offered so many alternatives for both relatedness and confrontation that Grant’s treatment was able to proceed effectively in both venues.

Many clients seek therapy without an explicit interpersonal complaint. They may cite the common problems that propel the contemporary client into therapy: a sense of something missing in life, feelings of meaninglessness, diffuse anxiety, anhedonia, identity confusion, mild depression, self-derogation or self-destructive behavior, compulsive workaholism, fears of success, alexithymia.
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But if one looks closely, each of these complaints has its interpersonal underpinnings, and each generally may be treated as successfully in group therapy as in individual therapy.
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Research on Inclusion Criteria

Any systematic approach to defining criteria for inclusion must issue from the study of successful group therapy participants. Unfortunately, as I discussed at the beginning of this chapter, such research is extraordinarily difficult to control. I should note that prediction of outcome in individual therapy research is equally difficult, and recent reviews stress the paucity of successful, clinically relevant research.
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In a study of forty clients in five outpatient therapy groups through one year of group therapy, my colleagues and I attempted to identify factors that were evident before group therapy that might predict successful outcome.
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Outcome was evaluated and correlated with many variables measured before the start of therapy. Our results indicated that none of the pretherapy factors measured were predictive of success in group therapy, including level of psychological sophistication, therapists’ prediction of outcome, previous self-disclosure, and demographic data. However, two factors measured early in therapy (at the sixth and the twelfth meetings) predicted success one year later: the clients’ attraction to the group and the clients’ general popularity in the group.
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The finding that popularity correlated highly with successful outcome has some implications for selection, because researchers have found that high self-disclosure, activity in the group, and the ability to introspect were some of the prerequisites for group popularity.
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Recall that popularity and status in a group accrues to individuals who model the behaviors that advance the group’s achievement of its goals.
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The Lieberman, Yalom, and Miles study (see chapter 16) demonstrated that, in pregroup testing, those who were to profit most from the group were those who highly valued and desired personal change; who viewed themselves as deficient both in understanding their own feelings and in their sensitivity to the feelings of others; who had high expectations for the group, anticipating that it would provide relevant opportunities for communication and help them correct their deficiencies.
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