Practice Guidelines for Group Psychotherapy

Therapist Interventions

CONCURRENT THERAPIES

Although the effectiveness of group psychotherapy as an independent therapeutic modality has been well demonstrated (Burlingame et al., 2004), group therapy clients also may commonly participate in a concurrent form of treatment:  individual therapy, pharmacotherapy, or a 12-step group.  Group therapists aim at proper integration of these forms of therapy, recognizing opportunities for therapy synergy, complementarity, facilitation and sequencing (Paykel, 1995; Nevonen & Broberg, 2006). Clarity about the principles of integration of modalities is useful in ensuring maximum benefit.  Therapy integration increases the scope of clients that can be treated in group therapy and respects client choice and autonomy (Feldman & Feldman, 2005).  Combining treatments however carries potential risks and may be contraindicated if the second modality is redundant and unnecessary, or incompatible with the initial therapy, as will be described (Rosser et al., 2004). Concurrent individual therapy may dilute the group therapy intensity by reducing the press group members may have to address important material.  Engagement within the group may also be diminished if many group members are participants in an individual therapy (Davies et al., 2006).

Concurrent Group and Individual Therapy. Group and individual therapy are generally of equal effectiveness (McRoberts et al., 1998) but achieve their results through different mechanisms and therapist intent (Kivlighan & Kivlighan 2004; Holmes & Kivlighan, 2000).  Group psychotherapy tends to emphasize the interpersonal and interactional: individual therapy tends to emphasize the intrapsychic. They may be effectively co-administered. Conjoint therapy refers to situations in which the group and individual therapist are different: in combined therapy  one therapist provides both treatments (Porter, 1993) Conjoint therapy may increase the therapeutic power of treatment by adding the power of multiple therapeutic settings; maturational opportunities; transference objects; observers and interpreters, generally adding group therapy atop an established individual therapy (Ormont, 1981).  Clarity about the reason for adding a second therapy and agreement about the objectives of treatment between the referring therapist, group therapist and client increases the likelihood of successful treatment.  Group therapy may be added to individual therapy to move into the interpersonal and multi-personal from the dyadic and intrapsychic; facilitate interpersonal skill acquisition; or activate the psychotherapy. Individual therapy added to group therapy may help maintain a patient in group therapy who might otherwise terminate the group prematurely, or  address psychological issues the group unlocks for the client that require more focused attention (Yalom & Leszcz, 2005).  Simply adding a second therapy is unlikely to remedy a resistance to the first therapy and may encourage avoidance of working through.

Conjoint therapy works best when the client provides informed consent for ad lib communication between the group and individual therapist; recognizes the importance of working in good faith in both modalities; and accepts the responsibility of bringing clinical material appropriately to each setting.  A mutual, respectful collaboration between the individual and group therapist reduces the potential for competitiveness, rivalry, countertransference or client splitting and projections of idealization and devaluation to undermine one modality or the other (Ulman, 2002; Gans, 1990).  Mutual respect and open dialogue between both therapists, although time-consuming, increases therapy effectiveness. Failure to communicate between therapists may well undermine both psychotherapies.

In combined group and individual therapy one therapist provides both forms of therapy and hence may have fuller and more immediate access to client information than in conjoint therapy.  The group should be homogeneous for this dimension to reduce the potential of stimulating envy and generating unequal status of clients in group therapy. Frequency of meetings in conjoint and combined therapy can be determined mutually and may occur once-weekly for both or weekly only for group therapy with the individual therapy occurring at various frequencies.  Ending of therapy can be done simultaneously or sequentially, mindful however that each therapy’s ending is fully addressed.

Dealing with client information at the interface of modalities may pose a therapeutic challenge that can be best addressed by underscoring the client’s responsibility for bridging between settings.  The therapist should operate with maximum discretion and judgment but can offer no guarantee of absolute confidentiality across modalities (Lipsius, 1991; Leszcz, 1998).  Difficulties in addressing relevant material in one setting or the other is best viewed as an opportunity to understand core difficulties within the client and the feeling of impasse may become an important therapeutic opportunity.  Therapists are encouraged to preserve the essence of each treatment modality and explore in detail interface points between the modalities with a view to deepening the work in each.  The therapist may encourage the client to address material in the appropriate setting and may ultimately introduce it if therapist efforts to support and facilitate the client addressing the interface through encouragement and gradually increasing the degree of inference in interventions fail. Working through the resistance is generally of greater therapeutic value than merely achieving the self-disclosure. 

Combining Group Therapy and Pharmacotherapy.  The majority of group therapists will have clients in their groups who will require pharmacotherapy, often for treatment of chronic depression, chronic dysthymia and co-morbid personality and depressive difficulties (Stone et al., 1991).  Often untreated depression is a cause of impasse in psychotherapy and the appropriate use of antidepressant medication may increase the client’s access to psychotherapy, creating a level playing field for psychological treatment to ensue (Salvendy & Joffe, 1991).  Alternately, group therapy in a post-acute phase of treatment may provide interpersonal and cognitive skills that will improve patient resilience and diminish vulnerability to subsequent relapse (Segal et al., 2001).

