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Specialized Therapy Groups

GROUP THERAPY METHODS HAVE PROVED TO BE SO USEFUL IN so many

different clinical settings that it is no longer correct to speak of group
therapy. Instead, we must refer to the group therapies. Even a
cursory survey of professional journals shows that the number and
scope of the group therapies are expanding dramatically. This is true
for both face-to-face groups and for the explosion of online groups.
The Internet, as noted, now makes it possible for almost any
individual dealing with any malady or life challenge to find and join a
suitable group.1
Clinical necessity sparks clinical innovation. This is particularly
evident in college counseling centers.2 On campuses across North
America, counselors tailor groups to help students with a wide array
of concerns: eating disorders, social anxiety, developmental
challenges, separation anxiety, depression, nonsuicidal self-injury
disorder (NSSID), attention deficit hyperactivity disorder (ADHD),
autism spectrum disorder (ASD), diabetes, chronic fatigue, and
issues around substance abuse, sexual abuse and trauma, writing
blocks, gender identity and sexual orientation, communication skills,
assertiveness training, stress management, and the effects of racism
and discrimination. These are just a few of the commonly offered
groups. The groups are often brief, delivered in modules of four to
twelve sessions to fit within the academic semester.
Beyond the college campus we can find an even greater range of
groups. Clinical applications are growing by the day as we respond
to the many individuals seeking care for psychological, medical, and
social distress. Many groups are homogeneous for particular
conditions, responding to members’ needs for belonging,
destigmatization, and coping strategies. There are groups for
survivors of incest and sexual trauma, for people with HIV/AIDS, for
clients with eating disorders or panic disorder, for the suicidal, for
parents of sexually abused children, for compulsive gamblers and
sex addicts, for alcoholics, for children of alcoholics, for women with
postpartum depression, for sexually dysfunctional men, and for
sexually dysfunctional gay men. There are groups for survivors of
divorce, for children and spouses of people with Alzheimer’s, for
male batterers, for mothers of drug addicts, for families of the
mentally ill, for depressed older women, for angry adolescent boys,
for survivors of terrorist attacks, for children of Holocaust survivors,
for women with breast cancer, for dialysis patients, for people with
multiple sclerosis, for the deaf and hard of hearing, for people with
developmental disabilities, for transgendered individuals, for people
with borderline personality disorder, for irritable bowel (IBS)
sufferers, for amputees, for college dropouts, for people who have
had a myocardial infarction or a stroke, for parents of adopted
children, for bereaved spouses and parents, for the dying, for
refugees and asylum seekers, and for many, many others.3
Obviously, no single text could address each of these specialized
groups. Nor, even if it were possible, would it constitute an intelligent
training approach. Does any sensible teacher of zoology, to take one
example, undertake to teach anatomy by having the students
memorize the structures of each subspecies separately? Of course
not. Instead, the teacher teaches basic and general principles of
form, structure, and function and then proceeds to teach the
anatomy of a prototypical primal specimen that serves as a template
for all others. Remember those biology dissection laboratories?
The extension of this analogy to group therapy is obvious. The
group therapist must first master fundamental group therapy theory
and obtain a deep understanding of a prototypical therapy group. But
which group therapy best represents the original common ancestor?
If there is an ancestral group therapy, it is the interpersonal
outpatient group therapy described in this book. It was the first group
therapy, and over the past seventy years it has been the subject of a
great deal of systematic research and has stimulated an imposing
body of professional literature containing the observations and
conclusions of thoughtful clinicians and researchers.
Now that you have come this far in this text and are familiar with
the fundamental principles and techniques of the prototypical therapy
group, you are ready for the next step: the adaptation of basic group
therapy principles to any specialized clinical situation. That step is
the goal of this chapter. First, we describe the basic principles that
allow the group therapy fundamentals to be adapted to different
clinical situations, and then we present two distinct clinical
illustrations—the adaptation of group therapy for the acute
psychiatric inpatient ward, and the widespread use of groups for
clients coping with a variety of medical illnesses. The chapter ends
with a discussion of important developments in group therapy:
structured group therapies, self-help and support groups, and online
psychotherapy groups.
 MODIFICATIONS FOR SPECIALIZED CLINICAL
SITUATIONS: BASIC STEPS
To design a specialized therapy group, we suggest the following four
steps: (1) assess the clinical situation; (2) formulate appropriate
clinical goals; (3) modify traditional techniques to fit with the new
clinical situation and the new set of clinical goals; (4) evaluate the
effectiveness of your changes.

Assessment of the Clinical Situation

It is important to examine all the clinical factors that will bear on the
therapy group. Take care to differentiate the intrinsic limiting factors
(akin to computer hardware) from the extrinsic factors (akin to
software). The intrinsic ones are built into the clinical situation and
cannot be changed—for example, mandatory attendance for clients
on legal probation, the prescribed duration of group treatment in a
clinic, or frequent absences because of medical hospitalizations in
an ambulatory cancer support group.
The extrinsic limiting factors are arbitrary and within the power of
the therapist to change—for example, an inpatient ward may have a
policy of rotating the group leadership so that each group session
has a different leader, or an incest survivors group may traditionally
open with a long “check-in” (which may consume most of the
meeting) in which each member recounts the important events of the
week.
In a sense, the message of the AA serenity prayer has relevance
here: therapists must accept that which they cannot change (intrinsic
factors); change that which can be changed (extrinsic factors), if
necessary; and be wise enough to know the difference. Keep in mind
that as therapists gain experience, they often find that more and
more of the factors that seemed to be intrinsic are actually extrinsic
—and can be changed. For example, by educating the program’s or
institution’s decision-makers about the rationale and effectiveness of
group therapy, it is possible to create a more favorable atmosphere
for the therapy group.4 That is often the first task in creating
successful group therapies.

Formulation of Goals
When you have a clear view of the clinical facts—number of clients,
length of therapy, duration and frequency of group meetings, clinical
focus, type and severity of pathology, availability of co-leadership—
your next step is to construct a reasonable set of clinical goals.
You may not like the clinical situation. You may feel hampered by
the many intrinsic restraints that prevent you from leading the ideal
group. But do not wear yourself out by protesting an immutable
situation. Better to light a candle than to curse the darkness! With
proper modification of goals and technique, you will always be able
to offer some form of help.
We cannot overemphasize the importance of setting clear and
achievable goals. Nothing will so inevitably ensure failure as
inappropriate goals. The goals of the interpersonal outpatient group
we describe in this book are ambitious: to offer symptomatic relief
and to change character structure. If you attempt to apply these
same goals to, say, a group of young adults recently diagnosed with
a first episode of schizophrenia, you will rapidly become a
therapeutic nihilist and stamp yourself and group therapy as
ineffective or even harmful. An allied principle: do not underestimate
the broad impact of groups with tailored and circumscribed goals.
It is imperative that you shape a set of goals appropriate to the
clinical situation and achievable in the available time frame. The
goals must be clear not only to the therapists but to participants as
well. In our discussion of group preparation in Chapter 9, we
emphasized the importance of enlisting the client as a full
collaborator in treatment. You facilitate collaboration by making
explicit the goals and the group task and by linking the two: that is,
by making it clear to the members how the work of the therapy group
will help them attain those goals.
In time-limited, specialized groups, the goals must be tailored to
the capacity and potential of the group members. It is important that
the group be a success experience: clients enter therapy often
feeling defeated and demoralized, and the last thing they need is
another failure. In the discussion of the inpatient group in this
chapter, we shall give a detailed example of this process of goal
setting.

Modification of Technique
When you are clear about the clinical conditions and appropriate,
realizable goals, you must next consider the implications of these
conditions and goals for your therapeutic technique. In this step, it is
important to consider the therapeutic factors and to determine which
ones will play the greatest role in the achievement of the goals. It is a
phase of disciplined experimentation in which you alter technique,
style, and, if necessary, the basic form of the group to adapt to the
clinical situation and new goals of therapy. Keep in mind as well that
despite the unique clinical populations addressed and the group
modifications required, your understanding of the core principles of
group therapy process and of group leadership is an invaluable
asset.5
To provide a brief hypothetical example, suppose you are asked
to lead a group in an area that is unfamiliar to you. Say, for example,
that a large network of family doctors asks you to lead a brief group
for men who have suffered heart attacks. The men are often
depressed and resist cardiac rehabilitation.6 Your overriding goal is
to help these men become able and motivated to participate in their
own rehabilitation.
During your screening interviews (never skip that step), you
develop some additional goals: you discover that some clients are
negligent about taking their medication and that all of them suffer
from severe social isolation and pervasive feelings of hopelessness
and meaninglessness. They feel compromised as men, and many
dread their next heart attack. So, given the additional goals of
working on these issues, how do you modify standard group
techniques to achieve them most efficiently?
First, you must assiduously monitor the fluctuations and intensity
of their depression. You might ask members to fill in a brief
depression scale each week. Or you could begin each meeting with
a brief check-in focused on isolation and mood. Because of their
discouragement and social isolation, you may wish to encourage
rather than discourage extragroup contact among the members,
perhaps even mandating a certain number of phone calls, texts, or
email messages from clients to therapists and between clients each
week. You may decide to encourage an additional coffee hour after
the meeting or between meetings. Or you may address both the
isolation and the sense of uselessness by tapping the therapeutic
factor of altruism—for example, by experimenting with a “buddy
system,” in which new members are assigned to one of the more
experienced members, who serves as a mentor. The experienced
member would check in with the new member during the week to
make sure he is taking his medication and participating in rehab. The
veteran member can “sponsor” the new member in the group
session, making sure he gets sufficient time and attention.
There is no better antidote to isolation than deep therapeutic
engagement in the group; thus you must strive to create positive
here-and-now interactions in each meeting. Focusing on the
members’ immediate value to one another can work wonders.
Instilling hope is critical for these men, and to facilitate this you may
choose to include some clients in the group who have already
regained their self-efficacy and ability to function in the world.
Shame about physical disability is also an isolating force. The
therapist might wish to counteract this shame through physical
contact—for example, asking members to join hands at the end of
meetings for a brief guided meditation. In an ideal situation, you may
launch a support group that will evolve, after the group therapy ends,
into a freestanding self-help group for which you act as consultant.
It is clear from this example that therapists must know a good
deal about the special problems of the clients in their group. This is
true for each clinical population; there is no all-purpose formula.
Therapists must do their homework, immersing themselves in the
specific clinical area, in order to understand the unique problems and
dynamics that are likely to develop during the course of the group.7
For instance, therapists leading interpersonal groups of clients
with alcohol abuse must expect to deal with issues surrounding
sobriety, AA attendance, sneak drinking, deception, emotional
dependency, deficiencies in the ability to regulate anxiety, and a
proclivity to act out.8
Bereavement groups must often focus on guilt (for not having
done more, loved more, been a better spouse), on loneliness, on
major life decisions, on life regrets, on adapting to a new,
unpalatable life role, on feeling like a “fifth wheel” with old friends,
and on the need to “let go” of the dead spouse despite the pain that
is entailed. (Many widows and widowers feel that building a new life
would signify a betrayal of their dead spouse.) These groups must
also focus on issues around dating (and the ensuing guilt), and if the
therapist is skillful, on personal growth.
Retirement groups must address such themes as recurrent
losses, increased dependency, loss of one’s social role, the need for
new sources of validation for one’s sense of self-worth, diminished
income and expectancies, relinquishment of a sense of continued
ascendancy, late life developmental tasks, and shifts in one’s
spousal relationship as a result of more time shared together.9
Groups for burdened family caregivers of individuals with
Alzheimer’s disease must focus on the experience of loss and on the
horrific experience of caring for spouses or parents who are but a
shell of their former selves, unable to acknowledge their caregivers’
efforts or even identify them by name. They focus also on caregivers’
isolation, on their strategies for coping with their burden, and the guilt
they feel for wanting (or achieving) some emancipation from this
burden. These groups may involve role playing of difficult caregiving
scenarios, perhaps using trained actors (standardized patients) as
the individuals with dementia to build skills for managing difficult,
oppositional, or aggressive behavior. And importantly, these groups
will provide validation and recognition of the caregivers’ efforts and
personhood.10
Groups for health-care workers dealing with the stresses of
providing care in a pandemic create opportunities for members to
identify their chief concerns. These could include adequate access to
resources to care for their patients, fear for their own safety, access
to personal protective equipment, moral distress in not being able to
provide care according to their professional and personal standards,
and grief and loss. The groups would work to build safety for their
members, foster social support, educate about coping strategies,
restore a sense of efficacy, and promote hope for the future.11
Groups for psychological trauma would likely address a range of
concerns, perhaps through a sequence of different group tasks.
Building safety, trust, and security would be important at first. Being
together with others who have experienced a similar trauma and
learning about the impact of trauma on the mind and body can
reduce feelings of isolation and confusion. Later these groups might
use structured behavioral interventions, such as deep breathing or
imagery, to treat specific trauma symptoms. Next, they might
address how trauma has altered members’ basic beliefs and
assumptions about the world. If the trauma was caused by sexual
abuse, these groups would ideally be gender-specific in the earlier
stage of work. Later, a mixed-gender group may be necessary to
complete the process of the client’s reentry into the posttrauma
world.12
Or, if the traumatized clients were refugees escaping war and
violence, the leaders would need to modify the approach to provide
sensitive, culturally attuned care. Any psychoeducational materials
would need to be translated into the requisite language of the
participants and adapted to the clients’ varying levels of mental
health literacy. You might employ more nonverbal behavioral
interventions that require less use of language. An example would
be teaching parents how to play with their young children in ways
that promote security, communication, and mastery of fear.
Strengthening individual families increases, in turn, the sense of
security of the larger community.13
In summary, to develop a specialized therapy group, we
recommend taking the following steps:
 1. Assess the clinical setting. Determine the immutable clinical
restraints.
2. Formulate goals. Develop goals that are appropriate and
achievable within the existing clinical restraints.
3. Modify traditional technique. Retain the basic principles and
therapeutic factors of group therapy, but alter the techniques
to achieve the specified goals: therapists must adapt to the
clinical situation and the dynamics of the special clinical
population.
4. Evaluate your work. Study and attempt to improve your work.

