The Theory and Practice of Group Psychotherapy (60 page)

This strategy of providing full information to the members about the effects of extragroup socializing provides the therapist with far greater leverage than the strategy of the
ex cathedra
“thou shall not.” If group members engage in secretive subgrouping, you do not have to resort to the ineffectual, misdirected “Why did you break my rules?” but instead can plunge into the heart of resistance by inquiring, “How come you’re sabotaging your own therapy?”

In summary, this cognitive approach to group therapy preparation has several goals: to provide a rational explanation of the therapy process; to describe what types of behavior are expected of group members; to establish a contract about attendance; to raise expectations about the effects of the group; to predict (and thus to ameliorate) problems and discomfort in early meetings. Underlying these words is the process of
demystification
. Therapists convey the message that they respect the client’s judgment and intelligence, that therapy is a collaborative venture, that leaders are experts who operate on a rational basis and are willing to share their knowledge with the client. One final point is that comprehensive preparation also enables the client to make an informed decision about whether to enter a therapy group.

Though this discussion is geared toward a longer-term interactional group, its basic features may be adapted to any other type of group therapy. In brief therapy groups relying on different therapeutic factors—for example, cognitive-behavioral groups—the relevant details of the presentation would have to be altered, but
every therapy group profits from preparation of its members
.
†
If clinical exigencies preclude a thorough preparation, then a short preparation is better than none at all. In chapter 15, I describe a three-minute preparation I provide at the start of an acute inpatient group.

Other Approaches to Preparation

Straightforward cognitive preparation presented a single time to a client may not be sufficiently powerful. Clients are anxious during their pregroup interviews and often recall astonishingly little of the content of the therapist’s message or grossly misunderstand key points. For example, some group participants whom I asked to remain in the group for twelve sessions before evaluating its usefulness understood me to say that the group’s entire life span would be twelve sessions.

Consequently, it is necessary to repeat and to emphasize deliberately many key points of the preparation both during the pregroup sessions and during the first few sessions of the group. For my ambulatory groups that meet once a week, I prepare a weekly written summary that I mail out to all the group members after each session (see chapter 14). These summaries provide an excellent forum to repeat in writing essential parts of the preparation procedure. When a new member joins an ongoing group, I provide additional preparation by requesting that he or she read the group summaries of the previous six meetings.

Many therapists have described other methods to increase the potency of the preparatory procedure. Some have used another group member to sponsor and to prepare a new member.
⁷⁰
Others have used a written document for the new client to study before entering a group. The appendix to this book contains an example of a written handout to be used as a supplement for preparing clients entering a group. It stresses focusing on the here-and-now, assuming personal responsibility, avoiding blaming others, avoiding giving suggestions and fostering dependency, learning to listen to others, becoming aware both of feelings and of thoughts, and attempting to experiment with intimacy and with new behavior. We emphasize feedback and offer prospective members specific instructions about how to give and receive feedback: for example, be specific, give it as soon as possible, be direct, share the positive and the negative, tell how the other makes you feel, don’t deal with
why
but with
what
you see and feel, acknowledge the feedback, don’t make excuses, seek clarification, think about it, and beware of becoming defensive.
⁷¹

Other preparation techniques include observation of an audiotape or videotape of meetings.† For reasons of confidentiality, this must be a professionally marketed tape in the public domain or a tape of a simulated group meeting with staff members or professional actors playing the roles of members. The scripts may be deliberately designed to demonstrate the major points to be stressed in the preparatory phase.

An even more powerful mode of preparing clients is to provide them with personal training in desired group behavior.†
⁷²
Several experiential formats have been described. One brief group therapy team, for example, employs a two-part preparation. First, each group member has an individual meeting to establish a focus and goals for therapy. Afterward, prospective group members participate in an experiential single-session workshop at which eighteen to twenty clients perform a series of carefully selected structured interactional exercises, some involving dyads, some triads, and some the entire group.
⁷³

Another study used four preparatory sessions, each of which focused on a single concept of pregroup training: (1) using the here-and-now, (2) learning how to express feelings, (3) learning to become more self-disclosing, and (4) becoming aware of the impact one has and wishes to have on others. The researchers handed out cognitive material in advance and designed structured group exercises to provide experiential learning about each concept.
⁷⁴
Other projects use role playing to simulate group therapy interaction.
⁷⁵

In general, the more emotionally alive and relevant the preparation is, the greater its impact will be. Some research suggests that it is the active, experiential rather than the cognitive or passive, observing component of the pretraining that may have the greatest impact.
⁷⁶

Much current preparation research centers on the client’s motivation and change readiness.
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The focus on motivation as a target for intervention (rather than a prerequisite for treatment) originated in the treatment of addiction and has subsequently been applied effectively for clients with eating disorders and perpetrators of sexual abuse—clinical populations well recognized for denial and resistance to change.
⁷⁸

In the future, we can expect interactive computer technology to generate even more effective preparatory programs. However, the existing approaches, used singly or in combination, can be highly effective. Much research evidence, to which I now turn, attests to the general effectiveness of these techniques.

