Current Trends in Group Psychotherapy Practice
Hylene Dublin, MSW, CGP, FAGPA

This is an era of rapidly accelerating change in factors affecting clinical practice. It is important to consider how these factors are influencing the utilization of group psychotherapy throughout the country. This article is an attempt at a “state of the union” examination of developing group trends. Toward this end, several representative and highly visible individuals within AGPA have candidly shared their views of new and emerging trends within their locales. Greg Crosby, MA, CGP, of Oregon, Hillel Swiller, MD, CGP, FAGPA, of New York, David Hescheles, PsyD, CGP, FAGPA, of Long Island, Nanine Ewing, PhD, CGP, of Houston, and Darryl Pure, PhD, CGP, FAGPA, of Chicago have provided their perspectives on where group treatment is now and where it appears to be going. Readers might find it intriguing to contemplate how potentially locale-related these varying points of view are.

Ethnicity-based groups
Greg Crosby, a Licensed Professional Counselor and clinical member of AGPA, is Clinical Group Coordinator for the Kaiser Permanente Northwest region, covering Oregon and southwest Washington. In this capacity, he oversees 40 psychotherapy groups and 60 psychoeducational groups. Crosby was brought in to revamp Kaiser’s group treatment program in 1987, which at that time had an open-ended, mixed membership orientation but was having trouble keeping sufficient members in its groups. In addition, Kaiser wanted to begin time-managed groups, which Crosby sees as more relevant to patients’ needs than time-limited groups. In the time-managed approach, the patient is managed through time without specifically limiting the number of sessions allowed at the outset. While there is a limit on the number of sessions allowed in the Kaiser system, it is much more liberal than most (40 per year), which allows for more flexibility in tailoring a treatment regimen to a patient’s particular needs which is better than most managed care systems afford.

Part of the difficulty within the group program as it existed in 1987, Crosby determined, was the absence of sufficient screening/preparatory work, a factor frequently seen in larger clinical programs, where individuals are often shunted quickly into groups. Much of Crosby’s current effort focuses on teaching clinicians how to facilitate the entry process.
Another underlying factor in poor group attendance at Kaiser and elsewhere is that, with the recent emphasis on structured groups focusing on content, the therapeutic bond is often neglected. This results in a lack of a sense of connection and, eventually, inconsistent attendance. Crosby describes himself as having a “political mission” to alter this oversight in approaching his role as consultant to Kaiser’s group programs. He believes that cohesion is a factor to be addressed in psychoeducational, as well as psychotherapy groups, and laments the polarization of two group camps—one attending to process and group interaction and the other focusing on cognitive behavioral change and educational content. In fact, Crosby’s view is that the cutting edge group practitioner is blending a topical theme group focus with attention to group cohesion and interaction. Crosby sees psychoeducational groups as vehicles that may result in recruiting participants into group psychotherapy at some subsequent point.

Not neglecting the growing emphasis on structured homogeneous, Crosby construes themes as a specific group element that facilitates feelings of universality. He underscores the proliferation of focal diagnostic theme groups such as groups for panic disorder, depression, and such medical foci as migraine and tension headache groups, chronic pain management groups, and cardiac, asthma and diabetes treatment groups.

On the West Coast in particular, Crosby describes some new variations on the structured theme group, which are growing in popularity: ethnicity-based groups. These include such specifics as “black women’s anger” groups, multi-family parenting groups, cognitive behavioral depression groups for specific ethnic groups, integrated child and family group therapy, ADHD groups for parents and children, and a newly evolving focus on addressing childhood rage in a psychoeducational context. What also seems clear is that the boundary between an educational and therapeutic experience is more porous, with groups beginning with an educational or theme focus often evolving into a broader psychotherapeutic endeavor.