These steps are clear but too aseptic to be of immediate clinical

usefulness. We shall illustrate the entire sequence in detail by
describing the development of a therapy group for the acute
psychiatric inpatient ward.
We focus on an acute inpatient therapy group for two reasons.
First, it offers a particularly clear opportunity to demonstrate many
principles of strategic and technical adaptation. The clinical
challenge is severe: The acute inpatient setting is so inhospitable to
group therapy that radical modifications of technique are required.
Second, this particular example may have value to many readers
since the inpatient group is a common specialized group: therapy
groups are led on most acute psychiatric wards. This is true even in
this era of ever briefer hospital stays. Inpatient psychiatric care
appears to be increasing in prevalence as well, often as a result of
inadequate community-based care for clients.14 Clients value the
social and relationship opportunities on their inpatient units, yet in
many units they spend a staggering amount of time idle and socially
disconnected.15 Group therapy can address these relationship
needs. For many clients, it is their first therapeutic group exposure;
hence it behooves us to make it a constructive experience. And it is
significantly impactful on overall clinical outcomes. Group therapy in
inpatient settings also improves staff morale and increases the
providers’ sense of purpose.16 As any staff member can easily
perceive, group therapy is far more humane and effective than “beds
and meds” as a treatment philosophy.
 THE ACUTE INPATIENT THERAPY GROUP

The Clinical Setting

The outpatient group that we describe throughout this book is
freestanding; all important negotiations occur between the group
therapist(s) and the seven or eight group members. Not so for the
inpatient group! When you lead an inpatient group, the first clinical
fact of life you must face is that your group is never an independent,
freestanding entity. It always has a complex relationship to the
inpatient ward in which it is ensconced. What happens between
members in the small therapy group reverberates with what
transpires within the large group of the unit and institution.17
The inpatient group’s effectiveness, often its very existence, is
heavily dependent upon administrative engagement and backing. It
is important to distinguish between types of inpatient groups: ward
community meetings, group activities and programming, and group
therapy. All of these are important, but they have very different goals
as well as different training and leadership requirements.18 Some
groups exist at the interface, such as watching a well-selected film
and discussing its relevance regarding recognition and
communication of clients’ feelings and social relationships.19 If the
ward medical director and the clinical nursing coordinator are not
convinced that the group therapy approach is effective, they are
unlikely to lend support and may undermine the prestige of the
therapy groups in many ways: for example, they may not assign staff
members to group leader positions on a regular schedule, they may
ask less experienced staff members to lead the group, or they may
not provide supervision or even schedule group sessions at a
functional, consistent time. Therapy groups under such conditions
are rendered ineffective. The group leaders are unsupported and
rapidly grow demoralized. Meetings are scheduled irregularly and
are often disrupted by members being yanked out for individual
sessions or for a variety of other hospital appointments.
 Is this state of affairs an intrinsic, immutable problem? Absolutely
not! Rather, it is an extrinsic, attitudinal problem and stems from a
number of sources, especially the professional education of the ward
administrators. Many psychiatric training programs and nursing
schools do not offer a comprehensive curriculum in group therapy
(and virtually no programs offer sound instruction in inpatient group
psychotherapy). It is completely understandable that ward directors
decline to invest ward resources and energy into a treatment
program about which they have little knowledge and in which they
have no faith. Interprofessional tensions may also play a role: Is
group therapy leadership valued, or considered a low-status activity?
Which disciplines are entrusted to provide psychotherapy? The small
therapy group must not be used as a battleground upon which
professional interests are contested.
Without a potent psychosocial therapeutic intervention, inpatient
wards rely only on medication, and the work of the staff is reduced to
custodial care. We believe that inpatient care can be improved
through greater clinical engagement. Copious research
demonstrates the effectiveness of inpatient group therapy.20
A well-functioning group program can permeate and benefit the
milieu as a whole, and the small group should be seen as a resource
to the system as a whole.21 By combining training, supervision, and
regular, measurement-based feedback to clinicians about their
inpatient group work, a large US behavioral health care network,
providing care to thirteen thousand clients annually, transformed
clinical care. They demonstrated the following: significant
improvements in clinical outcomes, significant improvements in client
satisfaction, significant reductions in aggression and critical
incidents, and significantly improved staff morale.22 Such is the
power of properly led group therapy.
In addition to these extrinsic, programmatic problems, the acute
inpatient ward poses several major intrinsic problems for the group
therapist. There are several particularly challenging problems that
must be faced by every inpatient group therapist.
Rapid Client Turnover. The duration of psychiatric hospitalization
has shortened inexorably. On many wards, hospital stays range from
a few days to a week or two. This means, of course, that the
composition of the small therapy group will be highly unstable. In
different inpatient settings we have led groups that have met three to
five times a week for many years, and these groups have rarely had
the same set of members for two consecutive meetings—almost
never for three.
This appears to be an immutable situation. The group therapist
has little influence on ward admission and discharge policy. In fact,
more and more commonly, discharge decisions are based on
economic and system pressures rather than individual clinical
concerns. Staff members feel overburdened and stretched. The
high-pressure, revolving-door inpatient unit is here to stay, and even
as the door opens and shuts ever faster, clinicians must continue to
keep primary focus on the client’s treatment, doing as much as they
can within the imposed constraints.23 But we also must not create
added staff demand without providing commensurate support.
Heterogeneity of Psychopathology. In Chapter 8, we stressed the
importance of composing a group thoughtfully and of avoiding
members who will fail to fit in with the group, and to selecting
members with roughly the same amount of ego strength. How, then,
to lead a group in which one has almost no control over the
membership, a group in which there may be floridly psychotic
individuals sitting side by side with higher-functioning, better-
integrated members?
In addition to the major confounding factors of rapid client
turnover and the range of psychopathology, several other intrinsic
clinical factors exert significant influence on the functioning of an
inpatient psychotherapy group, including time limitations, group
boundaries, and unique group leader challenges.
Time Limitations. The therapist’s time is very limited. Generally,
there is no time to see a client in a pregroup interview to establish a
relationship, let alone a therapeutic alliance, and to prepare the
person for the group. There is little time to integrate new members
into the group, to address endings (someone terminates the group
almost every meeting), to work through issues that arise in the
group, or to focus on transfer of learning.
Group Boundaries. Group boundaries in inpatient settings are
often blurred. Members are generally in other groups on the ward
with some or many of the same members. Extragroup socializing is
the rule rather than the exception: clients spend their entire day
together. The boundaries of confidentiality are similarly blurred.
There can be no true confidentiality in the small inpatient group:
clients often share important small group events with others on the
ward, and staff members freely share information with one another
during rounds, nursing reports, and staff meetings. It is therefore
imperative that the inpatient small group boundary of confidentiality
be elastic and encompass the entire ward staff rather than being
confined to any one group within that ward. Otherwise the small
group becomes disconnected from the unit. Negotiating and
managing these boundaries is a key group leader task.24
Challenges for the Group Leader. The role of inpatient group
leaders is complex because they may be involved with clients
throughout the day in other roles. Their attendance may often be
often erratic. Group leaders are frequently psychiatric nurses who,
because of the necessity of weekend, evening, and night coverage,
are on a rotating schedule and often cannot be present at the group
for several consecutive meetings.
Therapist autonomy is limited in other ways as well. For example,
just as therapists have only limited control over group composition,
they rarely have a choice about co-therapists, who are usually
assigned on the basis of the rotation schedule. Inpatient group
therapists usually feel more exposed than their outpatient
colleagues. Difficulties in the group will be readily known by all on
the unit. Lastly, the harried pace of the acute inpatient ward leaves
little opportunity for supervision, or even for a postmeeting
discussion between co-therapists.

Formulation of Goals
Once you have grasped these clinical facts of life of the inpatient
therapy group and differentiated intrinsic from extrinsic factors, it is
time to ask this question: Given the many confounding intrinsic
factors that influence (and hobble) the course of the inpatient group,
what can the group accomplish? What are reasonable and attainable
goals?
Let us start by noting that the goals of the acute inpatient group
are distinct from those of acute inpatient hospitalization. The goal of
the group is not to resolve a psychotic episode, not to regulate a
client with mania, not to diminish hallucinations or delusions, not to
resolve a deep depression. Inpatient groups can do none of these
things.
So much for what the inpatient group cannot do. What can it
offer? We will describe six achievable goals.

1. Engage clients in the therapeutic process.

2. Demonstrate to clients that talking helps.
3. Help clients identify and spot problems.
4. Decrease clients’ isolation.
5. Provide opportunities for clients to help others.
6. Reduce ward tensions and hospital-related anxiety.

1. Engage clients in the therapeutic process.

The contemporary pattern of acute psychiatric hospitalization—
brief but repeated admissions to psychiatric wards in general
hospitals—can be more effective than longer hospitalization only if
the inpatient stay is followed by adequate aftercare treatment. There
is good evidence that group therapy is a particularly efficacious
mode of aftercare treatment.25
A primary goal of inpatient group therapy emerges from these
findings—namely, to engage the client in a process that he or she
perceives as constructive and supportive and will wish to continue
after discharge from the hospital.
2. Demonstrate to clients that talking helps.
The inpatient therapy group helps clients learn that talking about
their problems is helpful. They learn that there is relief to be gained
in sharing pain and in being heard, understood, and accepted by
others. From listening to others, members also learn that others
suffer from the same types of disabling distress as they do, that one
is not unique in one’s suffering.
> In an inpatient therapy group, Sally, an agitated woman with
paranoid delusions, demanded to know why her roommate, Rose, had
asked her to play Ping-Pong on the unit table. Sally declared that she
loved Ping-Pong, but how could Rose know that? Sally was concerned
that Rose was able to read her mind and that Rose was stealing ideas
from her brain. Rose responded that she had no knowledge of Sally’s
thinking—it was an innocent request to pass the time. That message
needed to be repeated and reinforced, and Sally eventually replied,
“Then does that mean you cannot read my thoughts? I was so scared of
that.” <<

3. Help clients identify problems.

The duration of therapy in the inpatient therapy group is far too brief
to allow clients to work through problems. But participation in the
group can efficiently help clients spot problems that they may work
on effectively in ongoing individual therapy, both during their hospital
stay and in their post-discharge therapy. By providing a discrete
focus and direction for therapy, which clients value highly, inpatient
groups increase the efficiency of other therapies.26
It is important that the group identify client problems that are
circumscribed and malleable (not problems such as chronic
unhappiness, depression, or suicidality, all of which are too
generalized to offer a discrete handhold for therapy). The group is
most adept at helping members identify problems in their mode of
relating to other people. It offers the ideal arena to learn about
maladaptive interpersonal behavior. Emily’s story is a good
illustration of this point:
> Emily was an extremely isolated young woman who was admitted
to the inpatient unit because of depression. She complained that she
always called others to arrange social engagements but never received
 invitations, and she had no close girlfriends who sought her out. Her
dates with men always turned into one-night stands. She attempted to
please them by going to bed with them, but they never called for a
second date. People seemed to forget her as soon as they met her.
During the three group meetings she attended, the group gave her
consistent feedback about the fact that she was always pleasant and
always wore a gracious smile and always seemed to say what she
thought would be pleasing to others. In this process, however, people
soon lost track of who Emily was. What were her own desires and
feelings? Her need to be eternally pleasing had a serious negative
consequence: people found her uninteresting and inaccessible.
A dramatic example occurred in her second meeting, when I (IY)
forgot her name and apologized to her. Her response was, “That’s all
right, I don’t mind.” I suggested that the fact that she didn’t mind was
probably one of the reasons I had forgotten her name. In other words,
had she been the type of person who would have minded or made her
needs more overt, then most likely I would have remembered her
name. In her three group meetings, Emily had identified a major
problem that had far-reaching consequences for her relationships: her
tendency to submerge herself in a desperate but self-defeating attempt
to capture the affection of others. <<

4. Decrease clients’ isolation.

The inpatient group can help break down the isolation that exists
between members. The group is a laboratory exercise intended to
sharpen communication skills: the better the communication, the less
the isolation. It helps individuals share with one another, permits
them to obtain feedback about how others perceive them, and helps
them discover their blind spots.
Decreasing isolation between group members has two distinct
payoffs. First, improved communication skills will help clients in their
relationships with others outside the hospital. Virtually everyone who
is admitted in crisis to an inpatient ward suffers from a breakdown or
an absence of important supportive relationships with others. If the
client is able to transfer communication skills from the group to his or
her outside life, then the group will have fulfilled a very important
goal.
A second payoff is evident in the client’s behavior on the ward: as
isolation decreases, the client becomes increasingly able to use the
therapeutic resources available, including relationships with other
patients.27
> Jack, a man with chronic schizophrenia, reluctantly attended his
first meeting on the inpatient ward. He told the group that his guardian
angel, who regularly transmitted messages to him through the TV,
advised him to be very cautious about talking with anyone on the unit or
in the group. I (ML) welcomed Jack to the meeting, acknowledged his
caution, and noted that in telling us about his guardian angel, he was
informing us about his need for both safety and for connection. He
relaxed notably when I commented that I hoped that he would see that
the group and the ward were intended to be safe for him and for all
participants: we all could benefit from feeling that there was someone
out there looking out for us. Mary, admitted for depression marked by
feelings of worthlessness and ineffectiveness, then asked Jack if they
could eat together that evening. She had noticed his isolation and
wanted him to feel more comfortable. She added that she was pushing
herself hard to engage more and was taking a risk now. Jack responded
positively, saying, “We can sit together, but don’t expect me to talk yet.”
<<

