The Theory and Practice of Group Psychotherapy (120 page)

45
S. Wilkinson and G. Gabbard, “Therapeutic Self-Disclosure with Borderline Patients,”
Journal of Psychotherapy Practice and Research
2 (1993): 282–95.

46
K. Ullman, “Unwitting Exposure of the Therapist Transferential and Countertransferential Dilemmas,”
Journal of Psychotherapy Practice and Research
10 (2001): 14–21.

47
T. Gutheil and G. Gabbard, “The Concepts of Boundaries in Clinical Practice: Theoretical and Risk-Management Dimensions,”
American Journal of Psychiatry
150 (1993): 188–96.

48
T. Gutheil and G. Gabbard, “Misuses and Misunderstandings of Boundary Theory in Clinical and Regulatory Settings,”
American Journal of Psychiatry
155 (1998): 409–14. A. Elfant, “Group Psychotherapist Self-Disclosure: Why, When, and How?” presented at the annual meeting of the American Group Psychotherapy Association, New Orleans, February 21, 2003.

49
Self-disclosure was carried to extreme in the time-extended marathon groups popular in the 1970s (see chapter 10), which met from twenty-four to forty-eight consecutive hours and placed paramount emphasis on total self-disclosure of the group as well as the group leader. The sheer physical fatigue wore down defenses and abetted maximal disclosure. Then there is the ultimate in self-disclosure: group therapy in the nude. In the late 1960s and early 1970s, the mass media (for example,
Time
magazine) gave considerable coverage to nude marathons in Southern California (
Time,
February 23, 1968, 42). Many of the wilder innovations in therapy have sprung from Southern California. It brings to mind Saul Bellow’s fanciful notion in
Seize the Day
(New York: Viking Press, 1956) of someone tilting a large, flat map of the United States and observing that “everything that wasn’t bolted or screwed down slid into Southern California.”

50
D. Kivlighan and J. Tarrant, ”Does Group Climate Mediate the Group Leadership-Group Member Outcome Relationship? A Test of Yalom’s Hypothesis About Leadership Priorities,”
Group Dynamics: Theory, Research and Practice
3 (2001): 220–34.

51
M. Parloff, “Discussion of Accelerated Interaction: A Time-Limited Approach Based on the Brief Intensive Group,”
International Journal of Group Psychotherapy
28 (1968): 239–44.

52
Ferenczi, quoted in M. Green,
Interpersonal Analysis
.

53
R. Dies, “Leadership in Short-Term Groups,” in
Advances in Group Psychotherapy,
ed. R. Dies and R. MacKenzie (New York: International Universities Press, 1983), 27–78. R. Dies, “Group Therapist Transparency: A Critique of Theory and Research,”
International Journal of Group Psychotherapy
27 (1977): 177–200. R. Dies and L. Cohen, “Content Considerations in Group Therapist Self-Disclosure,”
International Journal of Group Psychotherapy
26 (1976): 71–88.

54
S. McNary and R. Dies, “Co-Therapist Modeling in Group Psychotherapy: Fact or Fantasy,”
Group
17 (1993): 131–42.

55
E. O’Neill,
The Iceman Cometh
(New York: Random House, 1957).

56
H. Ibsen,
The Wild Duck
(New York: Avon Press, 1965; orig. published 1884).

57
V. Frankl, personal communication, 1975.

CHAPTER 8

1
W. Piper, M. McCallum, A. Joyce, J. Rosie, and J. Ogrodniczuk, “Patient Personality and Time-Limited Group Psychotherapy for Complicated Grief,”
International Journal of Group Psychotherapy
51 (2001): 525–52. R. Kadden, M. Litt, N. Cooney, E. Kabela, H. Getter, “Prospective Matching of Alcoholic Clients to Cognitive-Behavioral or Interactional Group Therapy,”
Journal of Studies on Alcohol
May (2001): 359–69.

2
G. Burlingame, A. Fuhriman, and J. Mosier, “The Differential Effectiveness of Group Psychotherapy: A Meta-Analytic Perspective,”
Group Dynamics: Theory, Research, and Practice
7 (2003): 3–12. G. Burlingame, K. MacKenzie, and B. Strauss, “Small-Group Treatment: Evidence for Effectiveness and Mechanism of Change,” in
Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change
, 5th ed., ed. M. Lambert (New York: Wiley, 2004), 647–96.

3
R. Toseland and M. Siporin, “When to Recommend Group Treatment: A Review of the Clinical and the Research Literature,”
International Journal of Group Psychotherapy
36 (1986): 171–201.

4
C. McRoberts, G. Burlingame, and M. Hoag, “Comparative Efficacy of Individual and Group Psychotherapy: A Meta-Analytic Perspective,”
Group Dynamics: Theory, Research, and Practice
2 (1998): 101–17.

