Group Psychotherapy: Alternative Treatment Formats

Alternative Treatment Formats

Cotherapy

In some settings, groups are conducted by cotherapists. This format provides opportunities for clinicians to learn from one another, share leadership responsibilities, more readily recruit members and provide continuity in the absence of one leader. Cotherapy uniquely offers therapists chances directly to observe another clinician’s work and to learn about countertransferences. The model is utilized for training neophyte group therapists who can be paired with a more experienced therapist. For patients, this model is thought to offer a recreation of the family, as thera-pists are cast in parental roles, whether or not the therapists are of the same or different gender.

The conduct of cotherapy is not without special problems (Lang and Halperin, 1989). Cotherapists need to attend to their relationship because they are susceptible to a variety of transfer-ence responses to one another, most commonly competitive and narcissistic strivings. They will need to predetermine under what circumstances they might address their inevitable disagreements directly in the session.

Pharmacotherapy and Group Therapy

The inclusion of patients receiving pharmacotherapy in dynamic psychotherapy groups is common practice. Eighty-three percent of surveyed psychiatrists included patients requiring medication in group therapy (Stone et al., 1991).

Combining medications with psychotherapy has become widespread. The evidence for modification, if not cure, of major debilitating symptoms is substantial and yet patients will be left with emotional responses and unexplored meaning of their ill-ness. Moreover, discontinuation of medication is highly corre-lated with recurrence of symptoms. In my opinion, clinicians’ and patients’ objections to the combined treatment approach can be sensitively addressed and inclusion of patients receiving medi-cations in groups offers opportunities effectively to treat a wider patient population.

Time-limited Groups

As pressure mounts to conduct therapy in briefer periods, inter-est in time-limited groups has increased (MacKenzie, 1997). The number of sessions may range from 12 to 30. Many insurance companies limit coverage to 20 sessions and thus a 16-session model allows for preparatory interviews and, if necessary, one or two sessions after termination of the group.

Time-limited goals are established by the therapist. Groups may be organized along specific symptom constellations, such as bereavement, sexual abuse, bulimia, or anorexia nervosa, or they may explore a personality sector with the expectation that the individual will continue to utilize the learning after termination.

Selection of patients for time-limited groups is of central importance. Therapists may opt to organize groups with ability to work with interpretations or one that is primarily supportive. Members should be assessed for their degree of psychological mindedness, that is, are they able to reflect on themselves and their interactions and on their ability to find a focus, not neces-sarily of recent origin. Difficulties should be formulated in inter-personal terms to facilitate the exploration of the problems in the group setting (e.g., a delayed grief reaction).

In most circumstances, once treatment begins additional members are not accepted. The agreement is similar to that of longer-term groups with the exception that the number of ses-sions is limited. Using this format, the therapist needs to be more active in defining the focus for the members. In the context of group development, interventions are made that focus on the in-terpersonal aspects of the particular dynamic stage. These groups can be particularly useful in addressing issues of engagement, trust, unfulfilled hopes, separation and loss. The combination of time pressure, maintaining focus on interpersonal processes and providing encouragement to apply learning in the external world has produced a treatment format that may be as effective as indi-vidual treatment (Budman et al., 1988).

Chronically Mentally Ill

This special population of patients requires modification of tradi-tional dynamic approaches (Kanas, 1996; Stone, 1996; Schermer and Pines, 1999). The population is broader than individuals with major psychiatric disorders (schizophrenia or bipolar disorders) and includes some disabling anxiety or personality disorders. In-deed, chronicity is determined primarily by duration and disabil-ity rather than by diagnosis. In some instances, groups are organ-ized homogeneously for patients with schizophrenia or bipolar disorder (Cerbone et al., 1992). These groups often emphasize the importance of continuing with medication and include important educational components. They may have greater structure and focus on particular topics, such as managing hallucinations, par-anoid thinking, or social relations (Stone, 1996).

More typically, groups are structured to include a spec-trum of patients within a relatively small range of disability. Patients are prone to attend erratically and a flexible format that accepts this propensity may serve these individuals well (Stone, 1996). The sessions are usually shorter, 45 to 60 minutes and the group census may range from 12 to 16 persons. In the flex-ible format, core and peripheral subgroups develop and, over extended periods, groups develop a sense of continuity and cohesion.

Treatment goals should be concordant with patients’ strengths and are generally formulated to help in adaptation to everyday problems, improving social relations and managing feelings. The agreement is modified and patients may be encour-aged to socialize outside of the meetings. Therapists attempt to help patients manage their isolation and sense of shame over their illness.

Countertransferences require particular attention in part due to the difficulty patients have in linking to their therapists, which may leave the clinician expecting more than the patients can deliver. Moreover, in the current climate, particularly for ma-jor mental illness, medications are valorized and therapy is de-preciated, a state of affairs that affects the therapist (Della Badia, 1999).