5. Provide opportunities for clients to help others.

This goal, the therapeutic factor of altruism, is closely related to the
previous one. Clients are not just helped by their peers; they are also
helped by the knowledge that they themselves have been useful to
others. Clients generally enter psychiatric hospitals in a state of
profound demoralization. They feel that not only can they not help
themselves, but they have nothing to offer others. The experience of
being valuable to other ward members is enormously affirming to
one’s sense of self-worth. Mary’s response to Jack in the last
vignette is an illustration of that process.
6. Reduce ward tensions and hospital-related anxiety.
The process of psychiatric hospitalization can be intensely anxiety
provoking. Many clients experience great shame and are concerned
about stigmatization and the effects of hospitalization on their jobs
and friendships. Many are distressed by events on the ward—not
only the bizarre and frightening behavior of very ill clients, but also
the evident staff tensions.
Many of these secondary sources of tension compound the
client’s primary dysphoria and must be addressed in therapy.
Inpatient group therapy (as well as the larger, unit-wide community
meeting) provides a forum in which clients can air these issues, and
often they are reassured simply from learning that other members
share these concerns. They can learn, for example, that their
roommates are not hostile or intentionally rejecting them, but
preoccupied and fearful. One man who had been quite frightening on
the unit while in an agitated manic state came to inpatient group
therapy to apologize for his threatening behavior when he had been
psychotic. He was mortified and wanted to tell us that such behavior
was not typical of him. We have seen variations on the same theme
many times. For this man, the experience was also a powerful
reminder to adhere to his medication regimen.

Modifying Technique
We have now accomplished the first two steps of designing a group
for the contemporary inpatient ward: (1) assessing the clinical
setting, including identifying the intrinsic clinical facts of life on the
unit, and (2) formulating an appropriate and realistic set of goals.
Now we are ready to turn to the third step: designing a clinical
strategy and technique that provides support, education, and the
acquisition of communication, coping, and life skills.28
The Therapist’s Time Frame. In the conventional outpatient
therapy group we have described earlier in this text, the therapist’s
time frame is many weeks or months, sometimes years. Therapists
must be patient, must build cohesiveness over many sessions, and
work through issues repetitively from meeting to meeting. The
inpatient group therapist faces an entirely different situation: the
group composition changes almost every day, and the duration of
therapy for members is often very brief—indeed, many attend the
group for only a single session.
Hence the inpatient group therapist must adopt a radically
shortened time frame. Perhaps there will be continuity from one
meeting to the next, and perhaps there will be culture-bearers who
will be present in several consecutive meetings, but do not count on
it. It is best to assume that your group will last for only a single
session, and you must strive to offer something useful for as many
participants as possible during that session.
Efficiency and Activity. The single-session time frame demands
efficiency. You have no time to allow issues to build, to let things
develop in the group and slowly work them through. You have no
time to waste; you have only a single opportunity to engage the
clients, and you must not squander it. There is no place in inpatient
group therapy for the passive, reflective group therapist. You must
activate the group by calling on, supporting, and interacting
personally with members. This increased level of activity requires a
major shift in technique for the therapist who has been trained in
long-term group therapy, but it is an absolutely essential modification
of technique. Though leading inpatient group therapy is often more
challenging than leading outpatient open-ended groups, all too often
little attention is paid to the training, development, and supervision of
the inpatient group therapist.29
Keep in mind that one of the major goals of the inpatient therapy
group is to engage clients in a therapeutic process they will wish to
continue after leaving the hospital. Thus, it is imperative that the
therapist create in the group an atmosphere that members
experience as supportive, positive, and constructive. Members must
feel safe, understood, and accepted.
The inpatient therapy group is not the place for confrontation, for
criticism, or for the expression and examination of intense anger.
There will often be members in the group who are conning or
manipulative and who may need powerful confrontation, but it is far
better to let them pass unchallenged than to run the risk of making
the group feel unsafe to the vast majority of participants.
Recognizing group process and group dynamics is no less important
in the inpatient setting than in the open-ended, longer-term group,
but there is a difference: in the inpatient group, you use your
understanding to make the group safe and supportive rather than to
deepen exploration.30
Group leaders need to recognize and incorporate both the needs
of the group and the needs of the individual into their intervention.
Consider, for example, Jared, an angry man with bipolar disorder
who arrived at the group the day after being forcibly restrained and
secluded by unit staff. He had earlier threatened to harm a nurse
who refused his request for a pass off the ward. Jared obstinately sat
silently outside of the circle with his back to the group members.
Addressing Jared’s behavior was essential—it was too threatening to
ignore—but it was also potentially inflammatory to engage Jared
against his evident wish. The group leader chose to acknowledge
Jared’s presence, noting that it likely was hard for Jared to come to
the group after the tensions of the night before. He was welcome to
participate more fully if he chose, but if not, just coming was
welcomed. Though Jared maintained his silent posture, the group
was liberated and able to proceed.
In the long-term outpatient group, therapists provide support both
directly and indirectly: direct support through personal engagement,
empathic listening, and understanding, expressed in accepting
glances, nods, and gestures; indirect support by building a cohesive
group that then becomes a powerful agent of support.
Inpatient group therapists must learn to offer support quickly and
directly. Support is not something that therapists reflexively provide.
Therapists are often trained to become sniffers of pathology, experts
in the detection of weaknesses, and often hold themselves back
from engaging in basic supportive behavior with their clients.
Support may be offered in myriad ways. The most direct, the most
valued by clients, and the most often overlooked by professional
therapists is a gentle acknowledgment of the members’ efforts,
intentions, strengths, positive contributions, and risks.31 If, to take an
obvious example, one member states that he finds another member
in the group very wise or very warm, it is important that this member
be supported for the risk he has taken. You may wonder whether he
has previously been able to express his admiration of another so
openly and note, if appropriate, that this is reflective of real progress
for him in the group. Or, suppose you note that several members
have been more self-disclosing after one particular member took a
risk and revealed delicate and important material—then openly
comment on it! Do not assume that members automatically realize
that their disclosures have helped others take risks. Identify and
reinforce the adaptive parts of the client’s presentation.32
Try to emphasize the positive rather than the negative aspects of
a defensive posture. Consider, for example, members who persist in
playing assistant therapist. Do not confront them by challenging their
refusal to work on personal issues; instead offer positive comments
about how helpful they have been to others and then gently
comment on their unselfishness and reluctance to ask for something
personal from the group. It is the rare individual who resists the
therapist’s suggestion that he or she needs to learn to be more
selfish and to ask for more from others.
The therapist also can help members obtain support from the
group. Some clients, for example, obtain very little support from the
others because they characteristically present themselves in a highly
objectionable fashion. A self-centered member who incessantly
ruminates about a somatic condition will rapidly exhaust the patience
of any group. When the leader spots such behavior, it is important to
intervene quickly before animosity and rejection have time to well up
and the client commits social suicide. The leader may try any
number of tactics—for example, directly instructing the client about
other modes of behaving in the group, or assigning the client the
task of introducing new members into the group, giving feedback to
other members, or attempting to guess and express what each
person’s evaluation of the group is that day.
> Consider a woman who talked incessantly about her many surgical
procedures. It became clear to me (IY) from listening to this woman’s
description of her life situation that she felt she had given everything to
her children and family and had received nothing in return. I suggested
that when she talked about her surgical procedures, she was really
saying, “I have some needs, too, but I have trouble asking for them. My
 talking about my surgery is a way of asking, ‘Pay some attention to
me.’”
Over the course of three sessions, she agreed with my formulation
and gave me permission, whenever she talked about her surgery, to
translate that into the real message, “Pay more attention to me.” When
she explicitly requested help, the members responded to her positively,
in contrast to their negative response to the endless recitation of her
litany of somatic complaints.33 <<

Another approach to support is to make certain the group feels

safe by anticipating and avoiding conflict whenever possible. If
clients are irritable or want to learn to be more assertive or to
challenge others, it is best to channel that work onto yourself: you
are, let us hope, in a far better position to handle criticism than are
the group members.
The inpatient group is not the place for intensification of affect or
hostility. If two members are engaged in conflict, it is best to
intervene quickly and to search for positive aspects of the conflict.
For example, keep in mind that sparks often fly between two
individuals because of the group phenomenon of mirroring: one sees
aspects of oneself (especially negative aspects) in another, and
dislikes that person because of what one dislikes in oneself.34 Thus,
you can deflect conflict by asking individuals to discuss the various
ways in which they resemble their adversary. Can they put
themselves into the shoes of the other and speculate on what their
adversary might be feeling? In this way you may turn tension into
empathy.
There are many other conflict-avoiding strategies. Envy is often
an integral part of interpersonal conflict, and it can be constructive to
ask adversaries to talk about those aspects of each other that they
admire or envy. Role switching is sometimes a useful technique: ask
adversaries to switch places and present the other’s point of view.
An effective technique is to remind the group that opponents
generally prove to be very helpful to each other, whereas those who
are indifferent rarely help each other grow.
One reason some members experience the group as unsafe is
that they fear things will go too far and that the group may coerce
them to lose control—to say, think, or feel things that will result in
interpersonal catastrophe. You can help these members feel safe in
the group by encouraging them to exercise control over their own
participation. Check in with members repeatedly by asking
questions: “Do you feel we’re pushing you too hard?” or “Is this too
uncomfortable for you?” or “Do you think you’ve revealed too much
of yourself today?” Make small engagement contracts along the way.
In groups of more disturbed, regressed clients, group leaders
must provide even more direct support. Find the latent human core
beneath the manifest psychotic symptoms. Examine the behavior of
the severely regressed client and find in it some positive aspect:
support the mute member for staying the whole session, compliment
the member who leaves early for having stayed twenty minutes,
support the member who arrives late for having shown up, support
inactive members for having paid attention throughout the meeting. If
members try to give advice, even inappropriate advice, reward them
for their intention to help. If statements are unintelligible or bizarre,
label them as attempts to communicate. One group member, Jake,
hospitalized because of a psychotic decompensation, angrily blurted
out in the group that he intended to get Satan to rain “hellfire and
brimstone upon this God-forsaken hospital.” Group members
withdrew into apprehensive silence. I (ML) wondered aloud what had
provoked this angry explosion. Another member commented that
Jake had been agitated since his discharge planning meeting. Jake
then said that he did not want to go to the hostel that was
recommended. He wanted to go back to his boardinghouse because
it was safer from theft and assault. That was something everyone in
the group could understand and support. Finding the underlying and
understandable human concern brought Jake and the group
members back together—a far better situation than isolating Jake
because of his bizarre behavior.

The Here-and-Now Focus of the Inpatient Group

Throughout this text, we have repeatedly emphasized the
importance of here-and-now interaction in the group therapeutic
process. We have stressed that work in the here-and-now is the
heart of the group therapeutic process, the power cell that energizes
the therapy group. Yet when we visit inpatient wards, we find that
groups rarely focus on here-and-now interaction. Such avoidance of
the here-and-now is, in our view, precisely the reason so many
inpatient groups are ineffective.
If the inpatient group does not focus on the here-and-now, what
other options are there? Most inpatient groups adopt a then-and-
there focus in which members, following the therapist’s cues, take
turns presenting their “back-home problems”—those that brought
them into the hospital—while the rest of the group attempts to
address those problems with exhortations and advice. This approach
to inpatient group therapy is the least effective way to lead a therapy
group and almost invariably sentences the group to failure.
The problems that brought a person into the hospital are complex
and overwhelming. They have generally foiled the best efforts of
skilled mental health professionals and will, without question, stump
the therapy group members. The then-and-there focus has many
other disadvantages as well. For one thing, it results in highly
inequitable time sharing. If much or all of a meeting is devoted to one
member, many of the remaining members will feel ignored or bored.
Unlike outpatient group members, they cannot even bank on the
idea that they have credit in the group—that is, that the group owes
them time and attention. Since they will most likely soon be
discharged or find themselves in a group composed of completely
different members, they are left clutching worthless IOUs.
Some inpatient groups focus on ward problems—ward tensions,
staff-client conflict, housekeeping disputes, access to smoking or
passes, and so on. Generally, this is also an unsatisfactory use of
the therapy group. In any therapy group meeting, only a few
members and one or two staff members will be present. There is no
quorum for meaningful discussion. A much better arena for dealing
with ward problems and ward business is the community meeting, in
which all clients and staff are present.35
 Other inpatient groups focus on one or more common themes—
for example, suicidal ideation, the experience of hospitalization and
treatment, symptoms such as hallucinations, or drug side effects.
Such meetings may be of value to some but rarely to all members.
Often such meetings serve primarily to dispense information that
could easily be provided to clients in other formats. It is not the most
effective way of using the inherent power of the small group.
The clinical circumstances of the inpatient group do not make the
here-and-now focus any less important or less advisable. In fact, the
here-and-now focus is as effective in inpatient as in outpatient
therapy. However, the clinical conditions of inpatient work demand
modifications in technique. As we mentioned earlier, there is too little
time to work through interpersonal issues. Instead, you must help
clients spot interpersonal problems and reinforce interpersonal
strengths while encouraging them to attend ongoing post-hospital
treatment where they can pursue and work through the interpersonal
issues they have identified in the group.
The most important point to be made about the use of the here-
and-now in inpatient groups is already implicit in the foregoing
discussion of support. We cannot emphasize too heavily that the
here-and-now is not synonymous with conflict, confrontation, and
critical feedback. We are certain that it is because of this erroneous
assumption that so few inpatient group therapists capitalize on the
value of here-and-now interaction.
Conflict is only one—and by no means the most important—facet
of here-and-now interaction. The here-and-now focus helps
members learn many invaluable interpersonal skills: how to
communicate more clearly, get closer to others, and express positive
feelings; how to become aware of personal mannerisms that push
people away; and how to listen, offer support, reveal oneself, and
form friendships.
The inpatient group therapist must pay special attention to the
issue of the relevance of the here-and-now. All the members of an
inpatient group are in crisis. All are preoccupied with their life
problems and immobilized by dysphoria or confusion. Unlike many
outpatient group members who are interested in self-exploration, in
personal growth, and in improving their ability to cope with crisis,
inpatients are in a survival mode, and unlikely to readily apprehend
the relevance of the here-and-now focus for their problems.
Therefore, the therapist must provide explicit instruction about its
relevance. We begin each group meeting with a brief orientation in
which we emphasize that, though individuals may enter the hospital
for different reasons, everyone in the group can benefit from
examining how he or she relates to other people. Everyone can be
helped by learning how to get more out of relationships with others.
We focus on relationships in group therapy because that is what
group therapy does best. In the group, there are other members and
one or two mental health experts who are willing to provide feedback
about how they relate to others in the group. We always
acknowledge that members have important and painful problems
other than interpersonal ones, but note that these problems need to
be addressed in other therapeutic modalities: in individual therapy, in
social work interviews, in couples or marital therapy, and/or with
medication or other biological treatments.