5
K. MacKenzie, “Where Is Here and When Is Now? The Adaptational Challenge of Mental Health Reform for Group Psychotherapy,”
International Journal of Group Psychotherapy
44 (1994): 407–28. M. Parloff and R. Dies, “Group Psychotherapy Outcome Research,”
International Journal of Group Psychotherapy
27 (1977): 281–322. W. Piper and A. Joyce, “A Consideration of Factors Influencing the Utilization of Time-Limited, Short-Term Group Therapy,”
International Journal of Group Psychotherapy
46 (1996): 311–28.

6
K. Graham, H. Annis, P. Brett, P. Venesoen, and R. Clifton, “A Controlled Field Trial of Group Versus Individual Cognitive-Behavioral Training for Relapse Prevention,”
Addiction
91 (1996): 1127–39.

7
D. Renjilian, M. Peri, A. Nezu, W. McKelvey, R. Shermer, and S. Anton, “Individual Versus Group Therapy for Obesity: Effects of Matching Participants to the Treatment Preferences,”
Journal of Consulting Clinical Psychology
69 (2001): 717–21.

8
F. Fawzy, N. Fawzy, and J. Wheeler, “A Post-Hoc Comparison of the Efficiency of a Psychoeducational Intervention for Melanoma Patients Delivered in Group Versus Individual Formats: An Analysis of Data from Two Studies,”
Psycho
-
Oncology
5 (1996): 81–89.

9
E. Westbury and L. Tutty, “The Efficacy of Group Treatment for Survivors of Childhood Abuse,”
Child Abuse and Neglect
23 (1999): 31–44.

10
K. MacKenzie, “Where Is Here and When Is Now? The Adaptational Challenge of Mental Health Reform for Group Psychotherapy,”
International Journal of Group Psychotherapy
44 (1994): 407–28.

11
S. Holmes and D. Kivlighan, “Comparison of Therapeutic Factors in Group and Individual Treatment Processes,”
Journal of Counseling Psychology
47 (2000): 478–84.

12
G. Gazda, “Discussion of When to Recommend Group Treatment: A Review of the Clinical and the Research Literature,”
International Journal of Group Psychotherapy
36 (1986): 203–6. F. de Carufel and W. Piper, “Group Psychotherapy or Individual Psychotherapy: Patient Characteristics As Predictive Factors,”
International Journal of Group Psychotherapy
38 (1988): 169–88.

13
E. Nash et al., “Some Factors Related to Patients Remaining in Group Psychotherapy,”
International Journal of Group Psychotherapy
7 (1957): 264–75. J. Johnson,
Group Psychotherapy: A Practical Approach
(New York: McGraw-Hill, 1963). E. Fried, “Basic Concepts in Group Therapy,” in
Comprehensive Group Therapy,
ed. H. Kaplan and B. Sadock (Baltimore: Williams & Wilkins, 1971), 50–51.

14
L. Horwitz, “Indications and Contraindications for Group Psychotherapy,”
Bulletin of the Menninger Clinic
40 (1976): 505–7.

15
S. Slavson, “Criteria for Selection and Rejection of Patients for Various Kinds of Group Therapy,”
International Journal of Group Psychotherapy
5 (1955): 3–30. S. Adrian, “A Systematic Approach to Selecting Group Participants,”
Journal of Psychiatric Nursing
18 (1980): 37–41.

16
Nash et al., “Some Factors.” Johnson, Group Psychotherapy. Fried, “Basic Concepts.” R. MacNair-Semands, “Predicting Attendance and Expectations for Group Therapy,”
Group Dynamics: Theory, Research, and Practice
6 (2002): 219–28.

17
M. Weiner, “Group Therapy in a Public Sector Psychiatric Clinic,”
International Journal of Group Psychotherapy
38 (1988): 355–65. M. Rosenbaum and E. Hartley, “A Summary Review of Current Practices of Ninety-Two Group Therapists,”
International Journal of Group Psychotherapy
12 (1962): 194–98. W. Friedman, “Referring Patients for Group Therapy: Some Guidelines,”
Hospital and Community Psychiatry
27 (1976): 121–23. A. Frances, J. Clarkin, and J. Marachi, “Selection Criteria for Outpatient Group Psychotherapy,”
Hospital and Community Psychiatry
31 (1980): 245–49. M. Woods and J. Melnick, “A Review of Group Therapy Selection Criteria,”
Small Group Behavior
10 (1979): 155–75.

18
R. Morgan and C. Winterowd, “Interpersonal Process-Oriented Group Psychotherapy with Offender Populations,”
International Journal of Offender Therapy and Comparative Criminology
46 (2002): 466–82. Toseland and Siporin, “When to Recommend Group Treatment.”I. Yalom, “Group Therapy of Incarcerated Sexual Deviants,”
Journal of Nervous Mental Disorders
132 (1961): 158–70.