Research Evidence

In a controlled experiment, my colleagues and I tested the effectiveness of a brief cognitive preparatory session.
⁷⁹
Of a sample of sixty clients awaiting group therapy, half were seen in a thirty-minute preparatory session, and the other half were seen for an equal period in a conventional interview dedicated primarily to history-taking. Six therapy groups (three of prepared clients, three of unprepared clients) were organized and led by group therapists unaware that there had been an experimental manipulation. (The therapists believed only that all clients had been seen in a standard intake session.) A study of the first twelve meetings demonstrated that the prepared groups had more faith in therapy (which, in turn, positively influences outcome) and engaged in significantly more group and interpersonal interaction than did the unprepared groups, and that this difference was as marked in the twelfth meeting as in the second.
⁸⁰
The research design required that identical preparation be given to each participant. Had the preparation been more thorough and more individualized for each client, its effectiveness might have been greater.

The basic design and results of this project—a pregroup preparation sample, which is then studied during its first several group therapy meetings and shown to have a superior course of therapy compared with a sample that was not properly prepared—has been replicated many times. The clinical populations have varied, and particular modes of preparation and process and outcome variables have grown more sophisticated. But the amount of corroborative evidence supporting the efficacy
on both group processes and client outcomes
of pregroup preparation is impressive.
⁸¹
Furthermore, few studies fail to find positive effects of preparation on clients’ work in group therapy.
⁸²

Pregroup preparation improves attendance
⁸³
and increases self-disclosure, self-exploration, and group cohesion,
⁸⁴
although the evidence for lower dropout rates is less consistent.
⁸⁵
Prepared group members express more emotion;
⁸⁶
assume more personal responsibility in a group;
⁸⁷
disclose more of themselves;
⁸⁸
show increased verbal, work-oriented participation;
⁸⁹
are better liked by the other members;
⁹⁰
report less anxiety;
⁹¹
are more motivated to change;
⁹²
show a significant decrease in depression;
⁹³
improve in marital adjustment and ability to communicate;
⁹⁴
are more likely to attain their primary goals in therapy;
⁹⁵
and have fewer erroneous conceptions about the group procedure.
⁹⁶
Research shows that cognitive preparation of clients in lower socioeconomic classes results in greater involvement, group activity, and self-exploration.
⁹⁷
Even notoriously hard to engage populations, such as domestic abusers, respond very positively to measures aimed at enhancing attendance and participation.
⁹⁸

In summary, a strong research consensus endorses the value of pregroup client preparation. Most of the findings demonstrate the beneficial impact of preparation on intervening variables; a direct effect on global client outcome is more difficult to demonstrate because the contributions of other important therapy variables obscure the effect of preparation.
⁹⁹

The Rationale Behind Preparation

Let us consider briefly the rationale behind preparation for group therapy. The first meetings of a therapy group are both precarious and vitally important: many members grow unnecessarily discouraged and terminate therapy, and the group is in a highly fluid state and maximally responsive to the influence of the therapist—who has the opportunity to help the group elaborate therapeutic norms. The early meetings are a time of considerable client anxiety, both
intrinsic
, unavoidable anxiety and
extrinsic
, unnecessary anxiety.

The
intrinsic
anxiety issues from the very nature of the group. Individuals who have encountered lifelong disabling difficulties in interpersonal relationships will invariably be stressed by a therapy group that demands not only that they attempt to relate deeply to other members but also that they discuss these relationships with great candor. In fact, as I noted in chapter 9, clinical consensus and empirical research both indicate that anxiety seems to be an essential condition for the initiation of change.
¹⁰⁰
In group therapy, anxiety arises not only from interpersonal conflict but from dissonance, which springs from one’s desire to remain in the group while at the same time feeling highly threatened by the group task. An imposing body of evidence, however, demonstrates that there are limits to the adaptive value of anxiety in therapy.
¹⁰¹
An optimal degree of anxiety enhances motivation and increases vigilance, but excessive anxiety will obstruct one’s ability to cope with stress. White notes, in his masterful review of the evidence supporting the concept of an exploratory drive, that excessive anxiety and fear are the enemies of environmental exploration; they retard learning and decrease exploratory behavior in proportion to the intensity of the fear.
¹⁰²
In group therapy, crippling amounts of anxiety may prevent the introspection, interpersonal exploration, and testing of new behavior essential to the process of change.

Much of the anxiety experienced by clients early in the group is not intrinsic to the group task but is
extrinsic,
unnecessary, and sometimes iatrogenic. This anxiety is a natural consequence of being in a group situation in which one’s expected behavior, the group goals, and their relevance to one’s personal goals are exceedingly unclear. Research with laboratory groups demonstrates that if the group’s goals, the methods of goal attainment, and expected role behavior are ambiguous, the group will be less cohesive and less productive and its members more defensive, anxious, frustrated, and likely to terminate membership.
¹⁰³