The Theory and Practice of Group Psychotherapy (57 page)

How long is “brief”? The range is wide: some clinicians say that fewer than twenty to twenty-five visits is brief,
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others sixteen to twenty sessions,
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and still others fifty or sixty meetings.
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Inpatient groups may be thought of as having a life span of a single session (see chapter 15). Perhaps it is best to offer a functional rather than a temporal definition: a brief group is the shortest group life span that can achieve some specified goal—hence the felicitous term “time-efficient group therapy”.
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A group dealing with an acute life crisis, such as a job loss, might last four to eight sessions, whereas a group addressing major relationship loss, such as divorce or bereavement, might last twelve to twenty sessions. A group for dealing with a specific symptom complex, such as eating disorders or the impact of sexual abuse, might last eighteen to twenty-four sessions. A “brief” group with the goal of changing enduring characterological problems might last sixty to seventy sessions.
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These time frames are somewhat arbitrary, but recent explorations into the “dose-effect” of individual psychotherapy shed some light on the question of duration of therapy.
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This research attempts to apply the drug dose-response curve model to individual psychotherapy by studying large numbers of clients seeking psychotherapy in ambulatory settings. Typically the form of therapy provided is eclectic, integrating supportive, exploratory, and cognitive therapy approaches without the use of therapy manuals. Although no comparable dose-effect research in group therapy has been reported, it seems reasonable to assume that there are similar patterns of response to group therapy.

Researchers note that clients with less disturbance generally require fewer therapy hours to achieve a significant improvement. Remoralization can occur quickly, and eight sessions or fewer are sufficient to return many clients to their precrisis level. The vast majority of clients with more chronic difficulties require about fifty to sixty sessions to improve, and those with significant personality disturbances require even more. The greater the impairment in trust or emotional deprivation and the earlier in development the individual has suffered loss or trauma, the greater the likelihood that a brief therapy will be insufficient. Failure of prior brief therapies is also often a sign of the need for a longer therapy.
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Whatever the precise length of therapy, all brief psychotherapy groups (excluding psychoeducational groups) share many common features. They all strive for efficiency; they contract for a discrete set of goals and attempt to stay focused on goal attainment; they tend to stay in the present (with either a here-and-now focus or a “there-and-now” recent-problem-oriented focus); they attend throughout to the temporal restrictions and the approaching ending of therapy; they emphasize the transfer of skills and learning from the group to the real world; their composition is often homogeneous for some problem, symptomatic syndrome, or life experience; they focus more on
interpersonal than on intrapersonal concerns
.
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A course of brief group therapy need not be viewed as the definitive treatment. Instead it could be considered an installment of treatment—an opportunity to do a piece of important, meaningful work, which may or may not require another installment in the future.
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When leading a brief therapy group, a group therapist must heed some general principles:

• The brief group is not a truncated long-term group;
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group leaders must have a different mental set: they must clarify goals, focus the group, manage time, and be active and efficient. Since groups tend to deny their limits, leaders of brief groups must act as group timekeeper, periodically reminding the group how much time has passed and how much remains. The leader should regularly make comments such as: “This is our twelfth meeting. We’re two-thirds done, but we still have six more sessions. It might be wise to spend a few minutes today reviewing what we’ve done, what goals remain, and how we should invest our remaining time.”

• Leaders must also attend to the transfer of learning, encouraging clients to apply what they have learned in the group to their situations outside the group. They must emphasize that treatment is intended to set change in motion, but not necessarily to complete the process within the confines of the scheduled treatment. The work of therapy will continue to unfold long after the sessions stop.

• Leaders should attempt to turn the disadvantages of time limitations into an advantage. Since the time-limited therapy efforts of Carl Rogers, we have known that imposed time limits may increase efficiency and energize the therapy.
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Also, the fixed, imminent ending may be used to heighten awareness of existential dimensions of life: time is not eternal; everything ends; there will be no magic problem solver; the immediate encounter matters; the ultimate responsibility rests within, not without.
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• Keep in mind that the official name of the group
does not determine the work of therapy
. In other words, just because the group is made up of recently divorced individuals or survivors of sex abuse does not mean that the focus of the group is “divorce” or “sexual abuse.” It is far more effective for the group’s focus to be interactional, directed toward those aspects of divorce or abuse that have ramifications in the here-and-now of the group. For example, clients who have been abused can work on their shame, their rage, their reluctance to ask for help, their distrust of authority (that is, the leaders), and their difficulty in establishing intimate relationships. Groups of recently divorced members will work most profitably not by a prolonged historical focus on what went wrong in the marriage but by examining each member’s problematic interpersonal issues as they manifest in the here-and-now of the group. Members must be helped to understand and change these patterns so that they do not impair future relationships.

