Brief Group Psychotherapy and Managed Care: Integration or Disconnection?

One of the fringe benefits of managed mental health care in the last decade has been the increased interest in and greater clinical experience with cost- and time-efficient models of psychotherapy. Short-term group therapies have been the major beneficiaries of this shift in emphasis spurred by concerns about the escalating health care costs.

Short-term group therapy has been the subject of increased study so that the mechanisms underlying its efficacy have been delineated clearly. It is a model that engages with the challenges of limited time and funding, and provides a format for therapists who are traditionally oriented to expand, not abandon, their existing skills and grow professionally. The focus of this article is to review some of the basic principles of time-limited groups and to see where the integration of brief groups into managed care systems currently stands.

Brief group formats have followed the lead of their individual psychotherapeutic counterparts and subscribe to many of the same general principles. Consensus exists that six elements are essential to brief group therapy.

1. Circumscribed Treatment Focus
Time constraints dictate that goals in short-term groups be focal and as specific as possible. Global, vague, or excessively ambitious treatment goals are not attainable in brief therapy groups. An example of a focal group goal is found in a cognitive therapy group that is designed to teach stress management skills and relaxation exercises to patients experiencing excessive anxiety symptoms. Contrast this with the more amorphous goals of resolving depressive symptoms, changing personality structure, or resolution of family problems. The latter examples are problematic in two ways. First, they may reflect an orientation of a group leader who has set goals that are either imprecise or too far-reaching for a brief therapy experience. Second, when the group is paid for by a managed mental health organization, the treatment plan with vague goals is very likely to be rejected.
When conducting groups under the umbrella of managed care, it is best to describe the group goals in terms of the functional impairments that group members demonstrate. With depressed patients, the global group goal of resolution of depressive symptoms translates into the focal goals of evaluation for anti-depressant medication; social skills training to counter isolation; psychoeducational components to inform members about the nature of their condition; and utilization of a group experience to encourage open expression of depressive feelings.

2. Active Group Leadership
When the leader of a brief therapy group is active from the outset, therapeutic group norms are more likely to emerge quickly. Constructive group leadership in brief groups includes setting a clear framework for the group, insuring that positive group norms are instituted, maintaining a relevant group focus, and guarding against potential harmful trends in the group.

Leaders of short-term therapy groups need to be prepared to be vigilant in keeping the group on target and avoiding the inevitable temptation for group members to detour off course owing to their own anxieties about change. Budman (1992) coined the term “informed eclecticism” to describe a leadership style felt to be most readily adaptable to a brief therapy format. The sentiment that is conveyed in this orientation appreciates the value of both flexibility and firmness as essential qualities of the group therapist in the time-limited approach. Leaders who are active and are comfortable with the idea of combining elements of several group orientations into their brief therapy approach are the ones most likely to maximize the inherent resources of the short-term therapy group.

3. Establishment of Group Cohesion
In brief as well as long-term groups, the early establishment of group cohesiveness is an essential task. In brief groups, a higher premium is placed on the rapid emergence of group cohesion since there is less overall treatment time available for the group. Short-term group leaders emphasize the similarities among members from the first meeting in order to promote the acceleration of group cohesion.

This emphasis on similarities also reinforces the commonality of goals for all group members. Cohesion acts as a safeguard against scapegoating in brief and open-ended groups. With an early sense of the security provided by group cohesion, the group can begin to address its therapeutic agenda more rapidly and comfortably.

4. Fixed-Group Time Limits
Setting a finite number of sessions communicates a sense of therapeutic emergency. Fixed time limits help define the tasks of the group and the period available for their completion. A pre-determined group format includes an estimate of the time needed to accomplish the group goals. Time limits in short-term group therapy are decided upon in advance and are not open for revision during the course of the group.

5. Contemporary Focus
Therapists in brief therapy groups ordinarily strive to keep the group centered on present-day themes. The focal points can be intra-group phenomena or events in the current life circumstances of group members. With rare exception, forays into histories are rare unless the group model is a brief psychodynamic one.

The underlying assumption for this is based largely on the fact that the interactions among group members will demonstrate “in-group” version of their problems. Rather than have the leader and members hear reports of historical events with people whom they have never met, it seems a much more viable alternative to keep the spotlight on the intra-group transactions that replicate unresolved historical themes.

6. Careful Patient Selection
The issue of screening and evaluating prospective group members takes on added significance in groups with time constraints. The necessity of having homogeneity in group composition dictates careful attention to the selection of members who share common problems and personal characteristics. Maximizing similarities among group members facilitates a more rapid induction into group, an accelerated first phase of the group itself, and a greater probability of attaining group cohesiveness built around similarities.

Other Critical Elements
Two other critical elements that are central to the success of time-limited groups are the notion of increased patient responsibility for change and the commitment to apply what is learned in group to real-life situations outside the group. Each member must have a clear and well thought out reason for being in a particular group. The leader of the brief therapy group has to convey the orientation that therapy is a joint venture, a major portion of which will rest on the shoulders of the patient. The leader can be explicit in defining how he/she will participate in a collaborative way with group members but that this is not a substitute for individual action on the member’s part.

