The Promise of Group Therapy: How to Build a Vigorous Training and Organizational Base for
Group Therapy in Managed Behavioral Healthcare
CHAPTER 2: Resistances to Group Therapy
Why does it take so much time and effort to create a group psychotherapy program? An interesting conflict of values emerges from the rise of group therapy practice. That conflict is the face-off between the profit motive on one hand and the belief in rugged individualism on the other. This larger context must not be undervalued as a cause for much of the ambivalence about implementing group therapy delivery to appropriate populations.
Economic good sense shows group therapy a winner. However, when the desire to lower costs of delivery and increase profits is matched against the powerful mythology of the rugged individualist, and the equally strong desire to find individual solutions to personal problems, there is a collision of values that confounds the patient, the caregiver, and the system in which the care is given. Let’s look at some of the ideas behind this conflict.
THE INDIVIDUAL AND THE GROUP
A central human paradox is confronted each time a person affiliates with a group: “Only I can truly know myself—and yet I feel terribly alienated and alone unless I am known by others.” Existentially, a man or woman in group is different than when alone. The shattering power of this experience calls into question many of our cherished assumptions about human nature, such as the enduring nature of identity and personality over time and place. Such unsettling experiences in group, where the defenses of individuals are laid open and the vulnerability of the individual exposed, become a terrifying prospect for the individual who rigidly holds to the belief that he is somehow immune to such influences.
Both Jacksonian and Jeffersonian democracy, as it is espoused and practiced in the United States, presuppose a self-reliant individual who only gives up his or her rights, and then only provisionally, for the common good. The idea of giving up one’s right to privacy for one’s own good is alien to the free-thinking individualist.
The guiding light for rationalism in the eighteenth-century Enlightenment, when ideas about democracy were reawakening, was René Descartes. The Cartesian world was a world in which individuals endeavored to understand reality based on each individual’s perceptions, like little islands of consciousness working independently to perceive the whole. Communication between these individuals was possible for practical purposes but not necessary to the understanding of the self, which could be divined through reflection and introspection.
The idea that the self was an intersubjective construction fashioned out of the necessity to communicate with others and dependent to a large degree on the perception of others, took hold in the late nineteenth and early twentieth centuries. There is now a large body of clinical data from social psychology, including group therapy, supporting this notion. However, Americans for the most part remain Cartesian in their thinking and assumptions about themselves.
I believe these forces of philosophy, myth, and national and cultural identity shape the historical context of our lives and quite unconsciously undermine our honest efforts to forge group therapy programs in the United States. Thus, despite strong economic incentives to provide group treatment, there are for many people equally strong sociological, cultural, and personal reasons to oppose entering group psychotherapy, and their reasons for opposition find considerable support in what Americans believe about themselves and tell each other they believe.
THE POWER OF HISTORICAL CONTEXTS
Alexis de Tocqueville, that astute observer of nineteenth-century American habits and customs, noted one of the defining characteristics of United States’ culture that distinguished it from the monarchies of Europe. “Americans,” he said, “are born free, not made so.” It was apparent to the Frenchman that, with the exception of blacks who were brought to America as slaves, Americans enjoyed an atmosphere of freedom that was their birthright—not something hard won by struggle or rivalry with others. This single characteristic, invisible and unconsciously experienced, set Americans apart and endowed them with certain traits and predictable kinds of behavior. For de Tocqueville, this was the historical context of liberty in which the American character was shaped.
In similar fashion, and on a smaller scale, we can expect historical contexts of various kinds to shape the behavior of organizations that manage mental health delivery. Within a specific historical context, the chief assumptions may go unchallenged because they are invisible to the people who hold them. Managed mental health organizations have radically changed the financing, management, and utilization review of individual treatment as practiced by the fee-for-service mental health professionals; ironically, they have also, without exception, adopted the prejudices and practices of the fee-for-service community in their neglect of group psychotherapy delivery. U.S. Behavioral Health, a major managed mental healthcare organization, will serve as an example.
