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 Practice Guidelines for Group Psychotherapy

Reducing Adverse Outcomes and the Ethical Practice of Group Psychotherapy

It is clear that not all individuals benefit from group therapy. In fact, therapeutic groups can directly contribute to adverse outcomes for some clients, including the experience of enduring psychological distress attributable to one’s group experience (Yalom, 1995). It is an expectation of professional practice that the group leader commit to provide quality treatment that maximizes member benefits while minimizing adverse outcomes.  This posture reflects an internalized system of values, morals, and behavioral dispositions that contribute to the successful application of ethical standards to the group setting (Brabender, 2002, 2006; Fisher, 2003). Achieving ethical competence not only entails gaining the knowledge of professional guidelines, federal and state statues, and case law related to practice (Hansen & Goldberg, 1999), but also includes the motivation and skills to apply these standards (Beauchamp & Childress, 2001). Clinician knowledge and moral dispositions acquired through social nurturance and professional education are critical to providing ethical care (Jordan & Meara, 1990).

Prominent frameworks of ethical decision-making, such as the Haas and Malouf (2002) comprehensive two-phased model of firstly gathering information and then delineating a course of action, assist the group leader. For instance, Haas and Malouf recommend that during the information gathering phase, the ethical problem should be identified and defined with the perspective that each stakeholder, including all members and leaders in the group, are likely to be individually affected by the ethical dilemma. Information gathering includes determining whether standards exist to guide decision making. In a situation without an established standard (e.g., dilemmas related to group members communicating through websites or via email) or in which ethical principles and codes are in conflict, ethical principles are first identified.  It is then determined whether any ethical principles supersede others to assist in decision making. Following this determination, the group leader generates possible consequences of various actions and evaluates these actions using three specific criteria:

1.      Does the considered course of action meet the preferences of the affected parties?

2.      Does the considered course of action pose any new ethical difficulties?

3.      Is the considered course of action feasible?

Professional Ethics: Principles, Codes, Guidelines, and State Regulations. Ethical principles can be viewed as the underlying tenets of codes. Ethical principles are aspirational in nature and not enforceable, whereas codes of ethics are mandates for behavior and require strict professional adherence for their memberships. Codes of ethics, such as those published by the American Psychological Association (APA; 2002) and the American Counseling Association (ACA; 1997) are established by professional organizations for their memberships. Ethical guidelines are also developed by professional associations and are not meant to provide specific directives for all potential situations, but instead provide parameters to guide professional behavior (Forester-Miller & Rubenstein, 1992). The American Group Psychotherapy Association (AGPA), for example, is a parent organization that provides ethical guidelines for group therapy to serve professionals in psychology, counseling, social work, psychiatry and other fields (AGPA, 2002). Another organization, the Association for Specialists in Group Work (ASGW), provides ethical guidance with Best Practice Guidelines (1998) and Training Standards (2000). Finally, group leaders must abide by the laws and regulations in the states where they practice and within the parameters of their respective colleges and licensing bodies.

Group Pressures. The fact that groups can be powerful catalysts for personal change also means that they may be associated with risks to client well being. Kottler (1994) asserted the importance of developing an ethical awareness as a group leader because of the possible adverse conditions that are associated with group work. These may include:

  • Verbal abuse (i.e., in member-to-member exchanges) is more likely to occur in groups than in individual therapy
  • The group leader has somewhat limited control in influencing what occurs within the group and outside the group between members
  • Member selection and screening processes may be done poorly resulting in bringing into the group clients who have a limited capacity to work productively in group therapy   (see also the section on Selection and Preparation)

Roback (2000) similarly recommends improving the risk-benefit analysis through early identification of high-risk members, those who are likely to become “group deviants” and who may need intensive leader intervention to safeguard against a destructive, hostile or rejecting group response. There has been little systematic study of group deviancy in the clinical group literature although this topic has received attention in the social psychological literature (Forsyth, 2006).  Unfortunately, the social psychology literature has little to offer clinicians given the disparate types of groups studied (e.g., analogue groups made up of college students as opposed to therapy groups made up of clients).  However, recent years have seen a few more studies examining deviancy and deterioration with clinically oriented groups (Hoffman, et al., 2007). Empirically-based instruments for member selection may be used for identifying high-risk clients in an effort to prevent dropout or other adverse outcomes and recommendations of appropriate tools can be found in the APGA CORE Battery-R (Burlingame, et al., 2006; MacNair-Semands, 2005a).