Modes of Structure
In acute inpatient group work, regardless of model, there is no place
for the nondirective group therapist. The group leader serves as an
essential and stabilizing anchor for the group participants. You are a
chief agent of any semblance of cohesion that the group will
experience. The great majority of clients on an inpatient ward are
confused, frightened, and disorganized; they crave structure and
stability. Consider the experience of individuals newly admitted to the
psychiatric unit: they are surrounded by other troubled, irrational
clients; their mental acuity may be dulled by medication; they are
introduced to many staff members who, because they are on a
complex rotating schedule, may not appear to have consistent
patterns of attendance; and they are being exposed, sometimes for
the first time, to a wide array of treatments and treaters.
Often the first step to acquiring internal structure is exposure to a
clearly perceived externally imposed structure. In a study of
debriefing interviews with recently discharged inpatients, the
overwhelming majority expressed a preference for group leaders
who provided an active structure for the group.36 They appreciated a
therapist who provided crystal-clear direction for the procedure of the
group, who actively invited members to participate, who assured
equal distribution of time, and who reminded the group of its basic
group task and direction. The research and clinical literature strongly
agree that such leaders obtain superior clinical results.37

Spatial and Temporal Boundaries

A secure space and time for the inpatient group should be
considered sacrosanct. The ideal physical arrangement for an
inpatient therapy group, as for any type of group, is a circle of
members meeting in an appropriately sized room with a closed door
and comfortable seating. It sounds simple, yet the physical plan of
many wards makes these basic requirements difficult to meet. The
failure to secure the group boundaries compromises group integrity
and cohesiveness and in turn compromises the work of the group; it
is far preferable to find some secure, safe, and reliable space, even
if it means meeting off the ward (provided it is safe to do so).
Structure is also provided by temporal stability. The ideal meeting
begins with all members present and punctual, and runs with no
interruptions until its conclusion. It is difficult to approximate these
conditions in an inpatient setting for several reasons: disorganized
clients arrive late because they forget the time and place of the
meeting; members may be called out for some medical or therapy
appointment; members with a limited attention span may ask to
leave early; heavily medicated members may fall asleep during a
session and interrupt the group flow; and agitated or panicked
patients may bolt from the group. Ward administration may advocate
for an open-door policy to maximize client attendance even if that
undermines the group boundaries.
Therapists must intervene in every way possible to provide
maximum stability. You should urge the unit administration to declare
the group time inviolable, so that group members cannot be called
out of the group for any reason (not because the group is the most
important therapy on the unit, but because these disruptions
undermine it, and group therapy, by its nature, has little logistical
flexibility). You may ask the staff members to remind disorganized
clients about the group meeting and escort them into the room. It
should be the ward staff’s responsibility, not the group leaders’
alone, to ensure that inpatients attend. And, of course, the group
therapists should always model promptness. Be wary of your
colleagues at the hospital using the phrase “your group.” It is not
your group; it is the ward’s group led by you and it must be
embedded in the unit structure and supported by the team.
The problem of bolters—members who run out of a group
meeting—can be approached in several ways. First, clients are
made more anxious if they perceive that they will not be permitted to
leave the room. Therefore, it is best simply to express the hope that
they can stay for the whole meeting. If they cannot, suggest that they
return the next session, when they feel more settled. The member
who attempts to leave the room in midsession cannot, of course, be
physically blocked, but there are other options. You may reframe the
situation in a way that provides a rationale for putting up with the
discomfort of staying: for example, in the case of a person who has
stated that he or she often flees from uncomfortable situations and is
resolved to change that pattern, you might recall that resolution. You
may comment, “Eleanor, it’s clear that you’re feeling very
uncomfortable now. I know you want to leave the room, but I
remember you saying just the other day that you’ve always isolated
yourself when you felt bad and that you want to try to find ways to
reach out to others. I wonder if this might not be a good time to work
on that by simply trying extra hard to stay in the meeting today?” You
may decrease Eleanor’s anxiety by suggesting that she simply be an
observer for the rest of the session, or you may suggest that she
change her seat to a place that feels more comfortable to her. You
may validate her distress and endorse her courage in coming for as
much of the meeting as possible. Reduce the client’s sense of
failure.
Groups may be made more stable by a policy that prohibits
latecomers from entering the group session once the door is closed,
perhaps after a five-minute grace period. Employing such a policy
poses an ethical dilemma in balancing inclusivity and protecting the
group’s boundaries. It may need to be discussed with the leadership
of the ward. This policy may create resentment in clients who arrive
late, but it also conveys that you value the group time and work and
that you want to get the maximum amount of uninterrupted work
each session. Interviews with discharged inpatients highlight that
they resent interruptions and approve of the therapists’ efforts to
ensure stability.38

Therapist Style
The therapist also contributes greatly to the sense of structure
through personal style and therapeutic presence. Confused or
frightened clients are reassured by therapists who are firm, explicit,
and decisive, yet who, at the same time are open about the reasons
for their actions. Judicious therapist transparency, as we have
discussed earlier (see Chapter 7), can reduce client anxiety and help
them make sense of the experience of the group. Inpatient groups
are disrupted repeatedly by major in-group events. Members are
often too stressed and vulnerable to deal effectively with such events
and are reassured if therapists act decisively and firmly. If, for
example, a manic member veers out of control and monopolizes the
group’s time, you must intervene and prevent that member from
obstructing the group’s work in that session. You may, for example,
tell the member that it is time to be quiet and to work on listening to
others, or, if the member is unable to exercise any control, you may
escort him or her from the room, inviting him to return when he is
feeling more settled.
Generally, it is excellent modeling for therapists to talk about the
dilemma they face and their ambivalent feelings in such a situation.
You may, for example, share both your conviction that you have
made the proper move for the welfare of the entire group and your
great discomfort at assuming an authoritarian pose. Everyone in the
group will be watching you and the manner in which you deal with
such tensions. Keep in mind the principles of nonshaming and
nonblaming, even in the context of firm limit setting. Conversely, you
may interrupt a detached and irrelevant discourse by reminding the
group members of their task regarding interpersonal support and
communication. Don’t hesitate in that spirit to be directive when it is
necessary to maintain the group’s therapeutic focus.

Group Session Protocol

One of the most potent ways of providing structure is to build a
consistent, explicit sequence into each session. This is a radical
departure from traditional outpatient group therapy technique, but in
specialized groups it makes for the most efficient use of a limited
number of sessions, as we shall see later when we examine
cognitive-behavioral therapy groups. In the inpatient group, a
structured protocol for each session increases efficiency and also
ameliorates anxiety and confusion in severely ill participants. We
recommend that rapid-turnover inpatient groups take the following
form:

1. The first few minutes. The therapist provides explicit structure

for the group and prepares the group members for therapy.
(Shortly, we will describe a model group in which we offer a
verbatim example of a preparatory statement.)
2. Definition of the task. The therapist attempts to determine the
most profitable direction for the group to take in a particular
session. Do not make the error of plunging in great depth into
the first issue raised by a member, for in so doing you may
miss other potentially productive agendas. You may determine
the task in several ways. You may, for example, simply listen
to get a feel of the urgent issues present that day. Or you may
provide some structured exercise that will permit you to
ascertain the most valuable direction for the group to take that
day. Your inpatient colleagues may inform you of critical
events that may affect the group members.
3. Filling the task. Once you have a broad view of the potentially
 fertile issues for a session, you attempt, in the main body of
the meeting, to address these issues, involving as many
members as possible in the group session.
4. Summing up. The last few minutes is the summing-up period.
You indicate that the work phase is over, and you devote the
remaining time to a review and analysis of the meeting. This is
the self-reflective loop of the here-and-now in which you
attempt to clarify, in the most lucid possible language, the
interaction that occurred in the session. You may also wish to
do some final mopping up: You may inquire about any jagged
edges or ruffled feelings that members may take out of the
session, or ask the members, both the active and the silent
ones, about their experience and evaluation of the meeting.

Disadvantages of Structure
Earlier in this text we remonstrated against excessive structure. For
example, in discussing the setting of norms, we urged that therapists
strive to make the group as autonomous and as responsible for its
own functioning as possible. As noted in Chapter 13, empirical
research demonstrates that leaders who provide excessive structure
may be positively evaluated by their members, but their groups fail to
have positive outcomes.39 The golden mean prevails: Too much or
too little leader structuring is detrimental to growth.
Thus, we face a dilemma. In many brief, specialized groups, we
must provide structure; but if we provide too much, our group
members will not learn to use their own resources. This is a major
problem for the inpatient group therapist, who must, for all the
reasons we have described, structure the group and yet avoid
infantilizing its members.
There is a way out of this dilemma—a way so important that it
constitutes a fundamental principle of therapy technique in many
specialized groups. The leader must structure the group so as to
encourage each member’s autonomous functioning. The following
illustration of an inpatient group will clarify this apparent paradox.
A Working Model
In this section we describe in some detail a model for the inpatient
group. It is best suited for those clients able to utilize a verbal format.
Those who are less able to participate may make better use of group
activities and group programming that engage clients in safe and
accessible tasks. The highly successful and impactful
implementation of this specific model across a large behavioral
health network in the United States is notable. It began in an inner-
city hospital treating indigent and marginalized psychiatric patients
with an average length of stay of five days. Building upon this initial
success, the model was used in the training of sixty group therapists
caring for over thirteen thousand psychiatrically ill individuals
annually. This model has been shown to produce better outcomes,
higher client satisfaction, a safer milieu, and improved staff morale.40
We suggest this approach for a group that meets three to five
times a week for approximately sixty to seventy-five minutes. Briefer
time frames of forty-five minutes have been employed with smaller
numbers of group participants. This model is described in greater
detail in an earlier text, Inpatient Group Psychotherapy.41

1. Orientation and Preparation: three to five minutes

2. Personal Agenda Setting: twenty to thirty minutes
3. Agenda Filling: twenty to thirty-five minutes
4. Review: ten minutes