U.S. Behavioral Health was founded by individuals who had deep roots in the community mental health movement, a movement that endeavored to make mental health services more readily available to the public and sought to employ methods of intervention appropri- ate to the populations served. The goals of community mental health were immediate access, timely intervention, early diagnosis, and short- term treatment—referring patients to the private sector of providers within the community when more in-depth, long-term psychotherapy was needed or requested by the patients themselves. Group therapy was a part of the community mental health movement from the beginning, and yet it is important to recall that community mental health, even at its height, never utilized group psychotherapy to any- where approaching its full potential. Similarly, U.S. Behavioral Health has never realized its potential as a provider of group therapy services. In 1994, the chairman of the board of U.S. Behavioral Health did a survey of its exclusive network of providers organized in group practices at specific geographic locations throughout the United States. The survey revealed that only one site used group psychotherapy for 40 percent of all patient visits. Most sites reported group therapy utilization rates of 10 percent or less. In light of this organization’s avowedly friendly posture toward group therapy, how can we explain this outcome?
In the case of U.S. Behavioral Health, the structuring of the benefit package such that the patient’s co-payment for group therapy is the same as for individual therapy is certainly not an incentive for patients to enter groups. Also, in the absence of capitation, the fact that providers—especially psychiatrists—can make more money treating a patient individually for fifty minutes than in a small group for ninety minutes, without the trouble of organizing a group, is another impediment. Yet these two factors account for only a part of this phenomenon. The larger issue is the historical context in which group therapy is perceived.
COMMON MISPERCEPTIONS OF GROUP THERAPY
In behavioral psychology, it is axiomatic that it’s easier to change behavior than to change attitudes and beliefs. Yet if our attitudes and beliefs prevent us from being effective as psychotherapists, it behooves us ethically to change as much as we can. This is particularly true when our beliefs and prejudices match those of our patients—and we reinforce their own fears and superstitions consciously or unconsciously by our avoidance of group therapy. In this complex process, therapists may project their own fears onto their patients, then watch the patients identify with the fears and act them out accordingly by avoiding group treatment. The attitude and beliefs of providers and managers for managed mental health, whether staff model HMOs or point-of-service, independent practitioner networks, are crucial to the functioning or nonfunctioning of psychotherapy groups. When their attitudes and beliefs are influenced by the historical context—as they must be—the effect can be prejudicial in the extreme.
Some commonly held beliefs about groups that derive directly from the historical context of the United States are elucidated here. I will address six common beliefs that adhere to our culture and language; for each of these beliefs I will also offer an alternative interpretation of group therapy that significantly shifts the frame in which it is usually perceived.
Fewer Choices for the Individual
In one of the earliest documents of the nation, The Federalist Papers, James Madison expressed the suspicion that groups, or as he called them, factions, might become a threat to the liberty of the individual by invoking the “tyranny of the majority.” This belief persists in the fear that I will have fewer choices in a group than I have as an individual, because I will be forced to do as others want. A corollary to that fear is that I will have to listen to others and never be heard myself.
Many people experience the loss of choice in their families of origin because they had to compete with siblings or, in some cases, with parents for what they wanted. They bring that perception to group, where they expect their wishes to be severely limited by the demands of others more powerful or deserving than they. The notion that participation in group can actually expand a person’s range of choices is novel, and is met with disbelief by more skeptical group members. Yet groups constantly strive for fairness among their members, and “Let’s take turns choosing,” is a commonly articulated sentiment.
It simply is not true that I have more choices as an individual than as a member of a group. I realize that this fact would not be so readily apparent to me had I never been a member of a group. There are three continua of choice that encompass the experience of people both in groups and alone. Whether I stand as an individual or with others, my experience of these continua is essentially the same.
