Practice Guidelines for Group Psychotherapy

Selection of Clients

        The starting point of client selection for group psychotherapy is the clear recognition that group psychotherapy can be recommended with great confidence. Research has repeatedly demonstrated that group psychotherapy is an effective form of psychotherapy - as effective, if not more effective, than individual forms of psychotherapy (McRoberts et al, 1998; Burlingame et al, 2004).  It is also important to recognize that when entry into group therapy is considered for an individual member, there is much research and accrued clinical wisdom to guide clinicians. As is the case for the entire document, this section will focus on the prototypical, ambulatory group focused on interpersonal learning, insight and personal change.  These groups are by definition constructed to be interactive and emotionally expressive. Typically, these groups are composed heterogeneously in terms of personality style and/or problem constellation and aim at addressing a broad range of client difficulties, in contrast to groups that are homogeneous for a particular problem or condition and that may employ psychoeducation and/or skill building techniques. Not uncommonly however, groups that are composed homogeneously with regard to gender, culture, ethnicity, problem or sexual orientation may also address similarly broad therapeutic objectives.

        Two important issues stand out: who is likely to benefit from group therapy – the issue of selection; and, what blending of clients will produce the most effective therapy group – the issue of composition. Bringing a client into a group therapy commits not only the group therapist to that client, but also commits the other members of that psychotherapy group to that individual.  Having relevant criteria for decision making is therefore useful both at the individual and group level. Group therapists can utilize two distinct but related approaches: clinical assessment and empirical measurements. A trial of group therapy following thorough preparation is an additional approach to consider.

Selection. One way to address the question of who will benefit from group therapy and who should likely be excluded from participation in a psychotherapy group is through the window of the therapeutic alliance.  There is robust evidence to support the finding that the quality of the therapeutic alliance is perhaps the most important predictor of positive outcomes in all psychotherapies (Martin et al, 2000).  The strongest therapeutic alliance occurs in situations in which the client and therapist agree about the goals of therapy; the tasks of therapy; and the quality of the relationship or bond within the therapy (Horvath & Symonds, 1991; Bordin, 1979).   

Clients generally do well in group therapy when their personal goals mesh with the goals of the group.  Realistic, positive expectancies of change are more likely with this convergence and there is significant evidence regarding the impact on outcome of positive client expectations at the start of psychotherapy (Seligman, 1995).  Attention to the second and third elements of the therapeutic alliance – the tasks of group therapy and the quality of the relationship and bond with the therapist and co-members – can also be important determinants of suitability for group therapy. 

Who should be selected for group therapy? Group therapy is indicated for clients with manifest interpersonal difficulties and interpersonal pathology; individuals who lack self-awareness in the interpersonal realm or who manifest ego-syntonic character pathology; clients who are action-oriented; clients who will benefit from the affective stimulation and interaction that group therapy generally provides; and clients who need either to dilute an overly intense and dependent therapeutic relationship or  to intensify an arid, sterile therapeutic relationship who will benefit from the presence of peers to support and challenge them (Grunebaum and Kates, 1977; Bellak, 1980; Rutan and Alonso 1982).  Many clients may benefit from group psychotherapy even if they do not identify primary interpersonal difficulties, if the interpersonal underpinnings of their psychological difficulties can be identified and articulated in the pre-group assessment and preparation sessions (Horwitz and Vitkus, 1986).

Clients who do well in group psychotherapy are highly motivated (Seligman, 1995) and attracted to the group (Anderson et al., 2001).  An ideal prototype is a highly motivated, active, psychologically minded and self-reflective individual who seizes opportunities for self-disclosure within the group.  A certain capacity for interpersonal relationships is required to work in the interpersonal forum, a finding demonstrated in psychotherapy trials (Sotsky et al, 1991; Joyce at al, 2000).  A cursory review of these statements will underscore the maxim that the rich seem to get richer and many clients who need group therapy and may benefit from it are particularly challenged in these essential domains. Yet all group therapists can attest that many group therapy participants who do not meet these prototypical characteristics benefit substantially from group therapy and a trial of therapy following a comprehensive phase of preparation may be worthwhile. Failure to recognize this clinical fact will likely mean many clients who do not meet these selection criteria would be excluded from a meaningful and effective therapeutic opportunity.