1. Orientation and Preparation. The preparation of clients for the

therapy group is just as important in inpatient settings as it is in
outpatient group therapy. The time frame, of course, is radically
different. Instead of spending twenty to thirty minutes preparing an
individual for group therapy during an individual session, the
inpatient group therapist must accomplish such preparation for all
members in the first few minutes of the inpatient group session. We
suggest that the leader begin every meeting with a simple and brief
introductory statement that includes a description of the ground rules
(time and duration of meeting, need for punctuality), a clear
exposition of the purpose of the group, and an outline of the basic
procedure of the group, including the sequence of the meeting. The
following is a typical preparatory statement:
I’m Irv Yalom and this is Mary Clark. We’ll co-lead this afternoon
therapy group, which meets daily at two o’clock for one hour and
fifteen minutes. The purpose of this group is to help members learn
more about the way they communicate and relate to others. People
come into the hospital with many different kinds of important
problems, but one thing that most individuals have in common here
is some unhappiness about the way some of their important
relationships are going.
There are, of course, many other urgent problems that people
have, but those are best worked on in some of your other forms of
therapy. What this kind of group does best of all is to help people
understand more about their relationships with others. One of the
ways we can work best is to focus on the relationships that exist
between the people in this room. The better you learn to
communicate with each of the people here, the better it will become
with people in your outside life. Other groups on our unit may
emphasize other approaches and goals.
(If applicable you may add: It’s important to know that observers
are present almost every day to watch the group through this one-
way mirror. [Here, point toward the mirror and also toward the
microphone, if appropriate, in an attempt to orient the group
members as clearly as possible to the spatial surroundings.] The
observers are professional mental health workers, often medical or
nursing students, or other members of the ward staff. In the last ten
minutes of the group these observers will join us and share their
observations with us.)
We begin our meetings by going around the group and checking
with each person and asking each to say something about the kinds
of problems they’re having in their lives that they’d like to try to work
on in the group. That should take fifteen to thirty minutes. It is very
hard to come up with an agenda during your first meetings. But don’t
sweat it. We will help you with it. That’s our job. After that, we then
try to work together on as many of these problems as possible. Near
the end of the meeting, the group leaders will discuss together how
the meeting has been and any observers will join us at that point. [If
there are no observers, then the group co-therapists use this time as
form of rehash but with the group participants present]. Then, in the
last few minutes, we check in with everyone here about how they
size up the meeting and about the leftover feelings that should be
looked at before the group ends. We don’t always get to each
agenda fully each meeting, but we will do our best. Hopefully we can
pick it up at the next meeting, and you may find also that you can
work on it between sessions with your nurse or doctor or other
supports.
Note the basic components of this preparation: (1) a description
of the ground rules; (2) a statement of the purpose and goals of the
group; (3) a description of the procedure of the group (including the
precise structure of the meeting). Some inpatient therapists suggest
that this preparation can be partly communicated outside of the
group and should be even more detailed and explicit by, for example,
including a discussion of blind spots, supportive and constructive
feedback (providing illustrative examples), and the concept of the
social microcosm.42 Written preparation handouts can be distributed
in advance to each client on the unit, mindful of the need to have
translated versions for ethnoculturally diverse clients.
2. Personal Agenda Setting. The second phase of the group is
the formulation of the task. Many group leaders find this the most
daunting component of the model. The overriding task of the group is
to help members explore and improve their interpersonal
relationships. The leaders then assist each member to formulate a
brief personal agenda for the meeting. The agenda must be realistic
and doable in the group that day. It must focus on interpersonal
issues and, if possible, on issues that in some way relate to one or
more members in the here-and-now of the group.
Formulating an appropriate agenda is a complex task. Clients
need considerable assistance from the therapist, especially in their
first couple of meetings. Each group member is, in effect, being
asked to make a personal statement that involves three components:
(1) an acknowledgment of the wish to change (2) in some
interpersonal domain (3) that has some here-and-now manifestation.
Think about this as an evolution from the general to the specific, the
impersonal to the personal, and the personal to the interpersonal. “I
feel unhappy” evolves into “I feel unhappy because I am isolated,”
which evolves into “I want to be better connected,” which evolves
into “with another member of the group.” There are innumerable
ways clients might begin, but there are only a few core agendas that
express the vast majority of client concerns:

• I want to be less isolated.

• I want to get closer to others.
• I want to be more assertive about what I need.
• I want to be a better communicator.
• I want to be a better listener and be less focused on myself.
• I want to not feel bottled up.
• I want to feel more trusting.
• I want specific feedback about how I come across regarding…
• I want to deal with anger more effectively and less
destructively.

Having these examples in mind may make it easier for therapists to

help clients create a workable focus.
Clients have relatively little difficulty with the first two aspects of
the agenda, but most will need considerable help from the therapist
in the third domain—framing the agenda in the here-and-now.
Fortunately, the third part is less complex than it seems, and the
therapist may move any agenda into the here-and-now by mastering
only a few basic guidelines.
Consider the following common agenda: “I want to learn to
communicate better with others.” The client has already
accomplished the first two components of the agenda: (1) he or she
has expressed a desire for change (2) in an interpersonal area. All
that remains is to move the agenda into the here-and-now, a step
that the therapist can easily facilitate with a comment such as,
“Please look around the room. With whom in the group do you
communicate well? With whom would you like to improve your
communication?”
Another common agenda is the statement, “I’d like to learn to get
closer to people.” The therapist’s procedure is the same: Thrust it
into the here-and-now by asking, “Who in the group do you feel close
to? With whom would you like to feel closer?” Another common
agenda is, “I want to be able to express my needs and get them met.
I keep my needs and pain hidden inside and keep trying to please
everybody.” The therapist can shift that into the here-and-now by
asking, “Would you be willing to try to let us know today what you
need?” or “What kind of pain do you have? What would you like from
us?”
Nota bene, the agenda is generally not the reason the client is in
the hospital. But, often unbeknownst to the client, the agenda may
be an underlying or contributory reason. It is rarely irrelevant. The
client may have been hospitalized because of substance abuse,
depression, or a suicide attempt. Underlying such behaviors or
events, however, there are almost invariably important tensions or
disruptions in interpersonal relationships.
Note also that the therapist strives for agendas that are gentle,
positive, and nonconfrontational. In the agendas we just cited that
deal with communication or closeness, we made sure to inquire first
about the positive end of the scale (for example, “With whom in the
group do you communicate well?”). That is often a powerful and yet
safe way to help members begin to open up.
Many clients offer an agenda that directly addresses anger—for
example, “I want to be able to express my rage. The doctors say I
turn my anger inward and that causes me to be depressed.” This
agenda must be handled with care. You do not want clients to
express anger at one another, and you must reshape that agenda
into a more constructive form.
We have found it helpful to use the following approach: “I believe
that anger is often a serious problem because people let it build up
to high levels and then are unable to express it. The release of so
much anger would feel like a volcano exploding. It’s frightening both
to you and to others. It’s much more useful in the group to work with
young anger, before it turns into red anger. I’d like to suggest to you
that today you focus on young anger—for example, impatience,
frustration, or very minor feelings of annoyance. Would you be willing
to express in the group any minor flickerings of impatience or
annoyance when they first occur—for example, irritation at the way I
lead the group today?”
The agenda exercise has many advantages. For one thing, it is a
solution to the paradox that though structure is necessary it can also
be growth inhibiting and infantilizing. The agenda exercise provides
structure for the group, but it simultaneously encourages
autonomous behavior on the part of the client. Thus, the agenda
encourages members to assume a more active role in their own
therapy and to make better use of the group. They learn that
straightforward, explicit agendas involving another member of the
group will guarantee that they do productive work in the session. An
example of a clear, direct, and accessible client statement would be,
“I tried to approach Sue earlier today to talk to her, and I have the
feeling that she rejected me, wanted nothing to do with me, and I’d
like to find out why.” Such a clear statement carries the added
benefit of potentially reducing interpersonal tensions on the unit,
which will also elevate the status of group therapy on the unit.
Some clients have great difficulty stating their needs directly and
explicitly. In fact, many enter the hospital because of self-destructive
behaviors that are indirect methods of signifying that they need help.
The agenda task teaches them to state their needs clearly and
directly and to ask explicitly for help from others. In fact, for many,
the agenda exercise, rather than any subsequent work in the group
meeting, is itself the therapy. If these clients can broaden their
repertoire in asking for help verbally rather than through some
nonverbal, self-destructive mode, then the hospitalization will have
been very useful.
The agenda exercise also provides a wide-angle view of the
group work that may be done that day. The group leader is quickly
able to make an appraisal of what each client is willing to do and
whose goals may dovetail with those of others in the group.
The agenda exercise is valuable but cannot immediately be
installed in a group. Often a therapy group needs several meetings
to catch on to the task and to recognize its usefulness. Personal
agenda setting is not an exercise that the group members can
accomplish on their own: the therapist must be extremely active,
persistent, inventive, and often directive to make it work. Once it is
established as a group norm however, a group culture will emerge
that reinforces this mode of working. You can count on group
members passing the model along to the next wave of participants,
and your colleagues on the unit can also reinforce it.
If members are extremely resistant, sometimes a suitable agenda
is for them to examine why it is so hard to formulate an agenda.
Profound resistance or demoralization may be expressed by
comments such as, “What difference will it make?” “I don’t have any
problems!” “I don’t want to be here at all!” If it is quickly evident that
you have no real therapeutic leverage, you may choose to ally with
the resistance rather than occupy the group’s time in a futile struggle
with the resistant member. You may simply say that it is not
uncommon to feel this way on admission to the hospital, and
perhaps the next meeting will feel different. You might add that the
client may choose to participate at some point in the session. If
anything catches his interest, he should speak about it. Remember,
the experience should be nonblaming and nonshaming and, as
much as possible, a nonfailure experience.
Sometimes if a client cannot articulate an agenda, one can be
prescribed that involves listening and then providing feedback to a
member the client selects. At other times, it is useful to ask other
members to suggest a suitable agenda for a given individual. Recall
that the group members often have a great deal of knowledge of one
another stemming from the vast amount of time they may have spent
together on the ward.
> Joey, a nineteen-year-old young man, offered an unworkable
agenda: “My dad treats me like a kid.” He could not comprehend the
 agenda concept in his first meeting, and I (IY) asked for suggestions
from the other members. There were several excellent ones: “I want to
examine why I’m so scared in here,” or, “I want to be less silent in the
group.” Ultimately, one member suggested a perfect agenda: “I want to
learn what I do that makes my dad treat me like a kid. You guys tell me:
Do I act like a kid in this group?” <<