If the group therapist is the prescriber of medication, logistical difficulties may arise regarding proper monitoring of the antidepressant medication within the group setting alone (Rodenhauser & Stone, 1993).  For this reason a separate meeting is indicated for monitoring of medication. Alternately a colleague may be engaged to prescribe and monitor medications (Salvendy & Joffe, 1991).

In situations in which two treaters are involved, clarity about communication, responsibility for the client and accessibility of the client to the prescriber increases the likelihood of an effective treatment (Segal et al., 2001).   Each treater should inform the other fully and operate with a sense of mutual respect and full valuing of both the psychological and biological dimensions of care.  Interprofessional practice is predicated upon this kind of mutuality and collaboration (Oandasan et al., 2003). Clarity about the objectives of pharmacotherapy is useful, recognizing that in some instances pharmacotherapy adds little to an already effective psychotherapy (Rosser et al., 2004).

In instances in which medication is clearly indicated, the group therapist should anticipate the psychological meaning and impact of medication on the client’s sense of personal self-control and attribution of responsibility, emotional availability, and connection in the group, as well as impact on the logistics of treatment (Rodenhauser, 1989; Porter, 1993; Gabbard, 1990).  The prescription of medications may well have multiple meanings that impact the client receiving medication, other clients in the group and the group as a whole, ranging from encouragement and recognition of the therapist’s commitment to client care, to feelings of personal shame and stigmatization to discouragement that psychotherapy has been insufficient.  In the same way that the group and individual therapists are most effective when they demonstrate mutual respect and valuing, the same is true for the pharmacotherapist and group therapist.  Dogmatic overvaluing of one modality and devaluation of the other will create a strain on the client and undermine the synergistic benefits combined treatment may create.

Twelve-Step Groups. The broad reach of 12-step groups and their recognized effectiveness in facilitating abstinence from addictions predict the likelihood that clients that have been in 12-step groups or are currently in 12-step groups will also be in leader-led group psychotherapy (Ouimette et al, 1998; Lash et al, 2001; Khantzian, 2001).   In this instance, as there is no other treater, it becomes the responsibility of the group therapist to facilitate the collaboration between the two models of treatment, building atop the 12-step treatment, by addressing the psychological and interpersonal context of addiction in a complementary fashion. 

Two important issues distinguish 12-step groups from group psychotherapy: First, feedback or core cross-talk is virtually absent in 12-step groups in contrast with their high value in group psychotherapy.  Second, attitudes toward extra-group contact are very different in 12-step groups. Extra-group contact between members and the sponsor/sponsee relationship are of critical importance in contrast to the less permeable boundary issues around extra-group contact in group therapy.  Recognizing these differences, the group therapist can better prepare a client transitioning into a psychotherapy group from a 12-step group environment, anticipating potential sources of antipathy, confusion or apprehension about the different ways in which these two group formats work.  The maintenance of sobriety is a key objective in the treatment of clients with addictions, and the group leader may need to pace the process of exploration so that it is containable by the client, cognizant of client vulnerabilities to relapse. 

Group psychotherapy and 12-step groups may employ different “narratives of recovery” (Weegman, 2004) but the historical antipathy between mental health treatment and addiction treatment is slowly being replaced by an increasing awareness and respect for the effectiveness of both and for their compatibility.  The group therapist will be most effective if he/she has an appreciation for the 12-step program and how these steps and culture can be integrated into interpersonal and dynamic forms of group psychotherapy.    The group therapist’s familiarity with the language employed in 12-step groups will also facilitate this process. Group therapy complements the 12-step articulation of the importance of self-repair through relationships; self-reflection; self-disclosure; and personal accountability in the context of trusting relationships (Matano & Yalom, 1991; Flores, 2004; Freimuth, 2000; Yalom & Leszcz, 2005).

                                                       Summary

1.     Group therapy is effective as an independent treatment format for many individuals, particularly when the

issues are framed in interactional and interpersonal terms.

2.     Individuals may be in group therapy in conjunction with individual therapy, pharmacotherapy or other

therapeuticformats such as a 12 step program.

3      Conjoint therapy in which different therapists provide individual and group therapy requires a trusting and open

relationship between the therapists which has the sanction of the client.

4.     In combined therapy, the same therapist provides individual and group therapy to the same set of individuals. 

It is important for the therapist in this format to keep the treatment formats distinct and to respect the privacy and

autonomy of the individuals, allowing them to bring up material at their own pace. It may at times be therapeutically

useful to help the individuals address material in group.

5.     Whether conjoint or combined, it is essential that both therapies work within their own framework - group in an

interpersonal mode and individual on intrapsychic or behavioral issues.

6.     Pharmacotherapy and group therapy can be effectively combined. 

7.     When the therapist is the prescriber, it is helpful to have a separate time to attend to the technical issues

related to medication, always recognizing that medication usage has its own dynamic and interpersonal aspects

which may also be addressed in the group therapy.  When the treaters are different, it is essential that mutual

respect and professional collaboration be fostered in order for the benefits of the two treatments to be maximized.

8.     In all multiple treatments, the therapists and clients are best served when mutuality and collaboration are the

guiding principles.

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©2007 American Group Psychotherapy Association