Who should be excluded from group psychotherapy?  This answer must be considered relative rather than absolute and may need to be reframed as to what kind of group would be suitable for which particular individual. For example angry, anti-social individuals are typically excluded from group psychotherapy, but such individuals may do very well in a group that is homogeneous for anti-social participants. Indeed, there is a tremendous breadth of effective therapy groups constructed homogeneously and specifically for individuals who would not meet standard selection criteria for the kind of heterogeneous group addressed here.   In brief, clients should be excluded from group therapy if they cannot engage in the primary activities of the group - interpersonal engagement, interpersonal learning and acquiring insight – due to logistical, intellectual, psychological or interpersonal reasons (Yalom and Leszcz, 2005). 

Premature Terminators from Group Therapy. Therapists can also learn about inclusion and exclusion criteria from the study of clients who have dropped out of group therapy or terminated prematurely (Yalom and Leszcz, 2005).  The phenomenon of dropouts is potentially very disruptive in group therapy and generally there is little positive to extract from a dropout experience.  Dropouts generally do not benefit personally from group therapy, and may negatively impact their group.  They stimulate poor morale and may produce a negative contagion regarding the ineffectiveness of the group.  Individuals who repeatedly engage the group in issues related to their commitment and participation may generate a unhelpful preoccupation and then disappoint and frustrate the group with their departure. Group therapists are advised to consider the risk of early dropout of clients who demonstrate poor psychological mindedness; little self-reflection; poor motivation; high degrees of defensiveness, denial and guardedness; and who elicit angry and negative reactions from others.  The therapist’s direct experience with such clients in the assessment phase may provide important interpersonal data if it can be harvested by recognition and working through with the client.  If not, the hazard is likely that the group will reconfirm for these clients their fundamental negative view of themselves in relationship to the world and reinforce their difficulties rather than create an opportunity for growth or repair. 

        Intensive individualized preparation, with some skill-building prior to entering into the group, may increase the scope of clients treated effectively in group therapy. Group therapy is a difficult treatment for many individuals to undertake as their first treatment.  Individuals who have had a prior successful course of therapy or are in concurrent individual therapy will likely do better in group psychotherapy than clients for whom the group is their first psychotherapy experience (Stone and Rutan, 1984).

Client Selection Instruments. The application of objective measures may supplement clinical judgment in this decision-making process.  The Group Therapy Questionnaire (Burlingame et al., 2006) is a self-report instrument that evaluates client variables that may effect group participation. Clients who manifest extremes of anger and hostility; social inhibition; substance abuse; and a medicalization of psychological problems can be recognized using this questionnaire: they generally do poorly in this form of treatment.  The Group Selection Questionnaire (Burlingame et al., 2006) is a self-report instrument that similarly recognizes individuals who are likely to do poorly in group psychotherapy because of problems related to their inappropriate expectations of group psychotherapy; their inability to participate in the group; and an inadequate level of social skills. 

        A third empirical approach to selection emerges from the use of personality inventories such as the NEO – Five Factor Inventory (NEO-FFI) (Costa and McCrae 1992; Ogrodniczuk et al., 2003).  This personality measure suggests that clients who score very high on the Neuroticism Scale, reflecting high levels of distress, vulnerability to stress and propensity for shame, do poorly in group psychotherapy generally.  In contrast, individuals who score high on dimensions of Extraversion (verbal, eager to engage; openness: embracing the novel and unfamiliar with creativity and imagination) and Conscientiousness (hard-working, committed and able to delay gratification) do particularly well in group psychotherapy.  Allied findings show that individuals with immature interpersonal relations or low psychological mindedness will do poorly in an exploratory, interpersonally oriented group. These individuals may benefit more from a group that is supportive and focuses on skill building (Piper et al, 1994; McCallum et al., 1997; Piper et al, 2001; Piper et al, 2003; McCallum et al 2003). 