Cognitive behavioral and time-limited groups
Hillel Swiller, secretary of AGPA and director of the Division of Psychotherapy at Mount Sinai School of Medicine in New York, approaches the question of group trends by examining the group training/treatment focus in the residency training program in his setting, which focuses on group treatment more than most. All PGY III’s at Mount Sinai are invited to participate in a process group which extends for 20 weeks and are encouraged to have a group co-leadership experience for a minimum of one year. However, as in most residency training programs, there is a general de-emphasis on psychotherapeutic training and a greater focus on neurobiology and psychopharmacology. Swiller does see some increased interest in groups on the part of the Mount Sinai faculty and does get good attendance at the course on group therapy he teaches each year at the American Psychiatric Association’s Annual Meeting.

Swiller also identifies greater interest in thematic groups that focus on such matters as PTSD, the Holocaust, sexual abuse, separation/divorce, as well as medical illnesses. There is more emphasis on cognitive behavioral and time-limited groups though he, like Crosby, notes more of an effort recently to combine a task focus with attention to process. He also points out that a number of training programs that focus, at least in part, on psychodynamic group treatment continue to thrive in the New York area, including EGPS’s one-year training program.

Psychoeducational groups for the less affluent
David Hescheles provides an interesting perspective from his vantage point as director of Brick Kiln Provider Network, Inc., a management service organization utilizing the services of 325 clinicians in a four-county area. These practitioners function autonomously (as independent contractors), and Brick Kiln provides billing, marketing, credentialing, and contracting services with insurance companies and managed care organizations.

The organization handles 500 to 600 intakes per month and does little or nothing regarding the provision of group treatment. Hescheles believes that economic factors prevent clinicians from having any interest in offering group services. With limits from six to 12 sessions and extremely low fees for group, he believes the headaches and increased paperwork required make this modality of little interest to most practitioners. Brick Kiln’s contract with Value Behavioral Health (VBH), for example, recently dropped the group fee from $50 to $35. Managed care, in his view, encourages more of a case management focus and supports at best only focused, time-limited groups. There is no recognition that fluid, easy-access groups would be desirable. VBH had promised to double the number of sessions allotted if groups are utilized. So far, however, no such action has been taken.

Regarding the future, Hescheles speculates that “boutique” psychotherapy will be reserved for the affluent and/or potentially die out; groups for the less affluent will be of a primarily psychoeducational or self-help nature and offered under the auspices of hospitals and medical practice offices.

Managed care forcing changes
Nanine Ewing has primarily a group treatment private practice in which she conducts six groups per week, with more than 50 individuals as members. Ewing sees this as a viable wave of the future providing we educate people about the fact that group psychotherapy is affordable (90 minutes per week for about one-third the cost of individual treatment) and that it is the most effective way to learn about the distortions in one’s self-perceptions. She emphasizes to prospective patients that it is our interpersonal environment and our reactions to it that make us sick or well. She describes group treatment as more intense that other modalities and as moving faster. Ewing emphasizes the need to educate clinicians, agencies and other institutional settings, and the public to achieve more widespread recognition of this viewpoint.

What often gets neglected in preparing individuals for group treatment, in Ewing’s view, are the inevitable negative components of evolving relationships within the group, which often make group members want to bolt just as they often impulsively terminate frustrating or difficult relationships outside the group. She tries to help prospective group patients appreciate that working to understand and resolve these conflictual impasses is an important opportunity and that it is primarily available in psychotherapy groups.

In regard to local general group trends, Ewing identifies managed care and third party payers as not covering group treatment adequately and advocating instead for free support group experiences. The clinician often needs to make the case to the patient that group is an effective treatment modality and that a longer-term experience beyond coverage limitations is not only affordable but results in a lack of recidivism and a higher quality of life. Group psychotherapy can actually hold a self-paying client longer once insurance has run out because of the relatively low cost, as well as the relationships forged within the group.

Regarding institutional settings where groups tend to be available for a maximum of three months of care, Ewing feels group-oriented practitioners must concentrate on educating clinicians and administrators. As practitioners become educated, the value of a more process-oriented focus becomes clearer.