The first continuum ranges from “No Choice” to “Too Many Choices.” The one side of this continuum expresses the sadness and rage of being a victim, as in “I would not have done it, but I had no choice.” The other side of this continuum expresses the overwhelming omnipresence of freedom, as in “I can’t escape being free even if I want to.”
The second continuum ranges from “Refusing Choice” to “Embracing Choice.” The one end of this continuum voices the wish to remain in doubt, as if by doing so I could entertain the illusion of endless possibility. The other end of the continuum voices my belief in finitude and the painful, exquisite loss and exhilaration I experience by choosing one direction and not the other.
The third continuum ranges from “Making the Wrong Choice” to “Making the Right Choice.” Both positions firmly fix me in the realm of judgment, which determines my emotional responses. If I choose wrongly, I can be hopeful that I’ll choose more wisely in the future; or, feeling irreverent, I can claim that it doesn’t really matter how I choose.If I choose rightly, I can be fearful that I won’t be so lucky next time; or, feeling reverent, I can aspire even more fervently to choose wisely in the future.
Groups Are Inherently Fearful
Fear is the emotion most commonly reported by people entering therapy groups of any kind or size, and this phenomenon becomes the thesis around which I develop criteria for the readiness of a clinician to conduct groups (see Chapter Nine). People want to avoid groups because groups are perceived as scary: unpredictable things happen, people become angry and unruly, and as the process becomes chaotic, people resort to violence. I can project my fantasies of violence on others and then become frightened by my own projections.
Group leaders themselves are not immune to fear. To learn to understand and manage one’s own fear in group is one of the central goals of training and supervision in group therapy. Normalization of fear as a defining experience in group becomes a goal for both patients and leaders. Providing information about the groups to patients before entry can diminish their anxiety somewhat, yet the existential impact of fear remains—and emerges for most people in our culture in any social setting or group where they are called upon to speak about themselves. Focal group psychotherapy lessens the fear of the patient (and the therapist) by establishing highly structured group interactions that focus on the achievement of goals that are stated and defined in operational terms.
However, people gather in groups not to frighten themselves but to garner courage from their association and exchange with others. If fear is the most commonly expressed emotion early in a group’s formation, courage is the quality most frequently admired by group members in the later stages of development. Perseverance, tenacity, and even stubbornness come to be appreciated as valuable assets by a group that has faced its anxieties, stayed committed to each other, and, through struggle, increased the self-esteem of its members.
The Individual Gets Lost in the Crowd
Another belief is that I will become lost in the group. My wish to be seen is primary, and my belief that I will not be seen can be a torment. “No one will see me. I’ll be invisible. If I am seen, it will not be for who I am but simply how another person wants me to be. I’ll be manipulated into being someone I am not.” People often say these phrases to themselves as they anticipate joining a therapy group.
The truth is that groups have the capability to acknowledge the existence and value of members in a way that is quite unlike any other. Group members act as mirrors for each other, and in those mirrors we can see ourselves very close to the way others see us. In this regard, groups are most efficient in reducing the deleterious effects of the “Don’t Be Important” injunction that so many people with low self esteem carry around inside them. Group members are witnesses to each other’s lives. People learn how much they matter because they are listened to and their stories are remembered and retold in the group. Far from being lost, the standard operating procedure of cohesive groups is to make sure that all of their members are seen and heard, that all have roles to play in the work of the group.
Group Interaction Kills Introspection
There is a belief that my intense involvement with a group reduces my capacity for introspection. In fact, the opposite is the case. There is no opposition between group relations and probing deeply into the self. Group therapy stimulates deeper reflections on the self because individuals see so many parts of themselves in others, and this perception awakens the individual to an inner life to which she may have been oblivious.
The Individual Lacks Privacy in Groups
The group violates the privacy of the individual. The curiosity of others is corrosive and will not help me attain knowledge of myself but will cause shame and embarrassment as I expose myself to other people’s eyes.
