Creating Successful Therapy Groups

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Practice Guidelines for Group Psychotherapy

Creating Successful Therapy Groups

Overview. Creating a therapy group that has the potential of becoming an effective treatment for clients, a rewarding experience for therapists, and an accessible intervention for referral sources is a complex endeavor. Whether the group is part of the therapist’s private practice, managed care contract, or clinic caseload, this endeavor actually involves the creation of two groups. The first group of course is the group of clients who have come for treatment. The second and less obvious group is the group of colleagues of the therapist whose decisions regarding clients greatly affect the viability and success of the therapy group. After initially screening clients for suitability and preparing them for the possibility of group therapy, clinical colleagues refer clients to the group therapist or group therapy program within which the therapist works. Administrative colleagues in clinic or managed care settings provide tangible physical resources that are required of therapy groups and sometimes intangible institutional support for the group or program. Each of these two groups (clients and colleagues) requires preparation and education by the therapist. The better informed that clients are about the objectives and processes of the group, the smoother will be their entry into the group, and the more likely they will attend, work, and remain. The more informed that colleagues are regarding the objectives and processes of the group, the more likely the referrals will be appropriate and the more likely the group will operate smoothly without internal or external interference or disruption. In addition, in institutional settings, advocates or champions of group therapy may need to be developed within the institution to sustain the group therapy enterprise (Burlingame et al., 2002).

Although colleagues of the therapist may be less salient in creating a private practice group compared to creating a therapy group as part of managed care arrangements or a clinic program, they are very much present. While the therapist can and should engage in further client selection and preparation processes after the referral, there are almost always limits to the extent to which he or she can generate additional referrals: Rarely does a single therapist evaluate sufficient initial referrals to supply an entire therapy group with suitable clients. Thus, in most cases, a therapist is dependent on referrals from others.

In contrast to selection and preparation of clients, which have generated considerable published literature, Klein (1983) observed that relatively little had been written about the crucial task of ensuring enough suitable referrals for one’s group(s). This tendency seems to have persisted. It is true of journal articles and to some extent is true of otherwise comprehensive books that address the topic of starting groups.1

Starting Well-Client Referrals. Suitable referrals are the life source of a group. In addition to being required for the beginning of a group, they are frequently required to replace dropouts from therapy groups. Most dropouts, which often involve 30-40% of a therapy group, occur early in the life of a group (Yalom and Leszcz, 2005). Some therapists initially accept several more clients than they regard as an ideal number for a new group in anticipation of several dropouts. It can be argued that a successful therapy group has not really been created until it has experienced, addressed, and successfully weathered one or more initial dropouts.

Friedman (1976) distinguished three types of referrals. Using his terminology, there are legitimate referrals, which are clearly appropriate for the clinical objectives of the group; nonlegitimate referrals, who may or may not be appropriate for the clinical objectives of the group but who clearly were referred for other reasons such as training; and, there are also illegitimate referrals. These illegitimate referrals are usually a product of the referrer’s countertransferential rejection of the client or the therapist’s sense of emergency that new clients be added as quickly as possible after the group has experienced multiple dropouts. Training centers sometimes have a high proportion of nonlegitimate referrals. To decrease the number of inappropriate referrals, Klein (1983) suggested some simple procedures, including a brief telephone conversation between the referrer and the therapist prior to the referral and a brief note from the referrer stating the purpose of the referral.

It is important to note that group therapists may encounter resistance from fellow clinicians making referrals to their groups even with clear and specific their communications with colleagues and prospective group clients. Both professional colleagues and the broader public may have their own apprehensions and skepticism about the usefulness of group approaches. Many colleagues are not well disposed to group therapy, because of their unfamiliarity with it, a negative stereotype they carry about it, a belief they have that it is not really useful (the data notwithstanding), or for some other reason. Group therapists are encouraged to take the long view that over time they will be able to educate some of their colleagues about the efficacy of what they have to offer. They may be accomplished by virtue of the clinical work they do, the presentations they make, and the outcome data they can provide. They may have to accept the fact that they will never be able to overcome the resistance of some colleagues.

The overall objectives of the group, the required processes to attain the objectives, and the recommended roles of the clients and the therapist should be conveyed clearly to all of the parties who are involved in creating a therapy group. A needs assessment regarding target client populations or a formal review of existing groups can be very helpful in suggesting the type of groups that should be developed (Schlosser, 1993). It may suggest important areas that are neglected in the community or clinic. Piper and colleagues (Piper et al, 1992) described how the creation of a new program for clients experiencing complicated grief came about after observing how often the topic of loss came up in short-term therapy groups that were being conducted in the clinic.

