The Theory and Practice of Group Psychotherapy (98 page)

The agenda exercise has many advantages. For one thing, it is a solution to the paradox that
structure is necessary but, at the same time, growth inhibiting.
The agenda exercise provides structure for the group, but it simultaneously encourages autonomous behavior on the part of the patient. Members are required to take responsibility for the therapy and to say, in effect, “Here is what I want to change about myself. Here’s what I choose to work on in the group today.” 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: for example, “I tried to approach Mary 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.”

Some patients have great difficulty stating their needs directly and explicitly. In fact, many enter the hospital because of self-destructive attempts 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 patients can simply be taught to ask 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 patient is willing to do and which patients’ goals may interdigitate with other 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 facilitative, persistent, inventive, and often directive to make it work. 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 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 patient may choose to participate at some point in the session. If anything catches his interest, he should speak about it.

Sometimes if a patient cannot articulate an agenda, one can be prescribed that involves listening and then providing feedback to a member the patient selects. At other times it is useful to ask other members to suggest a suitable agenda for a given individual.

For example, a nineteen-year-old male offered an unworkable agenda: “My dad treats me like a kid.” He could not comprehend the agenda concept in his first meeting, and I 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 his 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’s being useful to him.

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.

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 the session, and it is important that patients 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?”

Nonetheless, the efficient and active therapist should be able to work on the majority of agendas in each session. The single most valuable guideline I can offer is 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, but 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.

Generally, during the personal agenda setting, the therapist collects several letters of credit—commitments from patients about certain work they want to do during the meeting. If, for example, one member states that she thinks it important 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 patient 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.

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. I have often led an inpatient group on a teaching unit and generally had two to four students observing the session through a one-way mirror. I prefer to divide the final phase of the group into two equal segments: a discussion of the meeting by the therapists and observers, and the group members’ response to this discussion.

In the first segment, therapists and observers form a small circle in the room and conduct an open analysis of a meeting, just as though there were no patients in the room listening and watching. (If there are no observers in the meeting that day, the co-therapists hold a discussion between themselves or invite the group members to contribute to a discussion in which everyone attempts to review and analyze the meeting.) In this discussion, leaders and observers review the meeting and focus on the group leadership and the experience of each of the members. The leaders question what they missed, what else they might have done in the group, whether they left out certain members. The discussants take pains to make some comment about each member: the type of agenda formulated, the work done on that agenda, guesses about a patient’s satisfaction with the group.

Although this group wrap-up format is unorthodox, it is, in my 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, of course, 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 a negative to a positive force. In fact, group members often 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 or 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.

The other 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 the 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.)

The final phase of the meeting thus has many functions: review, evaluation, pointing to future directions. But it is also a time for reflection and tying together loose ends before the members leave the group session.

In a study that specifically inquired into patients’ reactions to this format, there was strong consensus among the group members that the final phase of the group was an integral part of the group session.
²⁵
When members were asked what percentage of the value of the group stemmed from this final segment, they gave it a value that far exceeded the actual time involved. Some respondents, for example, ascribed to the final twenty minutes of the meeting a value of 75 percent of the total group value.

GROUPS FOR THE MEDICALLY ILL

Group psychosocial interventions play an increasingly important role in comprehensive medical care and are likely to proliferate in the future, given their effectiveness and potential for reducing health care costs.
²⁶
Reports of their use and efficacy in a wide range of ailments abound in the literature. Group therapy interventions have been employed for all the major medical illnesses, including cardiac disease, obesity, lupus, infertility, irritable bowel syndrome, inflammatory bowel disease, pregnancy, postpartum depression, transplantation, arthritis, chronic obstructive lung disease, brain injury, Parkinson’s, multiple sclerosis, diabetes, HIV/AIDS, and cancer.
²⁷

There are many reasons that psychological treatment is important in medical illness. First, there is the obvious, well-known linkage between psychological distress and medical illness—namely, that depression, anxiety, and stress reactions are common consequences of serious medical illness and not only impair quality of life but also amplify the negative impact of the medical illness.
²⁸
We know, for example, that depression after a heart attack occurs in up to 50 percent of men and significantly elevates the risk of another heart attack.
²⁹
Furthermore, the anxiety and depression accompanying serious medical illness tend to increase health-compromising behaviors, such as alcohol use and smoking, and disrupt compliance with recovery regimens of diet, exercise, medication, and stress reduction.
³⁰

Paradoxically, a new source of psychological stress stems from recent advances in medical technology and treatment. Consider, for example, the many formerly fatal illnesses that have been transformed into chronic illnesses: for example, fully 4 percent of Americans are cancer survivors—a state of being that carries with it its own inherent stress.
³¹
Or consider recent breakthroughs in prevention. Genetic testing now plays an important role in medical practice: physicians can compute the risk of an individual’s developing such illnesses as Huntington’s disease or breast, ovarian, and colon cancer.
³²
That, of course, is undeniably a good thing. Yet this technology comes with a price. Large numbers of individuals are tormented by momentous, anxiety-laden decisions. When one learns, for example, of a genetic predisposition to a serious illness, one is forced to face such questions as: Should I have a prophylactic mastectomy? (or other preventive surgery?) Is it fair for me to get married? To have children? Do I share this information with siblings who prefer not to know?