Identified pressures in therapy groups also include scapegoating, harsh or damaging confrontation, or inappropriate reassurance (Corey & Corey, 1997). Skilled leaders can help members avoid scapegoating by encouraging members to voice any understanding or agreement with unpopular viewpoints or feelings, utilizing the forces inherent in subgroups to reduce destructive isolation. In system-centered approaches (Agazarian, 1999), for example, leaders manage and direct these forces to drive towards healthy therapeutic development. Additional leader behaviors instrumental in reducing adverse outcomes include identifying group members’ vulnerabilities and encouraging members to describe behaviors rather than making judgments.  Group members should all be advised that they are free to leave the group at any point without coercion and undue pressure to remain (Corey, et al., 1995). Leader behaviors that can be problematic include pressuring members to disclose information with an overly confrontational manner or failing to intervene when a potentially damaging or humiliating experience occurs. Members who are socially isolated or coping with major life problems are particularly at risk for such adverse outcomes after disclosure in a group setting (Smokowski, et al., 2001). Leaders should be conscious of the potential for misusing power, control and status in the group. Preventive behaviors by clinicians may include avoiding professional isolation, accepting the demand for accountability, self-reflection on countertransference, and seeking consultation or supervision (Leszcz, 2004).

Record Keeping in Group Treatment.  Client records are kept primarily for the benefit of the client (APA, 1993), yet serve a variety of purposes. The clinical record documents the delivery of services to fulfill requirement for receipt of third party payments, provides a summary of services that may be necessary for other professionals, and fulfills legal obligations. In balancing the need for confidentiality with the need to track client progress appropriately, Knauss (2006) recommends that progress notes be written in objective behavioral terms with a focus on facts relevant to client problems rather than judgments or opinions.  Clinicians are advised to think out loud in the record by documenting how they intervened and why (Gutheil, 1980). This practice helps ensure that progress notes reflect an active concern for the patient's welfare (Doverspike, 1999). It is also important to develop a diagnostic profile and keep specific treatment notes for each member.  Individual notes on members should never refer to other members by name as this is an infringement of the confidentiality of the other member.

It is suggested that the treatment record document efforts to obtain past records of new clients as part of the entry into treatment.  It is also wise to document clinical interventions along with their rationale and clinical effect. Additionally, the willingness to seek consultation generally implies a high level of professionalism and should similarly be noted in the clinical record.

Confidentiality, Boundaries and Informed Consent.  Therapists should discuss with potential group members the problem of protecting clients’ confidentiality from one another, since confidentiality in group settings can be neither guaranteed nor enforced in most states (Slovenko, 1998). Group leaders must recognize that confidentiality is an ethically based concept which often has little or no legal basis in group therapy (Forester-Miller & Rubenstein, 1992). Although some states do provide privilege to co-patients regarding confidentiality, as in Illinois, most states do not. Accordingly, a common method of providing informed consent for group members is to have members complete a group confidentiality agreement explaining that co-members have no confidentiality privilege, and describing ways that members can discuss their own progress toward treatment goals without identifying other members. Sample confidentiality agreements are available in the literature (Burlingame, et al., 2006; MacNair-Semands, 2005b). Many therapists establish expulsion as a possible consequence of a violation of confidentiality (Brabender, 2002). Client agreements serve to protect the frame of therapy and elicit informed consent about not socializing with psychotherapy group members and, when necessary, reporting any outside contact with the leaders or members in the next group session (Mackenzie, 1997).

