Beyond Group Works
Steven Cadwell, PhD, CGP

I have been leading psychodynamic therapy groups for the past 15 years. As a tool to orient clients to group, I have developed an introduction to group therapy that I give to a prospective member after our first screening session. We then discuss it at our subsequent screening sessions. Over the years, this introduction has expanded from a few paragraphs about our agreements to an explanation of my philosophy to its current form, which includes information about how group therapy works.

Group therapy is a big commitment. Clients have a right to be informed about what they are joining. While the AGPA brochure ??Group Works!?? offers an excellent introduction to the potential group therapy consumer, I wanted to develop something that was more detailed and reflected my particular style.

Why include an introduction?

1. To correct misinformation. Many clients have misguided impressions from television sitcoms, movies, and books. I wanted to let them know what I offer.
2. To clarify expectations. The introduction delineates the techniques and expectations of a psychodynamic psychotherapy group compared to a support group, a cognitive-behavioral group, or psychoeducational group.
3. To promote my work. Clients are empowered consumers. I'm often one therapist on a shopping list of many. This introduction helps my clients be more informed about what they are getting if they choose me.
4. It's a great screening device. If clients "get" it, there's a fit. If they waver, I can assess whether they really can use a psychodynamic group.
5. It promotes early trust and alliance. It encourages a positive therapist-client collaboration before the full transference heats up. Joining a group is a leap of faith like any relationship and it's wise to have some sense of what to expect.
6. It jumpstarts the work. It starts us off on firmer footing. For example, naming the technique of the "here and now" makes members more aware and sometimes less resistant when I try to bring the group to the interaction in the room.
7. It prepares members for the hard work. Anticipating some of the bumps and describing them as both normal and beneficial helps when the work becomes uncomfortable. Also, the frame helps us sort out when the group isn't working. It allows us to push through an enactment or stop the action because the group is not healing; it's hurting.

I expanded the introduction a year ago when a group was caught in a negative transferential enactment. Two members left, which broke the logjam. For those who stayed, I wanted to be clear about the work we were doing. They were enormously relieved. I decided to use this new-expanded version with all my groups, and I found that the process in the other groups was also enhanced.

Not all members absorb all of what I've written. Some people aren't interested in reading instructions to operate anything! But when something breaks, it is useful to refer back to the owner's manual. I actively refer back to it, and some members actively bring up dimensions of it. However, user beware! Members challenge me to deliver what I've promised!

Following is a copy of a brochure, “An Introduction to Psychodynamic Group Psychotherapy,” which I developed to use with clients.

The following is an introduction to group therapy. I'm hoping it will help you understand how the group works. As with any manual, you will learn much more in the experience of actually participating than reading about it! Group psychotherapy can be a tool to better understand the conflicts in your life. Even more, it will help you to see better ways of moving beyond those conflicts in your interactions with others.

My approach to group psychotherapy utilizes the interpersonal model which assumes that each person develops his individual personality through interactions with others. In group therapy, you learn through interactions with other members as you receive feedback from others about yours and their impact on one another and on the group as a whole.

I draw upon psychodynamic theory to understand personality development. In this perspective, I seek to help my patients identify roles and patterns first learned in our families of origin and early peer groups, and later replayed in our lives more or less consciously. These roles will naturally recur in the therapy group and you will have an opportunity in the group to learn more about them and to experiment with new ones. Each participant in the group has committed to offer honest, responsible feedback and use others' feedback to uncover old ineffective patterns and learn new effective ways of relating. This process is also a way to learn to appreciate your strengths and resilience.

In other words, the group's purpose is to help you know yourself better and to help group members know themselves better. As such, the group becomes a "laboratory"—a chance to learn more about your patterns of relating: how you get close to others and how you push others away and what triggers your feelings and how you get stuck. Our membership agreements are designed to facilitate that work, and become the "vows" of our relationship, if you will. When honored, they lead to a growing trust around intimacy; when broken, that level of trust is shaken, and the effectiveness of the group is stalled for a while. At the same time, the broken agreement offers us a chance to understand the feelings that led up to it and followed it.

Confidentiality: 
To make the group a safe place to share personal information and to protect the privacy of members, each member agrees to keep names or identifying information about other group members to themselves. What happens in group stays in group.

Boundaries: 
Group members agree not to socialize with each other outside group. By keeping the relationships inside the group, you are creating a "safe container" in which everyone is on the same page. By keeping the relationships therapeutic and not social, you have a unique opportunity to explore topics such as sex and money, which are often taboo in ordinary social relationships.

This therapy group is an ongoing group. All members make a minimum of a year commitment. When you consider leaving the group, it's advisable to share your decision process with the group. This process helps others understand you better and will help you understand yourself better. Sometimes when people express the wish to leave, it is the right time to leave. At other times, especially when confronting a challenging moment in the group, you may feel the urge to leave quickly which would relieve your anxiety but would undermine an important opportunity to work. Enlisting the perspective of others can help you sort this out. Ideally, the group will come to some consensus about whether this is a good time for you to leave. If you are leaving, it's helpful if you give the group several weeks notice in order to have an opportunity to say goodbye and bring the relationships to as much closure as possible.

Time: 
The group begins and ends on time. If you are late or sick, please call. All members appreciate knowing in advance if you will miss a session.

