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
Reduce the initial anxiety
and misconceptions about joining a therapy group.
Provide information and
instruction about group therapy to facilitate the clientís ability to provide
Achieve consensus between
group leader and group members on the objectives of the therapy.
Establish a therapeutic
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
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 &
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,
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 memberís 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 patientsí informed
consent and commitment--sometimes written, but usually verbaló for regular
attendance, fees, and participation in group for an agreed upon purpose and
period of time (Beahrs & Gutheil, 2001). The patientís 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 patientís goals, it can also prepare the patient
experientially for the therapy groupís focus on learning though interpersonal
interactions (Yalom & Leszcz, 2005). Attempts can be made to predict the
patientís 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 &
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 &
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 &
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
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.
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).
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).
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.
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Group Psychotherapy Association