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Nuts and Bolts of Group Psychotherapy
By Marvin N. Kaphan, Licensed Clinical Social Worker
Presented at a GPASC workshop on January 11, 2004
About the time I began my full time private practice in 1960, I began to explore the use of group psychotherapy. The results were so exciting that I made group a part of my work with almost every patient. I soon had six groups running (which seems to be the maximum I can fit into my schedule). I used the groups as an adjunct to my individual psychodynamic psychotherapy practice, starting them with patients from my individual practice who were ready to use groups, then gradually reducing the individual sessions as the patients began group. This had several advantages. I knew the patients very well before I placed them in the groups. The patients saw it as a sign of progress. Since a group was charged at less than half the cost of an individual session, going from weekly to biweekly individual sessions when starting group, saved my patients money while increasing my income, but the most important effects were therapeutic. I'll talk more about the therapeutic benefits in a few moments.
The groups themselves are all open-end, heterogeneous psychodynamic groups. They tend to contain a mixture of older men, older women, younger men, and younger women, much like a typical family. Even though on paper the groups sound similar, each has developed a unique personality. Over the years, old patients left and new patients entered, but the character of each of the groups has remained the same to this very day.
In structuring psychotherapy groups, the single most important element is safety. If patients are to be encouraged to be open and vulnerable in the group, they must be sure that nothing they say or do in the group can impact jobs, marriages or friendships in their outside life. It is, therefore, the therapist's responsibility to ensure that no one is put in a group with anyone who is in contact with the patient's outside world, and to obtain a commitment from each new patient never to divulge identifying information about anyone in the group.
I also obtain a commitment that if patients are considering leaving the group, they must give the group a month's notice and try to use that month to focus attention on themselves, and what has led them to the decision that this is the time to leave. I also urge patients not to have contact with each other outside the group. If they meet accidentally, they are expected to report on the contact in detail in the next group.
Obviously, outside contact can establish an outside relationship, which can then affect the functioning of the group. One member of the group may be privy to information that is not shared with the group, there may be a subgroup set up which can create unconscious alliances ("I won't challenge you and you won't challenge meh), it may be easier to avoid letting out a burning secret to the group, if you can let it out in private to one person, and because of transferences, people in the group can become symbols to each other that might foster acting out outside the group.
Occasionally, over the years, some patients have broken this agreement. Almost always, one or both leave the group soon after. When patients challenge this agreement, there are usually some long time members who can attest to the damage they have seen done by such violations.
There are some groups where outside contact seems to work out well. For example, in support groups where one of the goals of the group is the development of support networks rather than exposure and vulnerability, patients are not running risks, and outside contact helps achieve group goals, but I have never seen it work out well in my groups.
There is extensive agreement that one of the most important considerations in placing a patient in a group is finding the right group for each particular patient, but very little helpful advice on how to do it. There are patients who are obviously unsuited for the usual psychotherapy group --- those who are too disturbed or dangerous to function in the group --- but there is disagreement beyond that. My approach is to go through a process of fantasy, picturing how this patient will affect each of the other members of the group, how each of them will affect this patient, and what effect this placement will have on the functioning of the group as a whole. A member of GPASC, Dr. Irene Harwood, has devised a more rigorous method that may help. She will be giving a presentation on that method later this year.
As my reputation as a group therapist grew, colleagues who didn't have groups would send me their patients who could benefit from group therapy. It turns out that group therapy supplements individual therapy very well, even if the two treatment modalities are administered by different therapists. This configuration requires close coordination between the two therapists and a series of individual interviews with the prospective group member until I know the patient well enough to make a group placement with sufficient confidence.
I give two instructions to a patient who is about to join a group:
- First, try to say everything that goes through your mind, without waiting your turn, without following the usual rules of politeness, and without worrying about whether anyone else wants to hear it.
- Second, remember that what goes on in the group is in large part up to you. So, every moment you're in the group, think about what would make the group more satisfying, more fun, more valuable to you, and make those things happen.
