Practice Guidelines for Group Psychotherapy

Preparation and Pre-Group Training

           There is a strong consensus in the group therapy literature that pre-group preparation can be profoundly beneficial for prospective members and, consequently, for the group as a whole. (Rutan & Stone, 2001; Burlingame et al., 2002; Yalom & Leszcz, 2005). While there is strong agreement emerging from both expert consensus and research findings that all therapy groups profit from preparation of its members, discrepancy exists regarding how much preparation is ideal, and in what specific ways the group and its members profit from its application (Piper & Ogrodniczuk, 2004).         It is well recognized in all aspects of health care delivery that interventions that increase client compliance with treatment recommendations will increase the success rates of treatment (Sapolsky, 2004). Since all forms of group treatment, regardless of duration (short term or long term), setting (inpatient or outpatient) or theoretical model (cognitive or psychodynamic) report benefits from group preparation (Budman et al., 1996; Rutan & Stone, 2001; MacKenzie, 2001), it is useful to identify the common factors that contribute to this effect. Pre-group preparation represents one aspect of a trans-theoretical approach to psychotherapy, inherent in all forms of group and individual treatment, and research aimed at understanding the change process in psychotherapy (Safran & Muran, 2000). It is widely recognized that a prerequisite for effective treatment consists of three interdependent components of the therapeutic (working) alliance: client and therapist agreement on goals, client and therapist agreement on tasks, and the quality of the bond between client and therapist (Luborsky, 1976; Bordin, 1979; Horvath, 2000). Properly conducted pre-group preparation aims to meet all of these prerequisites (Rutan & Stone, 2001; Burlingame et al., 2002; Yalom & Leszcz, 2005).

Objectives of Preparation. There is a great deal of agreement, both from empirical evidence and expert consensus, on the objectives that should be achieved by the preparation process (Rutan & Stone, 2001, & Burlingame, et al, 2002, Piper & Ogrodniczuk, 2004; Yalom & Leszcz, 2005). These goals fall into four general categories:

• Establish the beginnings of a therapeutic alliance.
• Reduce the initial anxiety and misconceptions about joining a therapy group.
• Provide information and instruction about group therapy to facilitate the client’s ability to provide informed consent.
• Achieve consensus between group leader and group members on the objectives of the therapy.

Establish a therapeutic alliance. A review of  the vast amount of empirical evidence for the positive relationship between the alliance and outcome (Martin et al., 2000) underscores the important role that pre-group preparation plays in the initial establishment of the alliance and subsequent cohesion in group (Rutan & Stone, 2001). The pre-group preparatory meeting not only promotes the initial establishment of the therapeutic alliance between the group leader and prospective group members, it also provides an opportunity for the leader to leverage that relationship into further promoting bonds with the group and other group members (Burlingame et al., 2002). Underscoring scientific support for the robust effectiveness of group therapy is helpful in allaying concerns about group therapy being an economical but second tier therapy. Clarifying expectations of the treatment helps to achieve both patient-therapist agreement and hopefulness (Burlingame et al., 2004).

        The first step in the development of alliances in group is the shared mutual identification that the group members have with the group leader (Yalom & Leszcz, 2005). It is recommended that the group leader take advantage of whatever currency he or she earns while establishing an alliance during the preparation phase and parlay that advantage into promoting cohesion in the group and alliances between group members (Burlingame et al., 2002). Should the preparer and the group leader be the same person? It is not always clear in the research literature if the individual doing the pre-group preparation is also the therapist who will be leading the group. Because empirical research on the therapeutic alliance has demonstrated that the alliance forms relatively early in treatment and is predictive of later therapeutic outcome (Hartley & Strupp, 1983, Horvath, 2000), many sources recommend that the therapist doing the preparation and the therapist leading the group be one and the same (Rutan & Stone, 2001; Yalom & Leszcz, 2005).

Reduce client anxiety. Joining a group is stressful and anxiety inducing (Rutan & Stone, 2001, Yalom & Leszcz, 2005). Consequently, one primary goal of pre-group preparation is to help prospective group members modulate the anxiety that usually accompanies entry into a group, through clarification and demythologizing of the group experience. For other members whose anxiety remains out of their awareness, it is important to help them be more conscious of their anxiety, lest they act out these feelings in group in a counter-therapeutic fashion (Rutan & Stone, 2001). Because anxiety about entering group is universal and intrinsic, it is helpful to eliminate iatrogenically induced extrinsic anxiety caused by the lack of clarity about goals, tasks, roles, or the direction of the group (Yalom & Leszcz, 2005).

Provide information. A succinct, simple set of instructions about how group therapy works furnishes a conceptual framework for understanding the roles that the group leader and group members are expected to fulfill. Information is geared towards correcting misconceptions and promoting group development by identifying common stumbling blocks, and mitigating unrealistic expectations about group treatment. Key aspects of appropriate group participation, including self-disclosure, interpersonal feedback, confidentiality, extra-group contact and the parameters of termination, are all defined (Yalom & Leszcz, 2005). Requisite norms for effective group therapy can be described, including issues such as attendance, punctuality, attending group under the influence of substances, sub-grouping, and socializing with other group members between group sessions (Burlingame et al., 2006).  Special attention needs to be paid to encourage confidentiality in group and the protection of each member’s anonymity (Salvendy, 1993; Rutan & Stone, 2001). The limits of confidentiality in group therapy, relative to individual therapy, must be carefully discussed.  Co-members are not legally bound to preserve as confidential the personal information disclosed in the group. Agreement should also be reached regarding the transmission and exchange of information between collaborating therapists in concurrent therapies or for the provision of monitoring medications (Leszcz, 1998).

