The Theory and Practice of Group Psychotherapy (64 page)

It is useful for therapists to take note of their reactions to the absence of the various members of the group. If some members are never absent, you may fantasize their absences and your reaction to it. Consider what thoughts, feelings, fantasies and actions these individuals generate in you, and what they do to generate that impact.
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If you dread the absence of certain members, feeling that there would be no life in the group that day, then it is likely that there is too much burden on those individuals and so much secondary gratification that they will not be able to deal with their primary task in therapy. Given the responsibility projected onto them, they may well be considered a form of scapegoat, although a positively viewed one, at least at first.
^ab

I believe much of the confusion about group development is that each group is, at the same time,
like all groups, like some groups, and like no other group! Of course,
all therapy groups go through some change as they proceed.
Of course
there is some early awkwardness, as the group deals with its raison d’être and its boundaries.
Of course
this is followed by some tension and by repeated attempts to develop intimacy. And
of course
all groups must face termination—the final phase. And from time to time, but only from time to time, one encounters a group that runs “on schedule.”

Some time ago at an A. K. Rice two-week group workshop, I took part in an intergroup exercise in which the sixty participants were asked to form four groups in any manner they wished and then to study the ongoing relationships among the groups. The sixty participants, in near panic, stampeded from the large room toward the four rooms designated for the four small groups. The panic, an inevitable part of this exercise, probably stemmed from primitive fears of exclusion from a group.
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In the group in which I participated, the first words spoken after approximately sixteen members had entered the room were, “Close the door. Don’t let anyone else in!” The first act of the group was to appoint an official doorkeeper. Once the group’s boundaries were defined and its identity vis-à-vis the outside world established, the group turned its attention to regulating the distribution of power by speedily electing a chairman, before multiple bids for leadership could immobilize the group. Only later did the group experience and discuss feelings of trust and intimacy and then, much later, feelings of sadness as the group approached termination.

In summary, there are some advantages to group therapists’ possessing some broad schema of a group developmental sequence: It enables them to maintain objectivity and to chart the voyage of a group despite considerable yawing, and to recognize if a group never progresses past a certain stage or omits some. At times, therapists may demand something for which the group is not yet ready: mutual caring and concern develop late in the group; in the beginning, caring may be more pro forma as members view one another as interlopers or rivals for the healing touch of the therapist. The therapist who is aware of normative group development is able to remain more finely tuned to the group.

But there is a downside to the clinical application of group developmental ideas. The inexperienced therapist may take them too seriously and use them as a template for clinical practice. I have seen beginning therapists exert energy on forcing a group, in procrustean fashion, to progress in lockstep through set phases. Such formulaic therapy—and it grows more common in these days of standardized therapy via treatment manual—lessens the possibility of real therapist-client engagement. The sacrifice of realness, of authenticity, in the therapeutic relationship is no minor loss: It is the loss of the very heart of psychotherapy.

Certainly, the first generations of psychotherapy manuals diminished the authenticity of therapy by their slavish attention to adherence to the model. More contemporary therapy manuals do less micromanaging of treatment and provide more scope for therapist flexibility and naturalness.
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Psychotherapy, whether with a group or with an individual client, should be a shared journey of discovery. There is danger in every system of “stages”—in the therapist having fixed, preconceived ideas and procedural protocols in any kind of growth-oriented therapy. It is precisely for this reason that some trends forced on the field by managed care are so toxic.

In the mid-1970s, I began the first group for cancer patients with Katy Weers, a remarkable woman with advanced breast cancer. She often railed about the harm brought to the field by Elisabeth Kübler-Ross’s “stages” of dying, and dreamed of writing a book to refute this concept. To experience the client against a template of stages interferes with the very thing so deeply desired by clients: “therapeutic presence.” Katy and I both suspected that therapists cloaked themselves in the mythology of “stages” to muffle their own death anxiety.

MEMBERSHIP PROBLEMS

The early developmental sequence of a therapy group is powerfully influenced by membership problems. Turnover in membership, tardiness, and absence are facts of life in the developing group and often threaten its stability and integrity. Considerable absenteeism may redirect the group’s attention and energy away from its developmental tasks toward the problem of maintaining membership. It is the therapist’s task to discourage irregular attendance and, when necessary, to replace dropouts appropriately by adding new members.

Turnover

In the normal course of events, a substantial number of members drop out of interactionally based groups in the first twelve meetings (see
table 8.1
). If two or more members drop out, new members are usually added—but often a similar percentage of these additions drop out in their first dozen or so meetings. Only after this does the group solidify and begin to engage in matters other than those concerning group stability. Generally, by the time clients have remained in the group for approximately twenty meetings, they have made the necessary long-term commitment. In an attendance study of five groups, there was considerable turnover in membership within the first twelve meetings, a settling in between the twelfth and twentieth, and near-perfect attendance, with excellent punctuality and no dropouts, between the twentieth and forty-fifth meetings (the end of the study).
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Most studies demonstrate the same findings.
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It is unusual for the number of later dropouts to exceed that of earlier phases.
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In one study in which attrition in later phases was higher, the authors attributed the large numbers of later dropouts to mounting discomfort arising from the greater intimacy of the group. Some groups had a wave of dropouts; one dropout seemed to seed others. As noted in chapter 8, prior or concurrent individual therapy substantially reduces the risk of premature termination.
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In general, short-term groups report lower dropout rates.
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In closed, time-limited groups, it is useful to start with a large enough number of clients that the group can withstand some attrition and yet be sufficiently robust for the duration of the group’s course. Too large a starting size invites dropouts from individuals who will feel detached and peripheral to the group. Starting with nine or ten members is probably ideal in this situation.