It is true that group members will probe each other for information and personal details, yet this curiosity can also be viewed as a sign of caring and interest by fellow human beings. One of the key boundaries that individuals must establish in group therapy is the capacity at any point to say no to interrogations. This is a fundamental assertion of the sovereignty of the individual, which paradoxically must exist if the group is to develop a true sense of intimacy among members. From the very beginning, the group therapist must strengthen this value as a cornerstone of group construction. One of the most powerful learning experiences possible in group is the discovery that the sharing of private thoughts and memories, in the proper context, will serve to deepen their meaning in our lives.
Patients Don’t Want Conflict
This belief seems intimately tied up with the projections of therapists who, as a class, tend to be placaters and conflict wary. The eighteenth century thinkers, including the authors of The Federalist Papers, knew that the central political significance of groups was conflict—a fact that modern clinicians often want to ignore. But what are the clinical consequences of conflict?
For many group members, conflict in their families of origin implied the possible loss of love or loss of control such that acts of abandonment or violence might occur. Conflict inevitably brings group members into emotional engagement with each other. Such engagement can prove to be quite positive, although at the time it may seem to the group that the opposite is true. The feeling of universalization and oneness is exploded by the comprehension of real differences in personalities and interests. Idealization collapses also, if the therapist herself is the object of attack. Group therapists must be willing and able to keep the focus on the conflict, lest the attention of the group be diverted in other directions.
The positive outcome for persons who can tolerate anger in their treatment group is the insight they can obtain when they see the resolution or cessation of the conflict without physical damage or loss of self esteem.
A NEW WAY TO PERCEIVE GROUPS
An innovative program must create a new paradigm as a substitute for the ways in which groups have been perceived historically. Sometimes the paradigm created may seem counterintuitive or paradoxical, as expressed in the statements “Groups of strangers are often easier to talk to than a single friend,” or “The distance group members perceive between themselves and their leader can sometimes be more helpful than the closeness they perceive in individual therapy.” The former is a statement often made by group members in clinical settings; the latter is a construct derived from experiments in social psychology that has practical utility in the treatment of borderline personality disorders. The effort to embrace a positive paradigm for the individual’s experience in the group must continue, not to “sell” the prospective group candidates on the modality but to realign the thinking of clinicians who buy into the chief assumptions of the historical context in which groups have been perceived. Such backward thinking stifles the creativity needed to experiment with new approaches to treatment.
I recall the trepidation with which many clinicians viewed our first homogeneous group for depressed outpatients at Puget Sound. The superstition of group contagion filled the air. Images of patients drag- ging each other lower and lower into the depths of melancholic obliv- ion fraught the minds of my colleagues. In fact, as we continued the experiment and started more of these groups, we discovered the tremendous potential for fun that was released in such groups. Patients who had developed exquisitely attuned senses of humor began to reveal themselves after they first tested if we in the group would accept them in their most depressed states. (I report in detail on this group in Chapter Three, where I describe it as an example of a group structured in response to an assessment of patient needs.)
An even greater fear of contagion swept the clinic when we began groups for parasuicidal patients, that is, people who had all tried to kill themselves at least once. Legal counsel for our malpractice insur- ance was put on alert. Tiresome jokes of “Jim Jones and his Kool-Aid club” abounded. Despite the research data of Rosen, Motto, Asimos, and Billings, which demonstrated the success of such groups, fear and prejudice reigned supreme in the minds of many of our colleagues.
Ultimately, we found in practice that the patients in this homogeneous, open-ended group strongly bonded to each other, and their cohesion served to prevent repeated attempts at suicide. This one group was able to offset the medical costs of repeated emergency care and hospitalizations that amounted to thousands of dollars.
Other paradigm shifts include further paradoxes, such as the following:
An individual can discover more about himself in a group of strangers than he can talking with a gathering of those he knows well.
A good deal of what is usually called external or social in human life is at the same time deeply internal and of powerful dynamic influence as the individual develops. Groups allow an individual to explore relations with others and at the same time probe deeper into the self.
