Practice Guidelines for Group Psychotherapy
Creating Successful Therapy Groups
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
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
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
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
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.
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.
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
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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Group Psychotherapy Association