Therapy in the Round

This article first appeared in the November/December 2010 issue.

Q: I’d like to learn more about therapy groups. Can you explain their therapeutic value and what skills are required to run them that are different from those of an individual therapist?

A: After many years as a group therapist, the main distinction I see between individual and group work is that clients tend to talk about relationship problems in individual therapy, whereas they inevitably exhibit them in group therapy. In a group context, a therapist can more easily and directly see what goes wrong interpersonally for a given client. In the presence of others, clients may exhibit isolating patterns, become self-protective, or engage in off-putting behaviors, all too often without even being aware of them.

Dave was a pleasant young man who came to see me for depression and social isolation. He’d suffered several important losses—his wife divorced him and then he lost his job—and was stuck in a stressful family situation of caring for a chronically ill relative. Through individual treatment, he grieved for his losses, and his mood improved; however, he couldn’t seem to develop social relationships, and he remained lonely. Friendships seemed to begin well, but never deepen. Neither he nor I was sure why, as he was bright and, when encouraged, a warm, forthcoming person.

After he joined a group that I lead, however, I began to understand what was holding him back. When other group members candidly shared their thoughts and feelings, he responded with agreeable, but entirely impersonal replies. He shifted the conversation away from any emotional engagement, making the others feel unheard and unacknowledged. For instance, he might respond to a member’s painful story with “I bet things will work out in the end,” or pick up on the least emotional aspect of a situation and inquire further about that.

When I shared this observation, using specific examples from group sessions, he was dumbfounded. His deflecting style was completely automatic behavior, developed years before to protect himself from intrusive and prying parents. But once he recognized it and acknowledged the old, lingering anxieties that he circumvented by not revealing anything about himself, he began to connect more directly with other group members and people outside the group.

Group therapy is a highly effective laboratory in which to practice new behavior and get honest feedback from others. The woman who consistently tells her individual therapist that she never gets her needs met in relationships may discover in group that she behaves in ways that inevitably make sure that others overlook her. The group members will let her know that if she doesn’t speak up, she will be overlooked. Members will ask where she learned how to be overlooked, and will encourage her to take the risk of asking for attention. The “nice guy” who’s always afraid of offending someone can express irritation with another group member and learn that the world hasn’t ended, and that he’s still accepted by the group.

In an effective therapy group, the majority of the work takes place in the room: although members talk about their lives “outside,” the real action is the moment-by-moment back-and-forth among group members. The group leader’s role is to help participants give constructive and honest feedback to each other—sometimes called the “hall of mirrors”—and avoid giving criticism or advice.

Because a well-run group offers a safe, contained space, it can help members try out new behaviors or ways of interacting that they wouldn’t attempt elsewhere. A large part of the leader’s role is to encourage members to try out new behaviors and responses. One group member, Susan, was the daughter of an unpredictable and intrusive mother. She’d learned to protect herself by always being in control, to the point that, in the group, she assigned herself the task of monitoring the process and drawing in silent members, as if she didn’t trust me to be the group leader. In one session, I invited her to experiment with allowing herself to let me be the one in charge. After stepping back during the session, she reported that she was amazed at the level of anxiety she experienced, and the strength of her long-buried yearning to allow herself to depend on someone else. She later said that she felt safer letting me be in control in group than in an individual session, because of the perceived protection of the other “siblings.”

In fact, although prospective members often imagine that the presence of the other members makes group therapy more anxiety-provoking, the opposite is often true. The group can actually support an individual member, especially when there’s a conflict or another issue with the group leader.

I once made a mistake in tallying the bill of a meek, superego-burdened group member. Raised by harsh, perfectionist parents, she’d never before stood up to authority. But with the encouragement of her fellow group members, she was able to tell me that the mistake had made her mad, and that she doubted my competence as a result of my error. She wouldn’t have dared stand up to me in a one-on-one session, but the group support gave her courage.

For group therapy to be effective, any new members should be up to the level of the group. A person who can’t describe what he’s feeling and experiences only body sensations won’t do well with group members who are more fluent in speaking about their emotions, but this same person might do well among people who have difficulty articulating their feelings. The basic requirement of membership in a group is that the client must be able to uphold the particular group agreement or contract, which typically covers attendance requirements, payment, confidentiality, limits on outside contact with group members, termination procedures, and the role of the leader.

Today, there are many varieties of group therapy, including standard interpersonal or psychodynamic therapy groups; open-term or time-limited groups; and CBT, psychodrama, and DBT groups. There are groups for specific populations or themes: men, women, gay, eating-disordered, first-break psychosis, medical illness, social anxiety, mind-body, and, of course, addictions. Naturally there are now cybergroups that make a group experience possible for people living in isolated places.

Groups have many healing qualities, but one of the most important is the basic human support they provide—giving a sense of belonging and group cohesion, factors that are increasingly scarce in our fragmented society. One client, reflecting on what he’d gained from the group as he was terminating therapy, said that what he found hardest to leave was the sense of being part of something—the feeling that the group was always there for him in a basic way. “My life is so much better, and I am so grateful,” he said, “but I’ll just plain miss being here with you guys every Tuesday evening!”

So why isn’t group therapy a more widely used treatment? For one thing, many insurance policies will pay for only a fixed number of visits, so group members who want to continue past the allotted 10 or 20 sessions must pay out of pocket for much of the year. This is a false economy on the part of the insurance companies. Since group sessions are so much less expensive than individual sessions, the reimbursement for a dozen private sessions would pay for the better part of a year of group sessions.

Another issue is client resistance to joining a group. Some clients are afraid they’ll get less attention from the therapist in a group—”I don’t want to share my therapist” is a common refrain. Other reactions include “How can a group of people with problems help me?” or “I can’t imagine telling my problems to strangers” or “What if I don’t like the group—or the group doesn’t like me?”

These concerns are legitimate. It can be scary joining a bunch of strangers, with whom intimate personal stories will be shared, and sometimes it doesn’t work out. I’ve never had a client who didn’t like at least one person in a group, although I’ve had clients who came to feel they weren’t in the right group.

What skills does a good group leader need? One of the most important is the ability to do mental multitasking. You’ll usually be thinking on at least four levels at once: about the individual members, the interpersonal interactions, the group as a whole, and your own internal reactions. Some therapists are not good at this, preferring the more intense focus of individual treatment.

Other clinicians dislike the exposure involved in leading a group. In fact, it is more uncomfortable to make a mistake in front of six or eight of your clients than to make one in the relative privacy of an individual session. I was genuinely embarrassed when I made the billing error with my client. While I knew that what my client did was therapeutic for her, it still stung me, all the more so because it happened in front of an audience—one that was pleased to see me brought down a peg, I might add.

Clinicians without a substantial referral base may find it too difficult to keep their groups filled. It’s demoralizing to have a group dwindle down to two or three members. Some clinicians have formed group-therapy networks to solve this problem, marketing the network and referring to each other’s groups. Involvement in local and national group-therapy associations can help keep group referrals coming too.

Should you just start a group yourself? Definitely not without specific training! The American Group Psychotherapy Association (www.agpa.org) has developed guidelines
for becoming a Certified Group Psychotherapist (CGP), and the parent group and its local affiliates offer many fine training opportunities.

Group therapy can be an excellent treatment for most clients. It’s cost-effective, and in many ways a better mirror of “real life” than individual therapy. Whatever happens in group, you’ll never be bored.