The group, therefore, becomes a microcosm of the outside world, where patients can practice taking charge of their lives. When they are successful, the group quickly becomes a very pleasurable, humorous and satisfying place.
One of the most exciting and unique aspects of group is the almost magical quality we call group process --- whereby a group of individuals is transformed, within the safe and loving environment created by the therapist, into something more than the sum of its parts. As the patients begin to accept and test that safety, they begin to take more chances and expose more about themselves that they had kept hidden from the world. They soon learn that letting down the defenses tends to be rewarded with love and acceptance. This leads to joy and satisfaction in the group. At the same time the patients are using the group to practice getting what they want from the world. Gradually the members begin to look forward to the group as the high point of their week. It is then only a matter of time until they decide that they are not willing to limit this experience to a mere ninety minutes a week, and they begin to take more chances in their everyday lives. By serving as a microcosm of the larger world, the group alters and improves its members daily functioning.
The group also serves a diagnostic function. Much of the material discussed in individual sessions, with the exception of patient-therapist interactions, deals with emotional situations which have taken place at some other time and place. Whether these are in the current week or long past, they are all historical accounts with some degree of the emotion buried. Moreover, human beings are notoriously bad reporters, especially if the reporter is emotionally involved in the scene being described. The group, on the other hand, can become a veritable emotion laboratory. If the members of a group are selected carefully, they can easily become symbols to one another. When emotions are displayed, the therapist and the entire group have an opportunity to observe them in real time. If one patient says, "blue", and another says, "that makes me angry", we have the chance to examine this process while it's happening, and to discover why.
Another important function of the group is educational. The environment of the group, and the experience of members who have been in the group for a longer time, tends to acculturate the new member and encourage increased psychological sophistication. In addition, since it is always easier to see through someone else's psychodynamics than our own, the group becomes a class in psychodynamics.
The patient is also exposed to increased opportunities for insight. A psychotherapist must always err on the side of caution. If, in an individual session, the therapist presents the patient with an interpretation he can't handle, the patient has very little defense. Since he has chosen the therapist because of his expertise, comes to his appointments, and pays his fees, it is difficult to insist that the therapist doesn't know what he's talking about. The group has no such limitation on it's interpretations, and since the group members soon become quite good at interpreting each other's behavior, they can come much closer to the edge of what the patient can handle. If they do present the patient with something too difficult, he can always say, "what do they know, they're only patients like me". Sometimes it is true that group interpretations are way off the mark, but this is extremely rare, and even if the patient does reject an interpretation, he has heard it and can recall it when he's ready. The net result is that patients progress much more rapidly in group psychotherapy with occasional individual sessions, than with individual sessions alone.
Finally, let me return to economics. We are all faced with patients we are treating who can no longer afford weekly individual sessions. This is especially true in this age of financial upheaval. I am not willing to abandon a patient in the midst of treatment simply because of money, but my income depends upon my receiving payment for my individual hours. Even if I am willing to reduce an individual fee or defer payment for one or two patients, I certainly can't afford to do this for many. On the other hand, if I add a patient to an existing group at a reduced fee, it costs me nothing, since my time would be taken with the group anyway. As a matter of fact, if I have three patients paying full fee in the group, I am already earning as much as I would with individual hours, and every additional patient, no matter how limited the fee, adds to my income.
In view of all these advantages, the unique benefits of the group in speeding treatment, in making long term treatment possible with reduced cost, in making it possible to continue to treat patients who are in financial straits, and the financial advantages to the therapist, I am altogether amazed to hear some colleagues doubt the future of group psychotherapy. If we are to enter a time when we attempt to offer treatment to everyone in the American population who needs it, I can imagine no other practical and effective solution.
Marvin N. Kaphan, MSW
(LCS 181) and (MFT 717)
Diplomate, American Board of
Examiners in Clinical Social Work
12520 Magnolia Boulevard, Suite 210
Valley Village, CA 91607
Fax: (310) 454-0700
Tel: (818) 766 - 9540
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