Fee:
The group fee is $__ per session, whether you attend a particular meeting or not, similar to a tuition for a class, or rent on an apartment. I will bill on the last meeting of the month and expect payment by the 20th of the next month. I will give the group ample notice of any change in the fee. As with all topics pertaining to group business, you agree to explore payment problems in the group.

How the group works: 
You'll discover many ways that group therapy can be helpful to you. You can find support from the other group members and offer support to them. You can practice communicating, recognize the universality of your experience, break out of your isolation, and learn to trust. All these healing aspects of group will be yours for the taking—the more you engage with the group. These aspects of our work are supportive.

In addition, there are some techniques, which I'll use to heighten our ability to do therapeutic work together. These techniques are useful in intensifying our engagement and identifying patterns, which have interfered with your ability to relate elsewhere. The techniques include: "using the here and now," practicing reactive and reflective communication, confronting broken agreements, assessing safety, making connections to childhood experience, and exploring the whole group's development.

Using the Group Relationships in the "Here and Now:"
Each group member decides for himself if he needs time. Although there are no rigid rules about what's okay to share, often the most change-enhancing work comes out of your ability to stay in the present with feelings about your experience of what's happening inside the group. The group's focus includes relationships, intimacy, sexuality, self-image, shame, grief, loss, aspirations and victories. All these topics will have meaning within the relationships in the group in the "here and now." Equally important to you may be discussing a recent encounter with a family member, a problem on your job, a realization about yourself, or a question that's been on your mind from the previous group's session. Feel free to bring them up. As your group therapist, I will bridge these experiences back to what is happening within the room. Examining dynamics right in front of us increases your awareness and adds meaning to your life outside the group. We can then explore how your dynamics originated in your earliest relationships in your family.

Communication:
As in any important relationship, relationships within the group are a balance between spontaneous reaction and more thoughtful reflection. You can practice both reaction and reflection and you can work at finding a healthy balance of both modes in your relationships in the group.

You can practice spontaneity and honesty; a reactive mode. You can go with your gut feeling, owning your own reaction as valid and worth expressing and understanding. A useful way to own your reaction is by saying, for example: "I'm feeling ____ in reaction to your saying ____," or "When you do____, I feel ____." You may not feel ready or wish to share each feeling but you will gain more from the group by taking risks and being responsible and honest about expressing your own experience. Expressing your feeling is different from acting on your feeling.

You also can practice reflecting on your feelings and impulses. "What feelings are being triggered in me? Are my feelings familiar? When have I felt this way before? What are my dynamics here? What am I repeating in this? Which of my buttons is getting pushed? Why now? Is it me or is it him? Is it the group?

Leader's role:
One of my main jobs will be to address places where the agreements don't hold a member's feelings safely enough. For example, members agree to put feelings into words not action. If a member is late, misses sessions, or forgets to pay his bill, I'll explore what feelings are expressed in action (i.e. the act of tardiness, absence, or nonpayment) not in words. I'll enlist the group to help us all understand what the action means for the member and for the whole group. For example, if a member is late, is he feeling anxious and avoiding what's been happening in the group? Or is he feeling inadequate and sacrificing his time because he feels unworthy of full membership? Is the group feeling competitive and colluding with his low self-regard by ignoring his tardiness? By keeping to our agreement to put feelings into words, we get back to the goal of knowing feelings and connecting with each other and increasing the climate of safety.

Safety doesn't mean a guarantee of pain-free experience. Rather, the safety in the group is based in trust that your feelings will be respected. If you do feel dismissed or injured, you have a right to be heard and we'll work to understand the source of your injury. In this way, despite the pain and injury, you will have a corrective experience. You learn that rather than using old ways of avoiding engagement to avert old pain, you can risk engagement and be less vulnerable. Rather than retreat to protected isolation, members can find deeper connection and interdependence. The whole group deepens and grows through this process.

I will have different ways of understanding what happens in our interaction. I will offer my perspective as a way to make unconscious patterns of thinking and acting more conscious. With awareness, comes freedom to change rigid patterns. Let me describe two of the ways:

I'll listen. I will pursue how members' words and actions are suggestive of dynamics from their childhood experience. For example, a member makes jokes and distracts the group whenever conflict occurs between members. With the help of our inquiry, he identifies he is afraid of conflict in the group because his father was intolerant, explosive and physically abusive. For this member to fight and confront in the group stirs up fear of physical and emotional injury. Now aware of this pattern, he is able to manage conflict in a new constructive, engaging way.

I will also identify dynamics in the whole group's development. For example, the group may be coalescing and becoming more intimate—or it may be fracturing and resisting out of fear or anxiety or competition. Often members have never had the experience of being a member in any group. This perspective can help you find your way as a part of the whole group.
I will not be the only one with useful perspective and insight. Each member's perspective is valid and adds to our enriched understanding of relationships. I will affirm the importance of our diverse perspectives.

One final thought:
I am open to hearing your concerns at any time within our sessions. You may feel a need to talk to me between sessions. If you are in crisis, I'm an additional resource to you. I'll encourage you to bring your concerns back to the group.

Welcome to the group!

I wish to thank my colleague, James Fishman, MSW, CGP, and my consultation group—Anne Alonso, PhD, CGP, DFAGPA; Robert Haas, MSW, CGP; David Griffiths, EdD, CGP; and Joyce Collier, MSW—for their ideas and support in this project. I also have been influenced by my experiences at AGPA and NSGP Institutes.

This article was published in the December 2002/January 2003 issue of The Group Circle.