Take note of why this was the perfect agenda. It addressed Joey’s
stated concern about his father treating him like a kid; it addressed
his behavior in the group that had made it difficult for him to use the
group; and it focused on the here-and-now in a manner that would
undoubtedly result in the group being useful to him.
3. Agenda Filling. Once the personal agenda setting has been
completed, the next phase of the group begins. In many ways, this
segment of the group resembles any interactionally based group
therapy meeting in which members explore and attempt to change
maladaptive interpersonal behavior. But there is one major
difference: therapists have at their disposal agendas for each
member of the group, which allows them to focus the work in a more
customized and efficient manner. The presumed life span of the
inpatient group is only a single session, and the therapist must be
efficient in order to provide the greatest good for the greatest number
of patients.
In our experience, six is the ideal size. But if the group is large—
say, twelve members—and if there are new members who require a
good bit of time to formulate an agenda, then there may be only
thirty minutes in which to fill the twelve agendas. Obviously, work
cannot be done on each agenda in each session, and it is important
that clients be aware of this possibility. You may tell members
explicitly that the personal agenda setting does not constitute a
promise that each agenda will be focused on in the group. You may
also convey this possibility through conditional language in the
agenda formation phase: “If time permits, what would you like to
work on today?” It is often helpful to encourage clients to continue
their agenda work with their nurse, doctor, or other trusted supports.
Even when an agenda may not be filled in that group session, clients
report great value in clarifying a focus in the midst of feeling
overwhelmed.43
Nonetheless, the efficient and active therapist should be able to
work on the majority of agendas in each session. The single most
valuable guideline we can offer is to try to fit agendas together so
that you work on several at once. If, for example, John’s agenda is
that he is very isolated and would like some feedback from the
members about why it’s hard to approach him, then you can fill
several agendas simultaneously by calling for feedback for John
from members with agendas such as, “I want to learn to express my
feelings,” “I want to learn how to communicate better to others,” or, “I
want to learn how to state my opinions clearly.”
Similarly, if there’s a member in the group who is weeping and
highly distressed, why should you, the therapist, be the only one to
comfort that individual when you have, sitting in the group, members
with the agenda of, “I want to learn to express my feelings,” or, “I
want to learn how to be closer to other people”? By calling on these
members, you stitch several agendas together.
In summary, during the personal agenda setting, the therapist
collects commitments from members about certain work they want to
do during the meeting. If, for example, one member states that she
thinks it would be important for her to learn to take risks in the group,
it is wise to store this and, at some appropriate time, call on her to
take a risk by, for example, giving feedback or evaluating the
meeting. If a member expresses the wish to open up and share his
pain with others, it is facilitative to elicit some discrete contract—you
may even make a contract for only two or three minutes of sharing—
and then make sure that individual gets the time in the group and the
opportunity to stop at the allotted time. It is possible, with such
contracts, to increase responsibility assumption by asking the client
to nominate one or two members to monitor him to ensure he has
fulfilled the contract by a certain time in the session. This kind of
“maestro-like conducting” may feel heavy-handed to the beginning
therapist, but it leads to a more effective inpatient group. Group
members generally can distinguish between the leader’s helpful
facilitation and over-controlling behavior.
 4. The End-of-Meeting Review. The final phase of the group
meeting signals a formal end to the body of the meeting and consists
of review and evaluation. We have often led inpatient groups on a
teaching unit and generally had students observing the session
through a one-way mirror. We prefer to divide the final phase of the
group into two equal segments: a discussion of the meeting by the
therapists and observers, followed by the group members’ response
to this discussion.
In the first segment, therapists and observers (if present) form a
small circle in the room and conduct an open analysis of a meeting,
just as though there were no group members in the room listening
and watching. In this discussion, leaders and observers review the
meeting and focus on the group leadership and the experience of
each of the members. For example, the leaders may question what
they missed, consider what else they might have done in the group,
or determine whether they left out certain members. We instruct the
discussants to make some comment about each member: the type
of agenda formulated, the work done on that agenda, and their
guesses about that individual’s satisfaction with the group.
Although this group wrap-up format is unorthodox, it is, in our
experience, effective. For one thing, it makes constructive use of
observers. In the traditional teaching format, student-observers stay
invisible and meet with the therapist in a postgroup discussion to
which the members do not have access. Members generally resent
this observation format and sometimes develop paranoid feelings
about being watched. To bring the observers into the group
transforms them from an opaque and negative force to a transparent
and more positive one. In fact, we have often heard group members
express disappointment when no observers are present.
This format requires therapist transparency and is an excellent
opportunity to do invaluable modeling. Co-therapists may discuss
their dilemmas, concerns, or puzzlement. They may ask the
observers for feedback about their behavior. Did, for example, the
observers think they were too intrusive or that they put too much
pressure on a particular individual? What did the observers think
about the relationship between the two leaders?
 In the final segment of the review phase, the discussion is thrown
open to the members. Generally, this is a time of great animation,
since the therapist-observer discussion generates considerable data.
There are two directions that the final few minutes can take.
First, the members may respond to the therapist-observer
discussion: for example, they may comment on the openness, or
lack thereof, of the therapists and observers. They may react to
hearing the therapist express doubt or fallibility. They may agree with
or challenge the observations that have been made about their
experience in the group. This joint rehash invites genuine
collaboration. The second direction is for the group members to
process and evaluate their own meeting. The therapist may guide a
discussion, making such inquiries as: “How did you feel about the
meeting today?” “Did you get what you wanted out of it?” “What were
your major disappointments with this session?” “If we had another
half hour to go, how would you use the time?” The final few minutes
are also a time for the therapist to make contact with silent members
and inquire about their experience: “Were there times when you
wanted to speak in the group?” “What stopped you?” “Had you
wanted to be called on, or were you grateful not to have
participated?” “If you had said something, what would it have been?”
(This last question is often remarkably facilitative.)
This last phase of the meeting thus has many functions: review,
evaluation, pointing to future directions. It is highly valued by the
members.44 It is also a time for reflection and tying together loose
ends before they leave the group session. Because the small group
is embedded in the larger milieu, it is wise to make the group as self-
contained as possible. It will not enhance your credibility to have the
group members empty out for the evening onto the unit in a state of
unsettled agitation because of the group.
Your final task is communicating about the group to the team at
large. This should be a timely, bidirectional flow of information that
promotes integration of care through team meetings and charting. A
postgroup debrief by the group leaders at the nursing station with
other team members present (who may be curious to know how the
patients they are working with did in the group) provides efficient and
timely communication.
A final comment about client boundaries. Clients will inevitably
interact with one another outside of the group in an inpatient setting.
That is highly desirable—but with the proviso that everyone commit
to honoring each person’s privacy and treating in-group disclosures
with respect on the unit.
 GROUPS FOR THE MEDICALLY ILL
Group interventions play an increasingly important role in
comprehensive medical care. Given their effectiveness and potential
for reducing health-care costs, this trend is likely to continue and
expand.45 The range of approaches used is as broad as the range
of conditions addressed. These groups are often homogeneous for
and include all the major medical illnesses and concerns that warrant
medical care, such as cancer, cardiac disease, obesity, lupus,
inflammatory bowel disease, pregnancy, postpartum depression,
infertility, transplantation, arthritis, chronic obstructive pulmonary
disease (COPD), brain injury, Parkinson’s, multiple sclerosis,
diabetes, HIV/AIDS, and somatic symptom disorder (SSD).46 These
groups are typically led by mental health experts in collaboration with
the medical providers whose support for their patients participation is
essential.
There has been a dramatic increase in the use of groups in the
integrated medical and psychological treatment of clients with
heterogeneous chronic medical illnesses.47 These groups are held
in primary care practices and are often co-led by a primary care
physician and a mental health professional. It serves as an effective
way to provide follow-up care. Many of the participating clients
experience significant psychosocial challenges in addition to their
chronic medical illnesses.48 Group medical visits offer peer support
and teach participants about their illnesses and related coping skills
in a cost-efficient way. Both medical and psychological clinical
outcomes are significantly improved.
Earlier in this chapter we identified several key principles for the
adaptation of group therapy: determine the clients’ needs, set
relevant goals, modify the group to meet those goals, and evaluate
outcomes to improve the group’s effectiveness. Distinguish between
the fixed and the mutable elements that may constrain the group
therapy. With medically ill clients there is an additional consideration:
these groups are most valuable for those in need of help and
support; they may not be valuable for those who are already coping
well.49
What psychological needs do the medically ill have? Depression,
anxiety, and stress reactions are common consequences of serious
medical illness and often amplify the impact of the medical illness.50
We know, for example, that depression after a heart attack occurs in
up to 50 percent of men, significantly elevating the risk of another
heart attack.51 Furthermore, the anxiety and depression
accompanying serious medical illness tend to increase health-
compromising behaviors such as alcohol use and smoking. They
also disrupt compliance with recovery regimens of diet, exercise,
medication, and stress reduction.52
Ironically, recent advances in medical treatment have created
new sources of psychological stress. For instance, many diseases
which were formerly fatal can now be managed as long-term chronic
illnesses. These lifesaving outcomes bring with them constant
worries of recurrence, or the need to adapt to body- or life-altering
surgeries.53 Recent breakthroughs in prevention and early detection
similarly may save lives at the cost of increased stress. Genetic
testing now plays an important role in medical practice, allowing
physicians to compute individual risk of developing such illnesses as
Huntington’s disease or breast, ovarian, and colon cancer.54 Yet this
knowledge comes with a cost. Large numbers of individuals are
tormented by momentous, anxiety-laden decisions. When one
learns, for example, of a genetic predisposition to breast cancer, one
is faced with numerous questions: Should I have a prophylactic
mastectomy? Is it fair for me to get married? To have children? Do I
share this information with my siblings, who may prefer not to know?
Am I doomed to follow in the footsteps of my mother? Many
individuals overestimate their risk and suffer significant emotional
distress as a result.55
There is also the great psychological stigma attached to many
medical illnesses, such as COVID-19, HIV/AIDS, hepatitis C, and
Parkinson’s. At a time when individuals are in great need of social
support, the shame and stigma of illness can cause social
withdrawal and isolation that is both stressful and harmful.56
Additionally, seriously ill individuals and their families fear uttering
anything that might amplify worry or fear in loved ones. The pressure
to “think positive” invites tentativeness in communication, which
further increases the affected individual’s sense of isolation.57
Collaborative, trusting communication between client and doctor
is generally associated with greater well-being and better decision-
making. Yet many clients, dissatisfied with their relationship with their
physicians, feel powerless to improve it. They need assistance in
asserting their needs and advocating for their care.58
Medical illness confronts us with vulnerability and limits. Illusions
that have sustained us and offered comfort are challenged. We lose,
for example, the sense that life is under our control; that we are
special, immune to natural law; that we have unlimited time, energy,
and choice. Serious illness confronts us with death and evokes
fundamental existential questions about the meaning of life,
transiency, and our place in the universe.59
And, of course, the strain of medical illness extends far beyond
the person with the illness. Family members and caregivers may
suffer significant stress and dysphoria.60 Groups often play an
important role in their support. Consider, to cite one example, the
enormous growth in groups for caretakers of individuals with
Alzheimer’s disease.61

General Characteristics
We may categorize the medical groups according to their emphasis:

1. Emotion-based coping—social support, emotional ventilation

2. Problem-based coping—active cognitive and behavioral
strategies, psychoeducation, stress reduction techniques
3. Meaning-based coping—increasing existential awareness,
realigning life priorities and finding purpose. These three
 different foci are readily combined into integrative group
models.62

Typically, groups for the medically ill are homogeneous for the
illness. They are typically brief and run for four to twenty sessions.
As we discussed in Chapter 9, brief groups require clear structure
and high levels of focused therapist activity. But even in brief, highly
structured, manual-guided group interventions, the group leader
must attend to group dynamics and group process, managing them
effectively so that the group stays on track. The quality of leadership
is just as important here as it is in traditional group therapy.63
Homogeneous groups tend to jell quickly. Still, the leader must
endeavor to engage outliers who resist group involvement. Certain
behaviors may need to be tactfully and empathically reframed into a
more workable fashion. For example, consider the bombastic, hostile
man in a ten-session post-myocardial infarction group who angrily
complains about the lack of concern and affection he feels from his
sons. Since deep personal work is not part of the group contract, the
therapist needs to have constructive methods of addressing such a
client’s concerns without violating the groups norms. For example,
the leader might take a psychoeducational stance and discuss how
anger and hostility are noxious to one’s cardiac health. The group
might address the latent sadness that the anger is masking and
invite the man to express those primary emotions more directly. Or
others in the group might be asked to share how they cope with
anger or with disappointment.
These groups do not emphasize interpersonal learning and the
leaders generally avoid strong here-and-now focus. Nonetheless,
many of the other therapeutic factors are particularly potent in group
therapy with the medically ill. Universality is prominent and serves to
diminish clients’ stigmatization and isolation. Self-disclosure of
anxiety and fear can generate relief and connection with group
members. Cohesiveness provides social support directly. Extragroup
contact is often encouraged and viewed as a successful outcome,
not as resistance to the work of the group. Seeing others cope
effectively with a shared illness instills hope, which can take many
forms at different stages of the illness: hope for a cure, for courage,
for dignity, for comfort, for companionship, or for peace of mind.
Generally, members learn coping skills more effectively from the
modeling of their peers than from experts.64
Imparting of information (psychoeducation about one’s particular
illness and more generally about health-related matters) plays a
major role in these groups and comes not only from the leaders but
from the exchange of information and advice between members.
Altruism is strongly evident and contributes to well-being through
one’s sense of usefulness to others. Existential factors are also
common, as the group supports its members in confronting the
fundamental anxieties of life that we conceal from ourselves until we
are forced to address them. Any work in the here-and-now focuses
on building support and connection and on reinforcing new and
adaptive behaviors, not on deep interpersonal exploration. Benefits
from these group interventions emerge from experiencing social
support and connection, finding meaning in the face of adversity, and
gaining coping skills.65

A Prototype Group for Medical Illness

Let’s examine a group for women with breast cancer. Breast cancer
serves as a compelling illustration for the role of group therapy
because of its high prevalence (one in eight women will be
diagnosed with breast cancer in their lifetime) and its breadth of
concern, ranging from genetic and familial predisposition, to early
primary breast cancer (which is often curable), to advanced disease
carrying a grave prognosis.66 The model we describe has
subsequently been adapted and used broadly. Related group models
used to good effect include cognitive-existential group therapy and
meaning-based group therapy.67
The Clinical Situation. At the time of the first experimental therapy
groups for women with breast cancer in the mid-1970s, women with
breast cancer were in serious peril. Surgery was severely deforming
and chemotherapy poorly developed. Women whose disease had
metastasized had little hope for survival, were often in great pain,
and felt abandoned and isolated. They were reluctant to discuss their
despair with family members and friends lest they bring them down
into despair as well. Moreover, friends and relatives often avoided
them, not knowing how best to speak to them. All this resulted in an
ever-increasing isolation. Women with advanced breast cancer often
felt guilty: the pop psychology of the day frequently made them feel
that they were in some manner responsible for their own disease.68
Finally, there was considerable resistance in the medical field to
forming a group because of the widespread belief that talking openly
about cancer and hearing several women share their pain and fears
would only make things worse. It was in this environment that I (IY)
first began to work with breast cancer patients.i
Goals for the Therapy Group. My primary goal was to reduce
isolation and improve coping. I hoped that bringing together several
individuals facing the same illness and encouraging them to share
their experiences and feelings would create a supportive social
network, destigmatize the illness, and help the members share
coping strategies. Many of the women’s closest friends had dropped
away, and I hoped to counter that by committing myself and the
group to staying with them—to the death if needed.
Modification of Group Therapy Technique. Mixing women with the
better prognosis of primary breast cancer with women with the
graver prognosis of metastatic disease undermined cohesion
because metastatic disease represented the former subgroup’s
worst fears. After some experimentation with groups of women with
different types and stages of cancer, I concluded that a
homogeneous group offered the most support and formed a group of
women with metastatic breast cancer that met weekly for ninety
minutes. It was an open group with new women joining the group
over time, cognizant that others before them had died from the
illness.
Support was the most important guiding principle. I wanted each
member to experience “presence”—to know others facing the same
situation. As one member put it, “I know I’m all alone in my little boat,
but when I look and see the lights on all the other boats in the
harbor, I don’t feel so alone.”
In order to increase the members’ sense of personal control, I
turned over as much of the direction of the group as possible to the
members. They invited each other to speak, to share their
experiences, to express the many dark feelings they could not
discuss elsewhere. They validated each member’s concerns,
modeled empathy, attempted to clarify confused feelings, and sought
to mobilize the resources available in the membership.
For example, if members described their fear of their physicians
and their inability to ask their oncologist questions, I encouraged
other members to share the ways they had dealt with their
physicians. At times, I suggested that a member role-play a meeting
with her oncologist. Not infrequently a member invited another group
member to accompany her to her medical appointment under the
principle that two heads are better than one while under stress. One
of the most powerful interventions the women learned was to
respond to a rushed appointment with the compellingly simple and
effective statement, “Doctor, I know that you are rushed, but if you
can give me five more minutes of your time today, it may give me a
month’s peace of mind.” No physician would refuse that request.
Members expressing affect, whatever it might be, was a positive
experience in the group: the members had too few opportunities
elsewhere to express their feelings. They talked about everything: all
their macabre thoughts, their fears of death and oblivion, the sense
of meaninglessness, the dilemma of what to tell their children, how to
plan their funerals. Such discussions served to detoxify some of
these fearsome issues. Expressing emotions almost invariably
improved the women’s well-being.69
I attempted to be always supportive, never confrontational. The
here-and-now, if used at all, always focused on positive feelings
between members. Members differed greatly in their coping styles.
Some members, for example, wanted to know everything about their
illness; others preferred not to inquire too deeply. I never challenged
behavior that offered comfort, mindful never to tamper with a group
member’s coping style unless I had something far superior to offer.
Some groups formed cohesion-building rituals, such as a few
minutes of hand-holding meditation or guided imagery at the end of
meetings.
Unlike traditional therapy groups, the members were encouraged
to have extragroup contacts: phone calls, luncheons, and the like,
and even occasional death vigils were part of the ongoing process.
Some members delivered moving eulogies at the funerals of other
members, fulfilling their pledge never to abandon one another. These
eulogies repeatedly demonstrated deep understanding and care of
one another.
Many members had overcome panic and despair and found
something positive emanating from the confrontation with death.
Some spoke of entering a golden period in which they prized and
valued life more vividly. Some reprioritized their life activities and
stopped doing the things they did not wish to do. Instead they turned
their attention to the things that mattered most: loving exchanges
with family, the beauty of the passing seasons, discovering creative
parts of themselves. One woman noted wisely, “Cancer cures
psychoneurosis.” The petty things that used to agonize her no longer
mattered. More than one member said she had become wiser but
that it was a pity she had to wait until her body was riddled with
cancer before learning how to live. How much she wished her
children could learn these lessons while they were healthy. Because
of these attitudes, they welcomed student observers rather than
resenting them. Having learned something valuable from their
encounter with death, they could imbue the final part of life with
meaning by passing their accrued wisdom on to others, to students,
and to their children and group leaders.
An illustration from a group session (led by ML) highlights this:70
> Kathleen, a sixty-five-year-old woman with advanced disease, told
the group about enjoying a respite from chemotherapy. Her oncologist
encouraged her to use this window of relative well-being wisely.
Kathleen recognized that she had a very poor prognosis, but she was
feeling better at this moment than she had in months. She even
 fantasized about taking a last trip to visit her older brother in Ireland. He
had a heart condition that prohibited him from traveling to see her, and
time was passing for them both.
The group encouraged Kathleen to seize this moment, and she
replied that she was obligated to care for her ninety-two-year-old
mother-in-law and so could not travel. A sense of resignation fell upon
the group until Sue, another group member, jumped in: “Kathleen, you
have four adult children in the city. Give them the gift of giving you the
gift of looking after their grandmother so that you can take this trip.” It
was a brilliant intervention; Kathleen thought for a moment and then
endorsed it. She quickly arranged a trip to Ireland. She returned after a
lovely visit and expressed deep appreciation to the group members for
their wisdom and support. She relapsed shortly after her return and
died a few weeks later.
After Kathleen’s death, her children sent a note to the group
members thanking them for encouraging this final trip. They loved their
mother but were frustrated at how hard it was to repay her for her
devotion to them. She always put herself last. By supporting this trip,
they felt they had reciprocated her love for them. Though they were
sad, the trip eased their grief and helped “balance the books a bit
better.” <<