Attendance and Punctuality

Despite the therapist’s initial encouragement of regular attendance and punctuality, difficulties usually arise in the early stages of a group. At times the therapist, buffeted by excuses from clients—baby-sitting problems, vacations, transportation difficulties, work emergencies, out-of-town guests—becomes resigned to the impossibility of synchronizing the schedules of eight busy people. Resist that course! Tardiness and irregular attendance usually signify resistance to therapy and should be regarded as they are in individual therapy. When several members are often late or absent, search for the source of the group resistance; for some reason, cohesiveness is limited and the group is foundering. If a group solidifies into a hard-working cohesive group, then—
mirabile dictu
—the baby-sitting and scheduling problems vanish and there may be perfect attendance and punctuality for many months.

At other times, the resistance is individual rather than group based. I am continually amazed by the transformation in some individuals, who for long periods have been tardy because of “absolutely unavoidable” contingencies—for example, periodic business conferences, classroom rescheduling, child care emergencies—and then, after recognizing and working through the resistance, become the most punctual members for months on end. One periodically late member hesitated to involve himself in the group because of his shame about his impotence and homosexual fantasies. After he disclosed these concerns and worked through his feelings of shame, he found that the crucial business commitments responsible for his lateness—commitments that, he later revealed, consisted of perusing his mail—suddenly evaporated.

Whatever the basis for resistance, it is behavior that must, for several reasons, be modified before it can be understood and worked through. For one thing, irregular attendance is destructive to the group. It is contagious and leads to group demoralization. Obviously, it is impossible to work on an issue in the absence of the relevant members. Few exercises are more futile than addressing the wrong audience by deploring irregular attendance with the group members who are present—the regular, punctual participants. Groups are generally supportive of individuals who are genuinely trying to attend regularly but fall short, in contrast to their intolerance of those who lack real commitment to the group.

Various methods of influencing attendance have been adopted by therapists. During pretherapy interviews, many therapists stress the importance of regular attendance. Clients who appear likely to have scheduling or transportation problems are best referred for individual therapy, as are those who must be out of town once a month or who, a few weeks after the group begins, plan an extended out-of-town vacation. Charging full fees for missed sessions is standard practice. Many private practitioners set a fixed monthly fee, which is not reduced for missed meetings for any reason.

There are few more resistant group clients than men who have physically abused their partners. At the same time, there is robust evidence that group interventions are effective with this population, if the men continue in treatment. However, dropout rates of 40–60 percent within three months are not uncommon. Clinicians working with this population have tackled the problem of poor motivation directly with intensive pregroup training, including psychoeducational videos to increase empathy for the victims and inform abusers about the physiology and psychology of violence.
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An even simpler intervention has proven powerfully effective. In a study of 189 men, group leaders who reached out actively via phone calls, expressions of concern, and personalized alliance-building measures produced dramatic results. These simple, low-tech interventions significantly increased both attendance and tenure in both interpersonal and cognitive-behavioral group therapies and significantly reduced the incidence of domestic violence.
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It is critical that the therapist be utterly convinced of the importance of the therapy group and of regular attendance. The therapist who acts on this conviction will transmit it to the group members. Thus, therapists should arrive punctually, award the group high priority in their own schedule, and, if they must miss a meeting, inform the group of their absence weeks in advance. It is not uncommon to find that therapist absence or group cancellation may be followed by poor attendance.

• Upon arriving at a psychotherapy group for elderly men, I discovered that half the group of eight was absent. Illness, family visits, and conflicting appointments all conspired to diminish turnout. As I surveyed the room strewn with empty chairs, one man spoke up and suggested with some resignation that we cancel the group since so many members were away. My first reaction was one of quiet relief at the prospect of unexpected free time in my day. My next thought was that canceling the meeting was a terrible message to those present. In fact, the message would echo the diminishment, isolation, and unwantedness that the men felt in their lives. Therefore I suggested that it might be even more important than ever to meet today. The men actively embraced my comment as well as my suggestion that we remove the unnecessary chairs and tighten the circle so that we could hear one another better.

A member who has a poor attendance record (whatever the reason) is unlikely to benefit from the group. In a study of ninety-eight group participants, Stone and his colleagues found that poor attendance early in the group was linearly related to late dropout (at six to twelve months).
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Thus, inconsistent attendance demands decisive intervention.

• In a new group, one member, Dan, was consistently late or absent. Whenever the co-therapists discussed his attendance, it was clear that Dan had valid excuses: his life and his business were in such crisis that unexpected circumstances repeatedly arose to make attendance impossible. The group as a whole had not jelled; despite the therapists’ efforts, other members were often late or absent, and there was considerable flight during the sessions. At the twelfth meeting, the therapists decided that decisive action was necessary. They advised Dan to leave the group, explaining that his schedule was such that the group could be of little value to him. They offered to help Dan arrange individual therapy, which would provide greater scheduling flexibility. Although the therapists’ motives were not punitive and although they were thorough in their explanation, Dan was deeply offended and walked out in anger midway through the meeting. The other members, extremely threatened, supported Dan to the point of questioning the therapists’ authority to ask a member to leave.