More medication management
Darryl Pure, associate in clinical psychiatry and coordinator of Group Psychotherapy Training and Services at Northwestern University Medical School, Chicago, highlights the relationship of his program to Northwestern Managed Mental Health Services (NMMHS). He describes the effects of this relationship on the provision of training to psychiatric residents, psychologists, and clinical social workers, as well as the treatment provided to patients. Pure describes NMMHS as being underbid by larger players, losing contracts and in danger of becoming defunct. As a managed care-supported organization as well as a training center, his program’s ability to train and supervise students is limited by the specification that only licensed providers can see managed care patients. Students cannot charge for seeing certain patients, and some patients can only be seen by licensed staff affiliated with their particular payers. This results in an administrative nightmare with respect to the assignment of patients to therapy groups.

The group program is funded by the Department of Psychiatry based on the number of patient visits. Since staff and students are credited with two patient sessions per group regardless of the number of group members and additional paperwork involved, group treatment is discouraged rather than encouraged.

Upon his arrival, Pure focused on developing theme-focused groups, but they had too few attendees to be successful. When attention shifted to general interactional process groups, including coed as well as men’s and women’s groups, these groups were more easily maintained. There are now 10 filled psychotherapy groups instead of the two they originally struggled to sustain.

Pure feels that Northwestern’s program is in a much better place than when he began as coordinator in 1995. For the 15 years preceding his arrival, there was little group activity. Currently, all residents and interns have been through Northwestern’s version of the AGPA Principles of Group Psychotherapy Course. More residents are referring their individual patients to groups and noting the benefits, despite the supervising psychiatrists’ antipathy to group psychotherapy. This is all occurring in a context similar to that described by Swiller: namely, less focus on psychotherapy and more on medication management.

Other emerging trends
In this brief examination of emerging group psychotherapy trends nationwide, a number of phenomena appear significant. Screening and preparation are becoming increasingly emphasized as crucial factors in fostering a successful group experience, regardless of the primary focus of the group. The ability to stick with groups appears to be largely a function of a patient’s successful initial engagement. While there is increasing emphasis on theme-focused and/or cognitive behavioral group experiences, the polarity between focusing on content versus interactional process seems to be diminishing. The resulting integration leads to more attention to engagement and relationship components regardless of the nature of the group.

Additionally, there are some indications of a different usage of time considerations. Time-management rather than predetermined time limits is increasingly prevalent and is preferable for people who believe in group treatment; it allows for participation in discrete modules of treatment and takes more heed of actual patient needs.

There appears to be some consensus that group psychotherapy is poorly utilized in the context of treatment offered under the auspices of managed care. MCO’s on the whole do not seem to appreciate the special utility of the group modality and managed care practitioners are often reluctant to provide group psychotherapy services because of financial and time utilization constraints. Larger treatment settings with a greater influx of patients tend to utilize theme-focused and time-limited groups more frequently. However, such groups do not thrive without sufficient ongoing referrals.

There is an expanding use of groups with the medically ill throughout the country, and often such groups are connected to medical facilities or physicians’ offices. There are new topical groups across the country, which appear connected with the popular themes of the moment and are geographically variable. In particular, ethnic, cultural and racial diversity are affecting the kinds of group experiences being provided in different areas. It is not surprising to note that there is a Holocaust survivors’ group in New York; similarly, there are groups addressing Mexican immigrants’ familial experiences in California and Texas.

Is there any general conclusion that can be reached? It is clearly a difficult time for the practice of psychotherapy in general and group psychotherapy in particular. Nonetheless, with attention to educating fellow professionals and the public, offering to run groups that are carefully chosen with regard to the needs of a particular locale, and thoroughly screening and preparing prospective patients, it may still be possible for the practice of group psychotherapy to survive and even thrive.

This article was published in the August 1998 issue of The Group Circle.