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Brown Chapter 8

Selecting Clients and Composing Groups

GOOD GROUP THERAPY BEGINS WITH GOOD CLIENT SELECTION. Clients improperly assigned to a therapy group are unlikely to benefit from their therapy experience. Furthermore, a poorly composed group may not be helpful to its members or may even disintegrate early in its life. It is therefore understandable that contemporary psychotherapy researchers are actively examining how best to match clients to psychotherapy groups according to their specific characteristics.1

In this chapter we begin by considering both the research evidence bearing on selection and the clinical methods of determining whether a given individual is a suitable candidate for group therapy. We next address the question of group composition: once it has been decided that a client is a suitable group therapy candidate, into which specific group should he or she go? Group therapy is complex, and at every step of the way the group leader should be guided by this question: What must I do to ensure the success of this group?

We focus particularly on a specific type of group therapy: the heterogeneous outpatient group pursuing the ambitious goals of symptomatic relief and characterological change. However, many of the general principles we discuss have relevance to other types of groups as well, including the brief problem-oriented group.2 Here, as elsewhere in this book, we provide the reader with fundamental group therapy principles coupled with strategies for adapting these principles to a wide variety of clinical situations. (We will discuss some more specialized clinical situations in Chapter 15.)

We would only refer a client to group therapy if we believe that this would be an effective form of treatment for that individual. We start therefore with observations about the benefits of group therapy.

Research consistently shows that group therapy is a potent modality producing significant benefit to its participants.3 It also indicates that group therapy offers unique benefits that in certain situations may make it more helpful than individual therapy.

The evidence for the effectiveness of group therapy is so persuasive that some experts advocate that group therapy be utilized as the primary model of contemporary psychotherapy, though they also acknowledge that it is a more complex treatment that requires therapists have specific training.4 Individual therapy may be preferable for clients who require active clinical management, or when relationship issues are less important and personal insight and depth understanding are particularly important.5

Group therapy is superior to individual therapy in providing social learning and in helping clients develop social support and improve social networks, factors of great importance for clients with substance use disorders.6 Clients with a medical illness acquire coping skills better in therapy with a group of peers than in individual therapy.7 Adding group therapy to the treatment of women who are survivors of childhood sexual abuse provides benefits beyond individual therapy: it results in reduced shame and greater empowerment and psychological well-being.8

Of course, personal choice matters. Clients tend to do better when they engage the type of therapy they prefer: a therapy that matches their expectations.9 We also recognize that clients may be reluctant to engage in group therapy for a host of reasons that the group leader will need to address as part of the selection and preparation process—an issue we will discuss later in this chapter.10

Predicting which clients will do best in group therapy and which are better referred to another form of therapy is not a simple matter. Each client is different, and decisions about treatment must be tailored to the individual. Our inclusion and exclusion criteria are best viewed as general guidelines, and even experienced clinicians are often surprised by who does much better or much worse than expected.11 Our limited clinical capacity to evaluate who will do well, and how our clients are actually doing, is part of the rationale for incorporating more empirical measurement in our clinical care.12 In many instances, the variables that seem to forecast a client’s failure in group therapy can be offset by thorough preparation, through empathic therapist responsiveness, and by securing a fit with a group that is better suited to that particular client at that point in the client’s treatment trajectory. We want to get this process as right as possible to safeguard the client’s care and to avoid the impact on the entire group of a member who is a poor fit.

CRITERIA FOR EXCLUSION

Question: How do group clinicians select clients for group psychotherapy? Answer: The great majority of clinicians do not select for group therapy. Instead, they deselect. Given a pool of clients, experienced group therapists determine that certain people cannot possibly work in a therapy group and should be excluded. And then they proceed to accept all the other clients.

That approach seems crude. We would all prefer the selection process to be more elegant, more finely tuned. But, in practice, it is far easier to specify exclusion than inclusion criteria; one characteristic may be sufficient to exclude an individual, whereas a more complex profile must be delineated to justify inclusion. Mistakes in selection are costly not only to the individual client but to the entire group. Here is a major guideline: We can predict that clients will fail in group therapy if they are unable to participate in the primary task of the group, be it for logistical, intellectual, psychological, or interpersonal reasons.

There is considerable and consistent clinical consensus13 that clients are poor candidates for a heterogeneous outpatient therapy group if they have a significant brain injury,14 are paranoid,15 somatizing,16 addicted to drugs or alcohol,17 acutely psychotic,18 or antisocial.19 More recent studies using validated questionnaires like the Group Selection Questionnaire (GSQ) or the Group Therapy Questionnaire (GTQ) echo this clinical consensus and expand it by indicating that a certain degree of interpersonal skill is required to work in an interpersonal group.20

An additional important point: if clients have no expectation of the group being of value, there is little chance of a successful outcome, and the therapeutic alliance—the alignment of client and therapist about the goals and tasks and quality of the therapeutic relationship—is undermined from the start.21 These considerations are even more compelling for brief, time-limited groups, which are particularly unforgiving of poor client selection.