It is important to note that leading such a group is deeply

emotionally demanding, and that co-therapy and supervision are
highly recommended. Leaders cannot remain distant, as these
issues deeply touch the leaders as well as the group members.
There is no “us and them.” We are all fellow travelers facing the
same existential threats.71
This particular group approach, which is now termed supportive-
expressive group therapy (SEGT), has been described in a series of
publications.72 It has been taught to many psycho-oncology
professionals for use with a range of cancer patients along the
continuum of illness.73
This approach has also been used for women with a strong
genetic or familial predisposition to develop breast cancer. Reports
describe effective homogeneous groups that meet for a course of
twelve weekly sessions. The last four meetings may be used as
boosters, meeting once monthly for four months, which extends
exposure to the intervention to six months. Central concerns in these
groups include coping with life’s uncertainty, decisions about
prophylactic mastectomy, and shattered illusions of invulnerability.
Feelings of loss and grief are prominent, often amplifying the sense
of personal risk for breast cancer. Working through these feelings
contributes to a better informed, more accurate assessment of one’s
personal risk.74
Effectiveness. Outcome research over the past twenty-five years
has demonstrated the effectiveness of these groups. Supportive-
expressive group therapy for women at risk of breast cancer, women
with primary breast cancer, and women with metastatic disease has
consistently been shown to reduce the experience of pain and to
improve psychological coping and adaptation. The medical
profession’s initial apprehensions—that talking about death and
dying would make women feel worse or cause them to withdraw
from the group—has been thoroughly disconfirmed.75
Can groups for cancer patients increase members’ survival time?
76 The first controlled study of groups for women with metastatic
breast cancer reported longer survival, but several other studies
have consistently failed to replicate those first findings. The original
reports spurred hope that we could find a
psychoneuroimmunological mechanism to account for a
psychosocial intervention prolonging life. Subsequent studies have
eliminated neither the controversy nor our wish to find survival
benefits. It is likely the case that any impact on survival is the result
of the group enhancing social support, reducing isolation for those
with limited relationships, promoting health equity, and helping
vulnerable individuals access and maintain compliance with difficult
treatment regimens. All of the studies, however, show significant
positive psychological results: less experience of pain, less
psychological distress, better quality of life, and even the capacity to
grow personally as one faces the trauma of mortal illness. Even if the
group intervention does not prolong life, there is little doubt that it
can improve the quality of life for its members.77
 ADAPTATION OF CBT AND IPT TO GROUP THERAPY
In this section we describe two widely used models of brief group
therapy. Cognitive-behavioral therapy (CBT) and interpersonal
therapy (IPT) were originally constructed, described, and empirically
tested in individual therapy.78 Both are now used as brief group
therapy interventions and are accruing good support for their
effectiveness.
It is important not to be misled by labels. A review of the current
literature on group therapy for women with breast cancer noted that
many of the groups identified as CBT were in fact integrative models
that synthesized contributions from multiple models.79 This
important finding is by no means the exception: it is often the case
that effective, well-conducted therapy of purportedly different
ideological models shares much in common. One of the major
conclusions of the encounter group study was exactly that: The
behavior of effective therapists resembled that of effective therapists
from other ideological schools far more than it did the behavior of
other, less effective practitioners of their own school.80 Why is this
so? Likely it is a result of the effective use of the common and
evidence-based factors that predict effectiveness across all therapy
models and that we have examined throughout this text.81 Good
group therapists are committed to being helpful to their clients and
not wedded to their model’s ideology.

Cognitive-Behavioral Group Therapy

Group CBT (CBT-G) initially arose from the search for greater clinical
efficiency. Cognitive-behavioral therapists used the group venue to
deliver individual CBT to a large number of clients simultaneously.
Note this important and fundamental difference: CBT therapists were
using groups to increase the efficiency of delivering CBT to individual
clients, not to tap the unique benefits inherent in group therapy that
we have emphasized throughout this text. At first, cognitive-
behavioral therapists had a narrow focus: they wanted to provide
psychoeducation and cognitive and behavioral skill training. They
used the group as a setting to deliver an intervention without
harnessing the group as an agent of change. What about peer
support, universality, instillation of hope, imitative behavior, altruism,
destigmatization, social skills training, and interpersonal learning?
They were considered merely backdrop benefits. What about the
presence of group process, cohesion, or phases of group
development? They represented noise in the system, often
interfering with the work of delivering CBT; in fact, some CBT
therapists initially raised the concern that the group format diluted
the power of CBT.82
We have now passed into a second generation of more
sophisticated CBT-G applications in which the essential elements of
group life are being acknowledged. CBT-G therapists are
productively utilizing groups to deepen learning and experience.
Greater attention to the use of the group therapy factors, the
development of group cohesion and early client engagement, and a
focus on group leadership style have all increased CBT-G’s
effectiveness.83 Group cohesion fosters more risk-taking, deeper
task engagement, and reduced shame and avoidance. Relationship
building and skill development reinforce one another, and the quality
of the group experience contributes substantially to the outcome of
the group treatment even in skill-focused groups.84
The CBT approach postulates that psychological distress is the
result of impaired information-processing and disruption in patterns
of social behavioral reinforcement.85 Although thoughts, feelings,
and behaviors are of course interrelated, CBT considers one’s
thoughts in particular to be central to the process. Often automatic
and flying beneath the radar of one’s awareness, one’s thoughts
initiate alterations in mood and behavior. CBT therapists attempt to
access and illuminate these thoughts through probing, Socratic
questioning, and the encouragement of self-examination and
rigorous self-monitoring reaching client core beliefs.
What type of core beliefs are uncovered? Core beliefs fall into two
main categories—relationships and competence: “Am I worth
loving?” and “Can I achieve what I need to confirm my worth?”
Integrative therapists have noted that core beliefs are often strongly
interpersonal at their center.86 Once these dysfunctional core beliefs
(for example, “I am entirely unlovable”) are identified, the next
objective of treatment is to restructure them into more adaptive and
self-affirming beliefs.
CBT-G has been applied effectively to an array of clinical
conditions: acute depression,87 chronic depression,88 chronic
dysthymia,89 depression relapse prevention,90 posttraumatic stress
disorder (PTSD),91 acute stress,92 eating disorders,93 insomnia,94
somatization and hypochondriasis,95 spousal abuse,96 panic
disorder,97 obsessive-compulsive disorder,98 generalized anxiety
disorder,99 social phobia,100 anger management,101 schizophrenia
(both for negative symptoms, such as apathy and withdrawal, and,
positive ones, such as hallucinations),102 perinatal anxiety,103
parent-child groups for childhood anxiety,104 and many other
conditions, including medical illnesses.105
Substantial and durable benefits have been regularly reported in
these applications. Recent generations of CBT-G in which group
therapists pay more attention to group cohesion and group process
have been found to be no less effective than individual CBT. CBT-G
generally does not have a higher rate of premature termination of
therapy. Exposure-based group treatment for PTSD, however, does
have a greater frequency of dropouts. Exposure-based treatments
require clients to gradually approach their trauma-related memories,
feelings, or situations, directly or in imagination. Group members are
often so overwhelmed by exposure to traumatic memories that a
brief format is likely not feasible. Desensitization must be conducted
over a considerable period.106
The application of CBT in groups varies according to the
particular needs of the clients in each type of specialty group, but all
share certain well-identified features.107 CBT-G is typically
homogeneous, time limited, and relatively brief, generally with a
course of eight to twenty meetings that last two to three hours.108
Group CBT emphasizes structure, focus, and acquisition of cognitive
and behavioral skills. Therapists assign homework between sessions
and make it clear that group members are each accountable for
advancing their own therapy. The homework is tailored to the
concerns of the individual client. It might involve keeping a log of
one’s automatic thoughts and how these thoughts relate to mood, or
it might involve a behavioral task that challenges avoidance.
Gradients of exposure to fearful stimuli can be jointly constructed by
the client and group leader and engaged by the client.
The review of the homework is conducted in each group meeting
and represents a key difference between group CBT and
interactional group therapy: the CBT leader substitutes “cold
processing” of the client’s at-home functioning for the “hot
processing” that typifies interactional group therapy.109 In other
words, the group focuses on clients’ descriptions of their at-home
functioning rather than on their real-time functioning in the here-and-
now interaction.
Measurement of clients’ distress and progress through self-report
questionnaires is ongoing, providing regular feedback that either
supports the therapy or signals the need to realign therapy.
The group CBT therapist makes use of a set of strategies and
techniques, in various combinations, that clients employ and then
discuss together in the group.110 These interventions deconstruct
the clients’ difficulties into workable segments and combat their
tendency to generalize, magnify, and distort. For example, clients
may be asked to:

• Record automatic thoughts. Make overt what is covert; link

thoughts to mood and behavior. For example, “I will never be
able to meet anyone who will find me attractive; why should I
try to date?”
• Challenge automatic thoughts. Challenge negative beliefs;
identify distortions in thinking; explore the deeper personal
 assumptions underlying the automatic thoughts. For example,
“How can I actually meet people if I keep refusing invitations to
go out for drinks after work?”
• Monitor mood. Explore the relationship between mood and
thoughts and behaviors. For example, “I think I started to feel
lousy when no one invited me for lunch today.”
• Create an arousal hierarchy. Rank anxiety-generating
situations and gradually confront each one, from easiest to
hardest. For example, a client with agoraphobia would rank the
places that elicit anxiety from the easiest to the most
challenging. Going to church on Sunday morning with a spouse
might be at the low end of arousal. Going shopping alone at a
new mall at night might be at the high end of arousal.
Ultimately, gradual exposure desensitizes the client and
extinguishes the anxious and avoidant response.
• Monitor activity. Track how time and energy are spent. For
example, one might take note of how much time is actually lost
to rumination about work competence and how that in turn
interferes with completing required tasks.
• Problem-solve. Find solutions to everyday problems.
Therapists challenge clients’ belief in their inevitable failure by
breaking a problem down into instrumental and workable
components. For example, clients may be asked how to
balance self-care with care for an ill family member.
• Acquire knowledge through psychoeducation. This might
include, for example, education about the physiology of anxiety
or the symptoms of the stress response.
• Learn relaxation training. Reduce emotional tension by
progressive muscle relaxation, guided imagery, breathing
exercises, and meditation. Generally, a meeting or two is
devoted to training in these techniques. The objective is to
increase the clients’ abilities to step back and reflect on their
experience, lessening the tendency to be highly reactive.
 • Perform a risk appraisal. Clients examine what feels
threatening and what resources they have to meet these
threats. This might include, for example, examining the client’s
belief that his panic attack is actually a heart attack and
reminding him that he can use deep breathing to settle himself
effectively.
• Employ guided imagery for exposure. Clients challenge
negative attributions about self-worth and the anticipation of
rejection that result in avoidance and escape behaviors. They
focus instead on constructing positive and healing imagery.
• Anticipate relapse and create a relapse prevention plan.
Clients identify potential triggers—both external events and
internal assumptions—and the core skills they need to respond
to these triggers. They plan and practice for the future.