Consensus on goals. Pre-group preparation provides an opportunity to obtain patients’ informed consent and commitment--sometimes written, but usually verbal— for regular attendance, fees, and participation in group for an agreed upon purpose and period of time (Beahrs & Gutheil, 2001).   The patient’s interpersonal patterns can be identified through careful examination of the interactional processes that occur in the here-and-now of the preparation meeting.  This not only helps to provide clarity about the patient’s goals, it can also prepare the patient experientially for the therapy group’s focus on learning though interpersonal interactions (Yalom & Leszcz, 2005). Attempts can be made to predict the patient’s experience in group and assess the impact, both positively and negatively, that the prospective member may have on the group (Salvendy, 1993). 

Methods and Procedures. While there is much agreement on the goals of pre-group preparation, there is much diversity in methods recommended for achieving those goals (Burlingame et al., 2002; Piper & Perrault, 1989).

• The number of sessions and times can vary, ranging from one session lasting an hour or less to four meetings (Piper & Perrrault, 1989).

• The settings in which preparation is done can also vary from meeting with clients one at a time or with two or more prospective group members in an actual pre-group preparation group (Yalom & Leszcz, 2005).

• Information is usually delivered across a spectrum from passive to more active or interactive formats with behavioral, cognitive, and experiential components (Burlingame, et al, 2006).  Combinations of four general methods can be identified: (1) written, (2) verbal, (3) audiovisual, and (4) experiential (Piper & Perrault, 1989).

• Passive procedures usually rely on instructions, delivery of cognitive information related to a model or example, and opportunities for vicarious learning through observation (Rutan & Stone, 2001).

• Active and interactive procedures rely more heavily on behavioral rehearsal and experiential components in which members are provided a brief, structured therapy like experience, role play or watch and discuss a video of group therapy (Piper & Perrault, 1989).

• Adaptations in procedures and special consideration for neophytes to group and new members joining an ongoing group are recommended (Salvendy, 1993, Yalom & Leszcz, 2005).  These may include orienting the incoming member to the current issues that the group is addressing.

• Adapting preparation to be culturally attuned to the client may be another important consideration (Laroche & Maxie, 2003).

• A combination of active and passive methods produces the most effective results (Leszcz and Yalom, 2005).

Impact and Benefit. While there is evidence that pre-group preparation strongly enhances some factors of treatment; there are also indications that other factors will be only mildly impacted, and other factors will demonstrate little or no effect.

Strong Effects. The strongest empirical evidence for the benefit of pre-group preparation concerns retention and attendance (Piper & Perrault, 1989). Evidence exists that pre-group preparation is related to more rapid development of group cohesion, less deviation from tasks and goals of group, increased attendance, less attrition, reduced anxiety, better understanding of objectives, roles and behavior, and increased faith in group as an effective mode of treatment (Burlingame et al, 2006). Evidence also exists suggesting client attraction to the group improves retention (Burlingame et al, 2002).

Mixed Effects.  Improved therapy process (interpersonal openness, more self-disclosure), increased cohesion, improved working alliance, and more exploratory behavior are generally supported by the research evidence. Pre-group preparation appears to be dose related:  more preparation sessions with experiential and emotional intensity are more likely to produce a positive impact (Yalom & Leszcz, 2005). Pre-group preparation has been linked to the beneficial effects of early leader-initiated group structure, which in turn has been demonstrated to predict other facilitative group processes and beneficial outcome (Burlingame, 2002).

Minimal Effects. While preparation will ensure the prospective group member will be more likely to stay in the group longer in order to be able to derive benefit from treatment, preparation in itself has not been found to greatly impact outcome greatly. The low relation between preparation and outcome can be explained by a number of factors.  Regular participation is a necessary ingredient of a successful outcome but it is insufficient in itself. A distant singular event such as a one or two time preparatory meeting will lose its potency over time. Over the course of treatment, other more influential variables (group membership composition, skills of the group leader, cohesion, and match between member characteristics and treatment) will have greater impact and consequently, a much more persuasive influence on treatment outcome. Even without compelling evidence in all domains, there is clear consensus that the relatively small resource expended in pre-group preparation is certainly worth the investment of time (Piper and Ogrodniczuk, 2001).

Summary

1.     Both empirical research and expert consensus endorse the value of pre-group preparation.

2.     Effective preparation exerts its effects through enhancing the therapeutic alliance.

3.     Effective preparation will modulate client anxiety and provide information that enables the client

to provide informed consent.

4.     Effective preparation promotes agreement between the therapist and prospective group

member on the goals and tasks of group therapy.

5.     Methods of preparation range from passive to active and from educational to experiential.

6.     Clients who are well prepared for group therapy are significantly more likely to participate

meaningfully, comply with treatment and are much less likely to stop therapy prematurely.

Return to Table of Contents
 

©2007 American Group Psychotherapy Association