The better my personal boundaries, the closer I can allow myself to be with others in a group.
In the effort to establish an historical context in which group therapy can thrive, the role of group therapy coordinator takes on great significance because it is that person’s job to call into question the commonly held beliefs about groups and to symbolize the realization of a different paradigm for understanding groups.
THE ROLE OF THE GROUP THERAPY COORDINATOR
As I indicated in Chapter One, a group therapy coordinator is an essential component in the development of a group therapy program. By outlining the salient features of the job description, I’ll show how the group therapy coordinator, when given the proper authority, can redefine the historical context in which group therapy is provided and create new models for perceiving groups. The following five points summarize the duties the coordinator must perform in order to make this transformation possible.
Program and Organization Development
A program begins with ideas, and the group therapy coordinator must become a source of ideas. These ideas may be new approaches to a familiar patient population, or familiar approaches to a newly identified patient population, or innovative ways to facilitate the referral of people to groups. Not all ideas are workable, so the coordinator must have the daring to test new ideas that, if proven viable, can be adopted as standard of practice by the entire HMO staff or the whole network of independent providers. Clinicians in either setting will be slow to experiment because they lack the authority to initiate or they allow their negative perceptions of groups to dissuade them. The wish to look good to their peers is a very understandable motivation for maintaining the status quo. By contrast, the group therapy coordinator is being paid to bend if not break the status quo in relation to how groups come into being.
As group therapy coordinator at Puget Sound, I sought the advice and consent of the Group Therapy Committee, composed of fellow group colleagues, in order to set program goals and arrange priorities for the kinds of groups needed, the duration of groups, and the physical space required. I implemented program decisions through cooperation with the clinic manager, clinic chief, and fellow clinicians. Together, we selected therapists to initiate and develop needed groups at the Mental Health Service. In addition, the group therapy coordinator must create a context in which group decision making is possi- ble, one that focuses the attention on process issues as they affect the everyday operation of the staff or network of providers at large. Such issues include the anticipation of conflict, and its prevention and res- olution among clinicians, between clinicians and management, and between clinicians and nonclinical support personnel. Attention to process in the organization becomes the work of the coordinator because she cannot perform her primary task of group expansion and coordination if conflict or confusion blocks the communication process in the larger organization. The group therapy coordinator must have the authority to initiate, when appropriate, the skillful application of her knowledge of group dynamics to the organization as a whole.
Program Management
The group therapy coordinator must become a highly visible, readily accessible manager of the group program. She must be the first to explain the position and defend the priorities of the group program to decision makers in the organization. Group therapists must feel that the group therapy coordinator is their advocate with both clinical and top management in the organization. The group therapists’ perception of the coordinator as their advocate is central to their willingness to take risks in the interest of providing group services. Without strong leadership as exhibited by highly vocal and vigorous advocacy of groups in the system, group therapists will lose confidence in their own ability to sustain groups over time.
The group therapy coordinator must be focused on both expansion and coordination in the discharge of her duties. In the area of expansion, she must build incentives for consumers to utilize groups and for therapists to lead them. She must also plan and anticipate for greater program capacity to accommodate increased patient demand for groups, as a result of improved systems of referral.
In the area of coordination, the coordinator must design, with the help of the Group Therapy Committee, an equitable system to spread existing and potential referrals among the several groups available. At the same time, she must streamline the referral system, keeping in mind sound clinical judgment, to help group therapists find appropriate people for their groups and prevent a backlog of patients waiting for groups. In this capacity, she will organize the task of making group referrals from entry personnel to group screening interviews by clinicians, or when suitable, directly into treatment groups. In all aspects of coordination, the group therapy coordinator should work in close collaboration with the group therapy program assistant, who carries out decisions and whose vital tasks are outlined in Chapter Three.