The group CBT treatment of social phobia is representative.111

Each group consists of five to seven members and meets for twelve
sessions of two and a half hours each. Each meeting has a
beginning agenda and check-in, a middle working phase, and an
end-of-session review. An individual pregroup or postgroup meeting
may be used with each member.
The first two group sessions address the clients’ automatic
thoughts regarding situations that evoke anxiety. For example, a
member might state, “If I speak up, I will certainly make a fool of
myself and be ridiculed.” Skills are then taught to challenge these
automatic thoughts and errors in logic. For example: “You assume
that you will express yourself poorly, and reach the worst outcome
possible. But when you voice your concerns here, others have
repeatedly told you that you are clear and articulate.”
The middle sessions address each individual’s target goals using
homework, in-group role simulations, and behavioral exposure to the
source of anxiety. The last few sessions consolidate gains and
identify future situations that could trigger a relapse. Imagery can be
added to deepen the client’s exposure to the aversive situation.112 In
summary, the group leader helps each member to identify
dysfunctional thinking, to challenge these thoughts, to restructure
thoughts, and to modify behavior.

Group Interpersonal Therapy

Individual interpersonal therapy (IPT), first described by Gerald
Klerman, Myrna Weissman and colleagues, has also been adapted
for group use.113 In the same way that CBT views psychological
dysfunction as a problem of information processing and behavioral
reinforcement, IPT views psychological dysfunction as a problem
rooted in one’s interpersonal relationships. As the client’s social and
interpersonal functioning improve, his or her presenting disorder—for
example, depression or binge eating—also improves. Interestingly,
this can occur with relatively little specific attention to the actual
disorder other than psychoeducation about its nature, course, and
impact.114 The improvement in social and interpersonal functioning
can have broad positive reverberations that reinforce and sustain
improvement in the primary symptoms.
Group IPT (IPT-G) emphasizes the acquisition of interpersonal
skills and strategies for dealing with social and interpersonal
problems.115 Group applications of IPT-G emerge from the societal
drive toward greater efficiency, but it also recognizes the many
therapeutic opportunities group members can provide one another in
addressing interpersonal dysfunction. These include reducing social
isolation, modeling, destigmatization, and supporting treatment
compliance and engagement. The first group IPT application was
developed for clients with binge eating disorder, but clinical
applications have proliferated since then. IPT-G is now used in the
treatment of depression, social phobia, postpartum depression, and
psychological trauma, among other clinical foci. It has been used
effectively as a stand-alone treatment and has been combined with
social rhythm interventions for clients with bipolar disorder in order to
help with self-regulation of sleep, activity, and exposure to
stimulation. It has proven effective in skills training for depressed
adolescents with poor school functioning.116 IPT-G can be employed
conjointly with pharmacotherapy, either concurrently or
sequentially.117
IPT-G’s relevance and efficacy have also been demonstrated in
other cultures, where it has been taught effectively to providers who
have little prior psychotherapeutic training.118 The World Health
Organization has published a manual to support the delivery of IPT-
G internationally in under-resourced countries where other
depression treatments may be inaccessible. IPT-G’s relational focus
makes it a good match across cultures and with diverse populations.
It has even been delivered in environments as challenging as
displaced persons camps.119
Group IPT closely follows the individual IPT model. A positive,
supportive, transparent, and collaborative client-therapist relationship
is strongly encouraged. Each client’s interpersonal difficulties are
ascertained beforehand in an intensive evaluation of relationship
patterns. These are categorized into one or two of four main areas:
grief and loss, interpersonal disputes, role transitions, or
interpersonal sensitivity. Self-report questionnaires and interpersonal
inventories may be used to refine the client’s focus and to measure
progress. The most commonly used self-report measurements
address the client’s chief areas of distress—mood, trauma, eating
behaviors, or interpersonal patterns. One to three goals are identified
for each client to help focus the work and to jump-start the group
therapy.
A typical course of therapy consists of one or two preliminary
individual meetings aimed at building a therapeutic alliance and
establishing therapy goals and then eight to twenty-four group
meetings of ninety minutes each, with an individual follow-up session
three or four months later. Some practitioners also use an individual
evaluation meeting after the group has completed half of its
sessions. Booster group sessions may be scheduled at regular
intervals in the months following the intensive phase of therapy.
The group therapy meeting consists of an initial introduction and
orientation phase, a middle working phase, and a final consolidation
and review segment.120 Written group summaries (see Chapter 13)
may be sent to each group member before the next session.
The first phase of the group, in which members present personal
goals, helps to catalyze cohesion and universality. Psychoeducation,
interpersonal problem solving, advice, and feedback are provided to
each client by the group members and the therapist(s). The ideal
posture for the therapist is one of active concern, support, and
encouragement. Transference issues are managed rather than
explored. Clients are encouraged to analyze and clarify their patterns
of communication with figures in their environment but not to work
through member-to-member tensions.
What are the differences between group IPT and the interactional,
interpersonal model described in this text? In the service of briefer
therapy and more limited goals, IPT-G generally de-emphasizes both
the here-and-now and the group’s function as a social microcosm.
These modifications reduce interpersonal tensions and the potential
for disruptive disagreements. (Such conflicts may be instrumental for
far-reaching change but may impede the course of brief therapy.)
The group, through its supportive and modeling functions,
nonetheless becomes an important social network. In some carefully
selected instances, group here-and-now interaction may be
judiciously employed and linked to the client’s focus and goals, but
generally this focus is much less prominent than in the interpersonal
group model we have described in this text. As we have noted
elsewhere, skillful group leadership regarding an appreciation of
group dynamics, group cohesion, group development, and group
process play an important role in enhancing effectiveness.121
SELF-HELP GROUPS AND ONLINE SUPPORT GROUPS
The number of participants in self-help groups (SHGs) is staggering.
To place some perspective on this, a report antedating the huge
expansion of Internet support groups reported that over ten million
Americans had participated in one of over five hundred thousand
self-help groups in the preceding year and twenty-five million
Americans had participated in a self-help group sometime in the
past. That study focused exclusively on self-help groups that had no
professional leadership. But in fact, more than 50 percent of self-help
groups have professional leadership of some sort, which means that
a truer measure of participation in self-help groups at that time, even
by a conservative estimate, was likely twenty million individuals in
the previous year and fifty million overall—figures that far exceed the
number of people receiving professional mental health care.122 This
trend will only increase in light of consumers’ growing self-
awareness, self-assertiveness, access to information online, and
difficulty in accessing costly professional care.
Group psychotherapists will regularly encounter clients who
participate in SHGs and may at times encourage client participation
in self-help groups. SHGs exist for virtually every condition and life
challenge and are particularly prominent for mental health concerns
and substance use disorders.123 Fortunately, there are many
excellent guides and entry points to this vast resource. The National
Alliance on Mental Illness (NAMI), for example, each year provides
millions of Americans with support, psychoeducation, and online
resources by working with five hundred local affiliates. NAMI
provides online support groups tailored to particular client concerns.
Online self-help clearinghouses such as Mental Health America and
the National Mental Health Consumers Self-Help Clearinghouse
similarly provide useful guides to the many types of self-help groups
available as well as materials, support, and guidance for the
development of self-help groups.124
 SHGs are proliferating rapidly, but they are certainly not new. In
fact, we can readily track an arc from the fraternal organizations of
the fourteenth century to the online support groups of today.125
While the means of delivery has changed, the objectives of SHGs
have remained consistent. SHGs provide their members with mutual
aid and support. This includes a sense of safety and belonging,
information sharing, and development of coping strategies. These
groups may also help members advocate for change, as exemplified
by Mothers Against Drunk Driving (MADD). In such cases, using
one’s lived experience to help others can lead to feelings of
empowerment and a greater sense of self-efficacy.126
Evaluation of outcomes is difficult, given that SHG membership is
often anonymous and records are unreliable. Nonetheless, some
systematic studies attest to the efficacy of these groups. Members
value the groups highly (sometimes more so than clients’ objective
improvement alone would predict) and report improved coping and
well-being, greater knowledge of their condition, and reduced use of
other health-care services.127
SHGs resemble therapy groups in many ways; the quality of peer
leadership and the development of group cohesion are critical. SHGs
make extensive use of almost all the group therapeutic factors, most
prominently, altruism, cohesiveness, universality, imitative behavior,
instillation of hope, and catharsis. But there is one important
exception: the therapeutic factor of interpersonal learning plays a far
less important role in the self-help group than in the therapy group.
Several factors account for the widespread growth of SHGs. They
are open and accessible, offering psychological support to anyone
who identifies with the group. Ailments that are underrecognized or
unaddressed by the professional health-care system are very likely
to generate self-help groups, and in these cases the groups are quite
reassuring, helping members accept and normalize their malady.128
Beyond traditional face-to-face SHGs, the Internet promotes
connections between isolated individuals who feel unique in their
distress. Instead of relying on restricted, perhaps unresponsive local
communities, those affected with rare maladies now have access to
support from kindred folks from around the world.
Self-help groups emphasize internal rather than external
expertise. They draw on the resources available within the group
rather than those available from external experts, and this shift is
empowering. The members’ shared experience makes them both
peers and credible experts. They become providers and consumers
of support at the same time, benefiting from both roles: their self-
worth rises through altruism, and hope is instilled by contact with
others who have surmounted similar problems. Active coping
strategies enhance functional outcomes.129
The presence of a professional leader in the SHG may facilitate
deeper disclosures by participants.130 These findings have led some
researchers to call for more active collaboration between
professional health-care providers and the self-help movement.
There is a risk, however, that professional status may overshadow
the SHG members’ expertise. In any such collaboration, mutual
respect and recognition of the value brought by both peer and
professional experts is critical.131

Telemental Health Applications

Online mental health platforms include mobile device applications,
remote health monitoring, and educational material. Apps and
personal devices that provide a stream of personalized feedback
about mood and stress aimed at promoting mental health self-
awareness and self-care are proliferating daily. Although the
feedback these provide is often generic and not individually tailored,
there is no question that they can be of benefit.132
The early and technologically simpler (but still popular) online
groups that first appeared operate either as real-time groups
(synchronous chat lines) or asynchronous groups (bulletin boards).
In both formats, members have no video contact but communicate
by posting written messages. Facebook groups, for instance, are
models of both. Groups may be time limited or ongoing; they may be
actively managed through a facilitator’s comments or questions
regarding posts; or they may operate without any professional input.
They may be of varying and even indeterminant size. If there is
professional input from moderators, their responsibility is to
coordinate and curate participants’ messages in ways that maximize
the functioning of the group.133
An online bulletin board or chat group is a support system that is
available 24/7 and allows its members time to rehearse, craft, and
fine-tune their narrative.134 That is the good news, and the impact is
often profound and positive. The less good news, at times, is that the
lack of boundaries may foster regressive online behaviors. Despite
its manifest appearance as a kind of therapy group, an online chat
group or bulletin board group can be a very large group in
cyberspace shaped by large group dynamics and forces. This may
include the expression of emotionally powerful, at times unconscious
social and cultural forces regarding race, identity, diversity, authority,
and inclusion. Participants only know one another through their
limited posts, and without deeper interpersonal knowledge,
assumptions and projections can easily mount.135 This may
encourage posting of attacking or inflammatory responses. Some
professional input can reduce the risk of destructive and damaging
posts.
A study of 103 participants in an online peer support group
message board for depression found that many of the members of
the group valued it highly, spending at least five hours engaged with
the group online over the preceding two weeks to post messages
and respond to others’ posts. Benefits of participation included
emotional support and tips about depression treatments. High users
of the message board were more likely to experience resolution of
their depression. More than 80 percent of the participants also
continued to receive in-person professional care. They saw the
online group as a supportive adjunct to, rather than as a substitute
for, traditional care.136 One participant’s account of her experience
describes many of the unique benefits of the online support group:
> I find online message boards to be a very supportive community in
the absence of a “real” community support group. I am more likely to
 interact with the online community than I am with people face to face.
This allows me to be honest and open about what is really going on with
me. There are lots of shame and self-esteem issues involved in
depression, and the anonymity of the online message board is very
effective in relieving some of the anxiety associated with “group
therapy” or even individual therapy. I am not stating that it is a
replacement for professional assistance, but it has been very supportive
and helped motivate me to be more active in my own recovery
program.137 <<

Posting messages as the vehicle for communication has the

serendipitous benefit of facilitating research, as every
communication can be examined. An analysis of postings in groups
for women with breast cancer demonstrated that members of groups
that had trained moderators were more likely to express distressing
emotions than members of groups without moderators. Greater
emotional expression by participants was associated with reduced
depression.138 The moderator, generally a mental health expert,
requires skill in facilitation and in activating, containing, and exploring
strong emotions. This appears to be as important in online support
groups as in face-to-face groups.139
Internet support group participants describe many other unique
advantages. Individuals, for example, who are unable to attend face-
to-face meetings, because of geographic distance, cost, physical
disability, infirmity, or the dearth of professionals in their
communities, are now able to participate in a self-help or therapy
group.140 Patients with stigmatizing ailments or social anxiety may
prefer the relative anonymity of an Internet support group. These
groups promote health equity by enhancing access to care. For
many people in search of help, an Internet support group is the
equivalent of putting a toe in the water in preparation for full
immersion in some other therapy endeavor; for others, it is a
definitive treatment. Intimacy itself is being redefined favorably in
online terms. Haim Weinberg has coined the term “E-ntimacy” to
describe the intimacy that online platforms generate.141
 Footnotes

i For a full description of the first group I led for cancer patients, see “Travels with Paula” in
Momma and the Meaning of Life (New York: HarperCollins, 1999), 15–53.