Informed consent for group therapy includes a discussion of the potential risks and benefits of group therapy and other treatment options (Beahrs and Gutheil, 2001).  Additional considerations include group expectations regarding physical touch, punctuality, fees, gifts, and leader self-disclosure. Boundary crossings are defined as behaviors that deviate from the usual verbal behavior but do not harm the client; boundary violations denote those transgressions that are clearly harmful to or exploitative of the patient (Gutheil & Gabbard, 1998). Consistently maintaining boundaries with a commitment to understanding the meanings of behaviors that violate the therapeutic frame are critical; however, rigidly refusing to cross a boundary that may be appropriate and therapeutic in a specific context could also have a deleterious effect on the therapeutic relationship (Barnett, 1998).  Clear, fair and firm billing and payment policies can provide another clear boundary for the group (Shapiro & Ginzberg 2006).

Dual relationships. Duality may arise in group therapy in circumstances when therapists have collegial or supervisory relationships with each other; when group members or leader(s) have outside contact with each other in a social context; or when multiple roles exist between and therapist and client. It has been argued that the profession has a significant blind spot about the danger of dual relationships in group psychotherapy (Pepper, 2006). Several ethical codes address dual relationships specifically related to group counseling. The APA’s ethical code emphasizes that students participating in mandatory group therapy as a part of training should not be evaluated by academic faculty related to such therapy (cite Standard 7.05, APA, 2002). Along these lines, Pepper encourages caution about dual relationship issues which may emerge following training groups when group clinicians later become colleagues or engage in professional relationships. It has also been recommended in ethical guidelines that group leaders exercise great caution in addressing confidential information gained during an individual session while in a group setting when clients are in concurrent individual and group treatments (Fisher, 2003).

Furthermore, therapists working with culturally diverse groups are encouraged to thoughtfully interpret codes about dual relationships, which may take on new dimensions when viewed through a multicultural lens (Herlihy & Watson, 2003).

Preventing Adverse Outcomes by Monitoring Treatment Progress.  Group therapists often informally monitor group member treatment progress, adjusting group interventions in accordance with group leader perceptions of client progress.   Research has shown that treatment progress can be formally tracked to great benefit because clinicians have difficulty making accurate prognostic assessments regarding which client is most likely to experience an adverse outcome (Hannan, et al., 2005).  More specifically, not only do clinicians have a difficult time identifying which clients may experience an adverse treatment outcome, but there is substantial evidence in individual therapy that if actual data about client progress is provided to clinicians on a regular basis, a significant reduction in adverse outcomes can be achieved (Lambert, et al., 2005). Treatment monitoring with the goal of preventing deterioration in treatment and better predicting outcome has also been successfully applied to children and adolescents (Burlingame, et al., 2004; Kazdin, 2005), confirming the notion that identifying potential adverse outcomes before they actually happen may create an opportunity for therapy realignment.  This is a clear example of engaging in an evidence-based treatment approach (Hannan, et al., 2005).

The CORE Battery-R (2006) offers clinicians a set of relevant and applicable measures to track both group process and individual member progress.  Preliminary applications suggest that this methodology is helpful to clinicians and well accepted by group members (Wongpakaran, et al., 2006).

 

  Summary

 

1.         Achieving ethical competence includes gaining knowledge about professional guidelines, federal and state statues, and case law related to practice.

2.         Empirically-based instruments for member selection may be used for identifying high-risk clients in an effort to prevent dropout or other adverse outcomes. Recommendations for selection instruments can be found in the APGA CORE Battery-R.

3.         Treatment begins with a clear statement about diagnosis, recommended treatment and the rationale for treatment.

4.         Therapists should keep specific treatment notes for individual members; individual notes for members should never refer to other members by name.

5.         Informed consent for group members can include having members sign a group confidentiality agreement explaining the limits of confidentiality, and describing ways that members can discuss their own experience in group with others without identifying co-members.

6.         Leaders should be conscious of the potential for misusing power, control and status in the group. Leader behaviors that can be risky include unduly pressuring members to disclose information or not providing intervention when a potentially damaging experience occurs between members.

7.         Monitoring treatment progress with standardized assessment instruments can identify members who are at risk for poor outcomes and provide opportunity for therapeutic realignment.

 

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©2007 American Group Psychotherapy Association