• The effective group therapist should be flexible and use all means available to increase efficacy. Techniques from cognitive or behavioral therapy may be incorporated into the interactional group to alleviate symptomatic distress. For example, the leader of a group for binge eating may recommend that members explore the relationship between their mood and their eating in a written journal, or log their food consumption, or meditate to reduce emotional distress. But this is by no means essential. Brief group work that focuses on the interpersonal concerns that reside beneath the food-related symptoms
is as effective as brief group work that targets the disordered eating directly
.
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In other words, therapists can think of symptoms as issuing from disturbances in interpersonal functioning and alleviate the symptom by repairing the interpersonal disturbances.†

• Time is limited, but leaders must not make the mistake of trying to save time by abbreviating the pregroup individual session. On the contrary, leaders must exercise particularly great care in preparation and selection. The most important single error made by busy clinics and HMOs is to screen new clients by phone and immediately introduce them into a group without an individual screening or preparatory session. Brief groups are less forgiving of errors than long-term groups. When the life of the group is only, say, twelve sessions, and two or three of those sessions are consumed by attending to an unsuitable member who then drops out (or must be asked to leave), the cost is very high: the development of the group is retarded, levels of trust and cohesion are slower to develop, and a significant proportion of the group’s precious time and effectiveness is sacrificed.

• Use the pregroup individual meeting not only for standard group preparation but also to help clients reframe their problems and sharpen their goals so as to make them suitable for brief therapy.
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Some group therapists will use the first group meeting to ask each client to present his/her interpersonal issues and treatment goals.
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Some clinicians have sought ways to bridge the gap between brief and longer-term treatment. One approach is to follow the brief group with booster group sessions scheduled at greater intervals, perhaps monthly, for another six months.
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Another approach offers clients a brief group but provides them with the option of signing on for another series of meetings. One program primarily for clients with chronic illness consists of a series of twelve-week segments with a two-week break between segments.
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Members may enter a segment at any time until the sixth week, at which time the group becomes a closed group. A client may attend one segment and then choose at some later point to enroll for another segment. The program has the advantage of keeping all clients, even the long-term members, goal-focused, as they reformulate their goals each segment.

Are brief groups effective? Outcome research on brief group therapy has increased substantially over the past ten years. An analysis of forty-eight reports of brief therapy groups (both cognitive-behavioral and dynamic /interpersonal) for the treatment of depression demonstrated that groups that meet, on average, for twelve sessions produced significant clinical improvement: group members were almost three times more likely to improve than clients waiting for treatment.
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Furthermore, therapy groups add substantially to the effect of pharmacotherapy in the treatment of depression.
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Brief groups for clients with loss and grief have also been proven effective and are significantly more effective than no treatment.
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Both expressive-interpretive groups and supportive groups have demonstrated significant effects with this clinical population.
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A study of brief interpersonal group therapy for clients with borderline personality disorder reported improvement in clients’ mood and behavior at the end of twenty-five sessions.
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Brief group therapy is also effective in the psychological treatment of the medically ill:
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it improves coping and stress management, reduces mood and anxiety symptoms, and improves self-care.

Some less salubrious findings have also been reported. In a comparison study of short-term group, long-term group, brief individual, and long-term individual therapies, the short-term group was the least effective of the four modalities.
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In a study in which subjects were randomly assigned to short-term group treatment and short-term individual treatment, the investigators found significant improvement in both groups and no significant differences between them—except that
subjectively
the members preferred brief individual to brief group treatment.
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In sum, research demonstrates the effectiveness of brief group therapy. However, there is no evidence that brief therapy is superior to longer-term therapy.
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In other words, if brief groups are necessary, we can lead them with confidence: we know there is much we can offer clients in the brief format. But don’t be swept away by the powerful contemporary press for efficiency. Don’t make the mistake of believing that a brief, streamlined therapy approach offers clients more than longer-term therapy. One of the architects of the NIMH Collaborative Treatment of Depression Study, one of the largest psychotherapy trial conducted, has stated that the field has likely oversold the power of brief psychotherapy.
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Size of the Group

My own experience and a consensus of the clinical literature suggest that the ideal size of an interactional therapy group is seven or eight members, with an acceptable range of five to ten members. The lower limit of the group is determined by the fact that a critical mass is required for an aggregation of individuals to become an interacting group. When a group is reduced to four or three members, it often ceases to operate as a group; member interaction diminishes, and therapists often find themselves engaged in individual therapy within the group. The groups lack cohesiveness, and although attendance may be good, it is often due to a sense of obligation rather than a true alliance. Many of the advantages of a group, especially the opportunity to interact and analyze one’s interaction with a large variety of individuals, are compromised as the group’s size diminishes. Furthermore, smaller groups become passive, suffer from stunted development, and frequently develop a negative group image.
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Obviously the group therapist must replace members quickly, but appropriately. If new members are unavailable, therapists do better to meld two small groups rather than to continue limping along with insufficient membership in both.

The upper limit of therapy groups is determined by sheer economic principles. As the group increases in size, less and less time is available for the working through of any individual’s problems. Since it is likely that one or possibly two clients will drop out of the group in the course of the initial meetings, it is advisable to start with a group slightly larger than the preferred size; thus, to obtain a group of seven or eight members, many therapists start a new group with eight or nine. Starting with a group size much larger than ten in anticipation of dropouts may become a self-fulfilling prophecy. Some members will quit because the group is simply too large for them to participate productively. Larger groups of twelve to sixteen members may meet productively in day hospital settings, because each member is likely to have many other therapeutic opportunities over the course of each week and because not all members will necessarily participate in each group session.