In groups that are psychoeducational, cognitive, or behavioral, patients are required to apply knowledge gleaned from the group and to practice specific techniques taught in the group. From a practical standpoint, the leader makes specific out-of-session assignments that are reviewed in the next group meeting. Relaxation training for patients with anxiety disorders, in vivo desensitization assignments for phobic patients, and homework tasks that help with assertiveness training for shy or passive patients are examples of work that can be done by members outside of the brief group to reinforce the goals of the group agenda.

In addition to specific task assignments, an underlying tenet of brief therapy is that change is an ongoing process, only part of which takes place in formal sessions. Patients are oriented to the philosophy that change will occur over the course of their lifetimes. The direction, rather than the degree, of the change is of central importance. Interrupting self-defeating patterns or putting checks on self-destructive individual and interpersonal behavior starts a therapeutic trend in motion that will be reinforced in the patient’s future living patterns and in subsequent psychotherapy experiences they may undergo.

Members are encouraged to be active participants in setting their therapeutic goals in brief groups. The clinical questions then become, “What is the purpose of this group at this point in time for you?” and “How can this be accomplished through membership in a short-term group?” When group members are taught to think about changes in their lives over a long period, it helps clarify for them what aspect of living the current group can best address.

Acknowledging Differences Among Group Members
A frequently neglected aspect of brief therapy groups is the heterogeneous factors present in the composition of the group. While the focus on similarities is universally accepted as a core element of the brief group therapy approach, group leaders should not lose sight the of the possibilities of simultaneous therapeutic use of the ways in which individual group members are unique. Despite the fact that members may be homogeneous for problem set, gender, diagnosis, age, or other factors, thinking of them exclusively in terms of their similarities is a convenience for the therapist since it eases management of the initial phase of group.

Acknowledging differences helps create a baseline group tension that can be used to counter the tendency to become complacent and can motivate patients to work on their treatment issues. Heterogeneity also spurs interaction, which picks up the pace of the group and helps the group achieve a sense of balance between similarities and differences. Teaching to differ openly but respectfully is another advantage of using group differences. Later in the life of a brief therapy group, when issues of individuality, separateness, and autonomy are being addressed, the therapeutic leverage for the group therapist derives form the differences, not the similarities among group participants.

With this brief review of some of the essential elements of short-term group therapy in mind, let us look at what the managed care field has done to include group therapy in general, and brief group therapy in particular, into their schema of regular service delivery.

An Update on Brief Group Therapy and Managed Care
Time-limited group therapies have received a great deal of attention by the managed care community. The economic advantages to third-party payers of using brief therapy formats are apparent. Despite this awareness, the actual implementation of group therapies into systems of managed care has lagged behind what would have been predicted by its advocates. Several factors have contributed to this delay.

• Referral Problems—The majority of practicing mental health professionals still subscribes to, or is more familiar with, individually oriented forms of intervention for psychological problems. Therefore, brief individual therapies and the use of psychotropic medications have taken precedence over their group counterparts. Since the initial evaluation for treatment is often by clinicians who are less aware of the broad utility of short-term groups, these evaluators rarely think of group therapy as a primary therapeutic option and, consequently, refer patients for individual therapies.
• Systemic problems—Even when a patient is deemed to be an appropriate candidate for brief group therapy, the managed care organization that approves or rejects the treatment plan is usually ill equipped to track the progress of a group and its members. Internal information systems and software programs are still largely individually oriented and have not yet been adequately adapted to incorporate data relevant to therapy in the group setting.
• Economic factors—Managed care is in a dramatic state of flux. The past few years have been characterized by a flood of mergers and acquisitions, resulting in fewer, but larger, health care companies. An inevitable by-product of these reorganizations and expansions has been to focus on staffing, organizational, and policy issues, rather than on treatment, resulting in a sense of discontinuity in many areas of treatment planning. Relegating groups to the “back burner” further delays the creation and implementation of group-specific treatment programming.
• Staffing Deficiencies—Very few managed care organizations have a staff position designated for a coordinator of group therapy services. The absence of such a person leaves a conspicuous gap in the process of mainstreaming group therapies into the overall treatment program. Hospitals, out-patient clinics, day treatment programs, and other milieus invariably have a person, with or without the formal title of group program director, who fulfills this vital function. It seems unlikely that managed care companies will be able to integrate successful group treatments into their program designs unless this aspect of staffing is given greater attention.
• Education and Training—A group program coordinator or director can also oversee the training and development of staff, who make judgements about the form and frequency of psychiatric treatment. Staff needs to be informed about the role and value of group therapies for patients in all diagnostic categories.

Some managed care companies have recognized this shortcoming and have contracted with outside group specialists to conduct brief, intensive training courses in group psychotherapy for permanent staff members. In spite of these efforts, many people in key decision-making positions, both on an individual case and an organizational level, are not fluent in the language of group therapy in general and brief group therapies in particular.

Brief group psychotherapy is a major, if not ??the?? major, area of study in contemporary applications of group treatment in the age of managed care. The appeal of the brief group model resides in the enhanced ability for clinicians to engage in a focal and definitive therapy involving problems that interfere with the successful adaptation of patients to aspects of their present-life circumstances. It seems clear that short-term group therapy will play a defining role in the way in which many mental health services are delivered to varied patient populations.

This article was published in the August/September 1999 issue of The Group Solution.