Direct Clinical Practice
The group therapy coordinator models the very essence of a group therapist, conducting as many or more groups than any person on staff or within the provider network. By example, this person leads other clinicians into thinking, “If she can do it, maybe I can too.” The coordinator need not be an outstanding group clinician, only a very competent one. In fact, a clinician that is too good at groups— and too willing to let everyone know about it—can prove a detriment to a group program. Hubris is not a leadership quality that endears colleagues nor does it bode well for teaching others a complicated skill.
While at Puget Sound, I would take the opportunity to work with any clinician as a co-therapist in a group they were beginning in order to help provide momentum during the start-up period. Often, these pairings were nequipo teams, because the clinician with whom I shared the group leadership was neither equal in experience nor equal in knowledge with me. The task in these teams was to supervise and assist the clinician in becoming more of a peer in the field of group therapy. I stress the importance of these teams to the overall vitality of the organization in Chapter Five.
Consulting and Teaching
The group therapy coordinator is in a unique position to reinforce positive beliefs about group process among clinic staff or network providers. He can disseminate information pertinent to developments in group psychotherapy and group process and act as a resource person in these fields. In this capacity, he can act as a resource person to consult with providers and management concerning issues of group process in general.
At Puget Sound, I conducted regular weekly seminars on topics essential to the practice of group therapy. These seminars were scheduled at times most convenient for therapists to attend. My job description called for me to visit various point-of-service sites in order to facilitate advanced learning in group therapy. Most of these teaching opportunities took place in group supervision or seminar formats, although I was available to consult with therapists requesting supervision about their treatment groups. These supervision sessions were face to face when possible, but I found that once I established initial rapport with a colleague, I was able to supervise successfully by telephone. In this way, I was able to encourage professionals within our organization to develop their skills as group therapists.
Evaluation and Research
The group therapy coordinator, with the advice and consent of the Group Therapy Committee, plans and organizes ways to define and evaluate the success of treatment groups in terms of meeting patient goals, clinician goals, and management goals. This is always an ongoing process. Instruments to evaluate and provide feedback to clinicians and administrators should be developed in collaboration with committee members. The group therapy coordinator must have the authority to seek help outside the organization, when necessary, to find the expertise he needs to create meaningful evaluation procedures.
The group therapy coordinator should also design and implement simplified research studies concerning the effectiveness of groups in treating patients, as well as studies that reveal the effect of increased group utilization on the morale and esprit de corps of the organization as a whole. Of particular interest to managed care mental health organizations are studies that attempt to measure the degree to which timely and appropriate mental health intervention offsets the cost of medical expenditures for the same set of patients. In Chapter Seven, I report on one patient study we designed at Puget Sound that looked at the dimensions of both consumer satisfaction and the offset effect.
After the many resistances to group have been at least confronted, if not surmounted, managers and clinicians can begin to consider the various processes of group formation. The next chapter addresses this subject and gives examples of how to proceed in creating groups.
Bibliography
de Tocqueville, Alexis. Democracy in America (vols. 1 and 2). New York: Vintage Books, 1945. (Originally published 1835)
Hamilton, Alexander, Madison, James, and Jay, John. The Federalist Papers. New York: NAL/Dutton, 1961. (Originally published 1787)
Roller, Bill, and Lankester, Dina. “Characteristic Processes and Therapeutic Strategies in a Homogeneous Group for Depressed Outpatients.” Small Group Behavior, 1987, 18(4), 565–576.
Roller, William L., and Shaskan, Donald A. “Patients’ Perception of Distance: The Same Therapist in Group Therapy Compared to Individual Treatment.” Small Group Behavior, 1982, 13(1), 117–124.
Rosen, David, Asimos, Chris, Motto, Jerome, and Billings, James. “Group Psychotherapy with a Homogeneous Group of Suicidal Patients.” Group Therapy and Social Environment. Proceedings of the 5th International Congress for Group Psychotherapy, Zurich, Aug. 19–24, 1973. Bern: Verlag Hans Huber.
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