Starting group therapy is almost always a very anxiety - provoking experience for the client. Despite reasonable efforts at preparation, many uncertainties remain. Often, due to anxiety or preoccupation, the client is only partially listening to or absorbing verbally conveyed information; thus, there is a need for written materials. For the client, the structure and framework of the group should be crystal clear. This means being informed about such items as the location of the group, the time and day that it meets, the duration of sessions(generally one and a half to two hours), the duration of the group, if time-limited, and the size of the group(generally seven to ten participants). Policies concerning eating or drinking during the group, notifying the group if an absence is anticipated, and leaving the group should also be clear. Clients often have mistaken conceptions about these concrete and essential practical factors. Other policies such as the mechanism for paying the therapist can also be specified in writing and can form part of an initial contract or agreement between client and therapist.

Clients can also benefit from the therapist reviewing expectations concerning therapist behavior in the group. This may range from practical issues such as the placement of chairs and number of chairs in the event of a client’s absence or departure from the group to technical issues concerning therapeutic interventions. As an example, Rutan and Alonso (1999) provide a brief, clear, and useful set of guidelines concerning a psychodynamic orientation to group therapy. Clients pay close attention to the therapist’s behavior, particularly at the beginning of a group. Therapist behavior should be consistent with the client’s expectations and with his or her own. Specifying the therapist guidelines in written form is an easy way to keep them in the forefront. For many current short-term group therapies, therapy manuals are available for this purpose (e.g., McCallum et al, 1995; Piper et al., 1995).

Good record-keeping from the beginning of the referral process to the onset of the group is also an important aspect of creating a successful therapy group. Price and Price (1999) provide useful examples of how to keep track of important referral information such as who provides suitable referrals and who does not, and the attendance of clients at initial pre-group individual sessions as well as at treatment sessions once the group begins.

Starting Well – Administrative Collaboration. In clinic settings, where a variety of groups are available, a program coordinator has been regarded as essential by therapists who have had considerable experience in such settings (Lonergan, 2000; Roller, 1997). Ideally, he or she should be both an effective therapist and an effective administrator. The coordinator serves as a crucial, ongoing communication link between the therapists and the two groups of clients and of colleagues. Involvement with clinical teams that make decisions about the treatment disposition of clients provides excellent opportunities to clarify selection criteria for group therapy. Collaborative planning with senior administrators does much to enhance the profile of the group program and the ability to acquire needed resources. This can include the sometimes not so simple matter of securing a group room of adequate size, with seating that is sufficiently flexible to promote discussion and interaction.

A number of authors have emphasized the desirability of the therapist forming a strong collaborative relationship with administrators (Cox et al, 2000; Lonergan, 2000; Roller, 1997). Similar arguments have been made for the importance of a close working relationship between administrators and therapists in school (Litvak, 1991) and university (Quintana et al., 1991) settings where therapy groups are provided. In the past, this primarily has involved the therapist’s relationship with senior administrators of clinics. In recent years, this also involves the therapist’s relationship with administrators of managed care companies. Among other things, such administrators determine whether treatment sessions qualify for reimbursement. While this additional step further complicates and may delay the initial creation of therapy groups, there is little doubt that a collaborative relationship is essential in developing and sustaining psychotherapy groups.

Roller (1997) and Spitz (1996) provide useful suggestions on building collaborative relationships between clinicians and administrators. Inevitably, it involves clinicians educating themselves about the responsibilities and challenges that administrators face, and, as noted, in some cases establishing and occupying positions such as “group coordinator” within large managed care clinics. For coordinators to have the authority to make important decisions concerning the allocation of resources, they must earn the respect and trust of higher level administrators. This can be established over time and grows out of coordinators or potential coordinators attending meetings where decisions about referrals and about support of group therapy are deliberated. Although this may involve sitting through parts of meetings that are not addressing group therapy issues directly, the investment of time usually proves to be well worth the effort. Creating therapy groups that have the potential to be successful from the perspectives of the clients, therapist, and administrators clearly requires a significant investment of time. By facilitating communication among the various parties, the therapist can increase the likelihood that the potential will be realized.

Footnotes

1. Examples of such books are Price, Hescheles, and Price’s (1999) A Guide to Starting Therapy Groups, which serves as a general guide, and both Roller’s (1997) The Promise of Group Therapy and Spitz’s (1996) Group Psychotherapy and Managed Care, which serve as specific guides to starting groups within managed care systems.

Summary

1. Creating a successful therapy group from the perspectives of clients, therapists, and referral

sources is a complex endeavor.

2. Both clients and referral sources require education by the therapist.

3. Suitable referrals are the life source of a therapy group.

4. Both clients and therapists benefit from specifying important information and guidelines in

writing.

5. A collaborative relationship between therapists and administrators is highly recommended.

6. In institutional settings, a group coordinator can serve many useful functions.

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