19
Friedman, “Referring Patients.” Woods and Melnick, “Group Therapy Selection Criteria.” Frances, Clarkin, and Marachi, “Selection Criteria.” Horwitz, “Indications and Contraindications.”

20
Horwitz, “Indications and Contraindications.” Friedman, “Referring Patients.” H. Grunebaum and W. Kates, “Whom to Refer for Group Psychotherapy,”
American Journal of Psychiatry
134 (1977): 130–33.

21
M. Linehan, “Dialectical Behavior Therapy for Borderline Personality Disorder: A Cognitive Behavioral Approach to Parasuicide,”
Journal of Personality Disorders
1 (1987): 328–33. M. Linehan, “Naturalistic Follow-Up of a Behavioral Treatment for Chronically Parasuicidal Borderline Patients,”
Archives of General Psychiatry
50 (1993): 971–74. E. Marziali and H. Munroe-Blum,
Interpersonal Group Psychotherapy for Borderline Personality Disorder
(New York: Basic Books, 1994).

22
I. Yalom, “A Study of Group Therapy Dropouts,”
Archives of General Psychiatry
14 (1966): 393–414.

23
M. Wierzbicki and G. Pekarik, “A Meta-Analysis of Psychotherapy Dropouts,”
Professional Psychology: Research and Practice
24 (1993): 190–95.

24
W. Stone and J. Rutan, “Duration of Treatment in Group Psychotherapy,”
International Journal of Group Psychotherapy
34(1984): 93–109. M. Leszcz, “Guidelines for the Practice of Group Psychotherapy,” in
Guidelines and Standards for the Psychotherapies,
ed. P. Cameron, J. Ennis and J. Deadman (Toronto: University of Toronto Press, 1998), 199–227. H. Roback, “Adverse Outcomes in Group Psychotherapy: Risk Factors, Prevention, and Research Directions,”
Journal of Psychotherapy Practice and Research
9 (2000): 113–22.

25
M. Lieberman, I. Yalom, and M. Miles,
Encounter Groups: First Facts
(New York: Basic Books, 1972).

26
M. Seligman, “The Effectiveness of Psychotherapy: The Consumer Reports Study,”
American Psychologist
50 (1995): 965–74.