        Other considerations that may anticipate a poor group therapy outcome relates to clients who are unable to participate in the task of the group because they are preoccupied with an acute crisis; or those who may be actively suicidal and require comprehensive management rather than exploratory psychotherapy. Any logistical challenge that prevents clients from attending the group regularly and reliably is likely to undermine the group therapy.

Composition of Therapy Groups.  Having articulated guidelines that can be of help in the selection of individuals for group therapy, the second question to be considered is “what blending of individuals is preferable in group psychotherapy?”.  Answering this question requires an examination of how each individual client will impact others and interact within the group as a whole.  It may seem a luxury to consider composition in the contemporary practice of group psychotherapy, but attention to composition, and to client fit and interpersonal impact, continues to be useful with regard to illuminating group processes for the group therapist.

        Clinical experience recommends that groups be composed heterogeneously with regard to the nature of interpersonal difficulties, but homogeneously with regard to the ego strength of the members of the group.  A variety of diagnostic tools may augment practitioners’ clinical assessments in determining the nature of interpersonal difficulties that their clients experience, and assist in creating good matches of clients with different interpersonal styles. Interpersonal inventories may be useful in complementing clinical judgment (MacKenzie and Grabovac, 2001; Chen and Mallinckrodt, 2002).  These measures categorize individuals’ manner of interaction in a way that synthesizes two key interpersonal dimensions: hostile - affiliative and controlling - submissive.  Ideally, a group should be heterogeneous with regard to the mix of hostile to friendly spectrum and controlling to submissive spectrum individuals.  For example, a group composed entirely of avoidant, compliant and submissive individuals would not generate much interpersonal tension or opportunities for interpersonal learning.

        Composition, however, is not destiny – it is merely a starting point and group therapists should be encouraged to facilitate maximal here and now interactions and interpersonal engagement through the articulation and modeling of group norms.  It should be expected that individuals will recreate their typical relational patterns within the microcosm of the group. Clients who are rigidly domineering or dismissive may negatively impact the group with regard to cohesion and trust.  A group that is top heavy with such members will suffer and not reach a high level of effectiveness.  Ensuring the presence of members who are eager for engagement; willing to take social risks; and who manifest psychological mindedness, will increase the likelihood of the group becoming a cohesive and effective forum for growth and development (Yalom & Leszcz, 2005). The presence of group members with more mature relationship capacities will benefit all members, including those with less mature relational capacities (Piper et al, 2007). Similarly, groups benefit from having some veteran membership. Clinical experience underscores that therapy groups can both benefit from and provide benefit to more challenging and difficult clients in these kinds of compositional contexts.  A blend of men and women certainly is beneficial for men, increasing their interaction and engagement, but may be less necessary for a maximal benefit for women (Rabinowitz, 2001; Holmes, 2002; Ogrodniczuk et al 2004).

        Overall, the therapist’s aim in composing groups is bringing together a mix of individuals who will both challenge and support one another and develop and maintain group cohesion.  Valuing the group task and being able to commit to it is of enormous importance.  In practical terms, group therapists may be best advised to invest time with regard to selection and preparation and look at composition only as fine tuning of what will likely be a successful enterprise.

                                        Summary

1.     Group therapy can be recommended broadly as an effective therapy.

2.     The selection process for heterogeneous, long-term outpatient

psychotherapy groups demands careful consideration and thorough assessment. 

3.     Selection criteria are relative and not absolute and therapists should err on

the side of inclusivity rather than exclusivity.

4.     Objective measures can supplement clinical judgment regarding selection for

group therapy suitability.

5.     Attention can be productively applied to the client’s level of interpersonal

functioning, psychological mindfulness, the quality of object relations, motivation

and commitment, and previous positive experiences in group.

6.     Prospective group members who may be unsuitable for one group could

thrive in another group and even enhance the functioning of that group.  Groups

that are constructed to be homogeneous for the factor that leads to exclusion

from a heterogeneous group can be a useful treatment alternative.

7.     Individuals who cannot attend to the group tasks due to logistical,

motivational or symptomatic factors are not suitable candidates for group

therapy.

8.     Groups should be ideally composed to reflect homogeneity regarding ego

functioning and heterogeneity regarding interpersonal difficulties.

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©2007 American Group Psychotherapy Association