27
W. Piper, A. Joyce, J. Rosie, and H. Azim, “Psychological Mindedness, Work and Outcome in Day Treatment,”
International Journal of Group Psychotherapy
44 (1994): 291–311; M. McCallum, W. Piper, and A. Joyce, “Dropping Out from Short-Term Group Therapy,”
Psychotherapy
29 (1992): 206–13. In a study of 109 patients with prolonged or pathological grief in brief (twelve-week), analytically oriented group therapy, the 33 dropouts were found to be significantly less psychologically minded than continuers. They also tended to have greater psychiatric symptomatology and greater intensity of target symptoms. S. Rosenzweig and R. Folman, “Patient and Therapist Variables Affecting Premature Termination in Group Psychotherapy,”
Psychotherapy: Theory, Research and Practice
11 (1974): 76–79. In a study of thirteen dropouts from V.A. outpatient clinic groups a battery of psychological tests did
not
distinguish between the continuers and the dropouts, but the therapists’ pretherapy judgments about their ability to empathize with the clients, their clients’ ability to form a therapeutic relationship, and the therapists’ overall liking of a client were significantly predictive of premature termination. B. Kotkov and A. Meadow, “Rorschach Criteria for Continuing Group Psychotherapy,”
International Journal of Group Psychotherapy
2 (1952): 324–31. A study of Veterans Administration ambulatory groups found that dropouts had less capacity to withstand stress, less desire for empathy, less ability to achieve emotional rapport, a lower Wechsler verbal scale IQ, and came from a lower socioeconomic class. (Many other studies have reported that dropouts [from any psychotherapeutic format] are disproportionately high among the lower socioeconomic class.) R. Klein and R. Carroll, “Patient Characteristics and Attendance Patterns in Outpatient Group Therapy,”
International Journal of Group Psychotherapy
36 (1986): 115–32; H. Roback and M. Smith, “Patient Attrition in Dynamically Oriented Treatment Groups,”
American Journal of Psychiatry
144 (1987): 426–43; L. Gliedman et al., “Incentives for Treatment Related to Remaining or Improving in Psychotherapy,”
American Journal of Psychotherapy
11 (1957): 589–98. M. Grotjahn, “Learning from Dropout Patients: A Clinical View of Patients who Discontinued Group Psychotherapy,”
International Journal of Group Psychotherapy
22 (1972): 306–19. Grotjahn studied his long-term analytic groups and noted that, over a six-year period, forty-three group members (35 percent) dropped out within the first twelve months of therapy. He felt that, in retrospect, approximately 40 percent of the dropouts were predictable and fell into three categories: (1) clients with diagnoses of manifest or threatening psychotic breakdowns; (2) clients who used the group for crisis resolution and dropped out when the emergency had passed; (3) highly schizoid, sensitive, isolated individuals who needed more careful, intensive preparation for group therapy. Nash et al., “Some Factors.” Nash and his co-workers studied thirty group therapy clients in a university outpatient clinic. The seventeen dropouts (three or fewer meetings) differed significantly from the thirteen continuers in several respects: they were more socially ineffective, experienced their illness as progressive and urgent or were high deniers who terminated therapy as their denial crumbled in the face of confrontation by the group. R. MacNair and J. Corazzini, “Clinical Factors Influencing Group Therapy Dropout,”
Psychotherapy: Theory, Research, Practice and Training
31 (1994): 352–61. MacNair and colleagues also studied two large groupings of clients treated at a university counseling service in 16 session interactional interpersonal group therapy. This study of 155 and 310 clients respectively over several years employed The Group Therapy Questionnaire (GTQ) to evaluate the group members. Dropouts and poor attenders could be predicted by the following characteristics: anger, hostility and argumentativeness; social inhibition; substance abuse; and somatization. In contrast, prior experience in some form of psychotherapy was a protective variable. (R. MacNair-Semands, “Predicting Attendance and Expectations for Group Therapy,”
Group Dynamics: Theory, Research and Practice
6 [2002]: 219–28.) This latter finding echoes an earlier report that demonstrated that dropouts were much more likely to be individuals for whom group therapy was their first experience in psychotherapy. W. Stone and J. Rutan, “Duration of Treatment in Group Psychotherapy,”
International Journal of Group Psychotherapy
34 (1984): 93–109. G. Tasca et al., “Treatment Completion and Outcome in a Partial Hospitalization Program: Interaction Among Patient Variables,”
Psychotherapy Research
9 (1999): 232–47. Tasca and colleagues studied 102 clients in an intensive group therapy day hospital program and reported that dropouts were predicted by the combined presence of reduced psychological-mindedness and chronicity of problems. High degrees of psychological-mindedness offset the negative impact of illness chronicity on treatment completion. M. McCallum, W. Piper, J. Ogrodniczuk, and A. Joyce, “Early Process and Dropping Out from Group Therapy for Conplicated Grief,”
Group Dynamics: Theory, Research and Practice
6 (2002): 243–54. Dropout rates for 139 clients participating in 12 session group therapy for complicated grief were 23% (regardless whether they were in an interpretive or a supportive model of group therapy). Dropouts experienced far less positive emotion in the early sessions and were less compatible with, and less important to the group. The therapists reported they had less emotional investment in these clients from the outset of therapy. The phenomenon of very early therapist divestment and antipathy to the clients who ultimately drop out has been reported by others as well. (L. Lothstein, “The Group Psychotherapy Dropout Phenomenon Revisited,”
American Journal of Psychiatry
135 [1978]: 1492–95; O. Stiwne, “Group Psychotherapy with Borderline Patients: Contrasting Remainers and Dropouts,”
Group
18 [1994]: 37–45. T. Oei and T. Kazmierczak, “Factors Associated with Dropout in a Group Cognitive Behavior Therapy for Mood Disorders,”
Behavior, Research and Therapy
35 [1997]: 1025–30.) In a study of 131 clients in CBT groups for depression, 63 clients (48%) dropped out prematurely. Pretherapy variables, including degree of depression did not predict dropouts. In contrast however, lack of participation in the group activities and exercises was predictive. Race and ethnicity are also important considerations. A number of recent studies have shown that visible minorities may terminate prematurely, feeling a lack of universality, comfort and familiarity within the group. (S. Sue, D. Hu, D. Takevch, and N. Zane, “Community Mental Health Services for Ethnic Minority Groups: A Test of the Cultural Responsiveness Hypothesis,”
Journal of Consulting and Clinical Psychology
59 [1991]: 533–40; K. Organista, “Latinos,” in
Cognitive-Behavioral Group Therapy for Specific Problems and Populations,
ed. J. White and A. Freeman [Washington, D.C.: American Psychiatric Press, 2000], 281–303; H. Chang and D. Sunders, “Predictors of Attrition in Two Types of Group Programs for Men Who Batter,”
Journal of Family Violence
17 [2002]: 273–92.) Clients’ negative expectations built upon negative experiences in society also play an important role. (C. Taft, C. Murphy, J. Elliott, and T. Morrel, “Attendance Enhancing Procedures in Group Counseling for Domestic Abusers,”
Journal of Counseling Psychology
48 [2001]: 51–60.)