What traits must a client possess to participate in a dynamic, interactional therapy group? Members must have a capacity and willingness to examine their interpersonal behaviors, to self-disclose, to reflect psychologically on themselves and others, to give and receive feedback, and to have some capacity and willingness to engage with the other group members. Unsuitable clients are those who tend to construct an interpersonal role that is rigid and that would prove detrimental to themselves as well as to the group. For such clients the group becomes a venue for re-creating and reconfirming maladaptive patterns.

Antisocial clients are exceptionally poor candidates for interactional group therapy. Although early in therapy they may be influential and active members, they will eventually manifest their basic inability to relate, often with considerable dramatic and destructive impact, as the following clinical example illustrates:

> Felix, a highly intelligent thirty-five-year-old man with a history of alcoholism and impoverished, exploitative interpersonal relationships, was added with two other new clients to an ongoing group that had been reduced to three by the recent graduation of members. The group had shrunk so much that it seemed in danger of collapsing, and the therapists were eager to reestablish its size. They realized that Felix was not an ideal candidate, but they had few referrals and decided to take the risk. In addition, they were intrigued by his stated determination to change his lifestyle. (Many antisocial individuals are forever “reaching a turning point in life.”)

By the third meeting, Felix had become the social and emotional leader of the group. He seemed to feel more acutely and suffer more deeply than the other members. He presented the group, as he had the therapists, with a largely fabricated account of his background and current life situation. By the fourth meeting, as the therapists learned later, he had seduced one of the female members, and in the fifth meeting he spearheaded a discussion of the group’s dissatisfaction with the brevity of the meetings. He proposed that the group, with or without the permission of the therapists, meet more often, perhaps at one of the members’ homes, without the therapists. By the sixth meeting, Felix had vanished, without notifying the group. The therapists learned later that he had suddenly decided to take a two-thousand-mile bicycle trip, hoping to sell an article about it to a magazine. <<

This extreme example illustrates many of the reasons why the inclusion of antisocial and exploitative individuals in heterogeneous outpatient groups is ill advised. Their social fronts are deceptive; they often consume such an inordinate amount of group energy that their departure leaves the group bereft, puzzled, and discouraged; they rarely assimilate the group therapeutic norms and instead often exploit other members and the group as a whole for their immediate gratification. We do not mean that group therapy per se is always contraindicated for antisocial clients. In fact, a specialized form of group therapy with a more homogeneous population and a wise use of strong group and institutional pressure may well be the treatment of choice.22

Most clinicians agree that clients in the midst of some acute situational crisis are not good candidates for group therapy; they are far better treated in a crisis-intervention therapy format.23 Deeply depressed suicidal clients are best not placed in an interactionally focused heterogeneous therapy group because the group cannot give them the specialized attention they require (except at enormous expense of time and energy to the other members); furthermore, the threat of suicide or self-harm is too taxing, too anxiety provoking, for the other group members to manage.24 This does not rule out group therapy for these clients, but they may require group therapy combined with individual therapy. Structured homogeneous groups for clients with chronic suicidality may be quite effective.25

Good attendance is so necessary for the development of a cohesive and effective group that it is wise to exclude clients who, for any reason, may not attend regularly. Poor attendance may be due to unpredictable and hard-to-control work demands, and it is best not to place individuals in the group whose work requires extensive travel that would cause them to miss even one out of every four or five meetings. Similarly, we are hesitant to select clients who have a very long commute to the group. Too often, especially early in the course of a group, a client may feel neglected or dissatisfied with a meeting, perhaps because another member may have received the bulk of the group time and attention, or the group may have been busy building its own infrastructure—work that may not offer obvious immediate gratification. Deep feelings of frustration may, if coupled with a long, strenuous commute, dampen motivation and result in sporadic attendance.

Obviously, there are many exceptions: some therapists tell of clients who faithfully fly to meetings from remote regions month after month or make a long commute through the winter season. One group member reliably left work in another city at 3:30 p.m. to attend a 6:00 p.m. group, getting home close to 10:00 p.m. each week. She was determined “to make the drive to the group worthwhile,” and her manifest commitment to the group was cited by others as reinforcing their valuing of the group. As a general rule, however, the therapist does well to take account of hardships imposed by time and distance. Online groups are an exception to this concern.

Exclusion criteria apply only for the type of group under consideration. Almost all clients will fit into some group. A characteristic that excludes someone from one group may be the exact feature that secures entry into another group. In our breast cancer group work, for example, women with advanced, metastatic disease fit poorly in groups in which most of the other women had early breast cancer—a cancer that carried a much better and much less frightening prognosis. A secretive, non-psychologically minded client with an eating disorder is generally a poor candidate for a long-term interactional group, but may be ideal for a homogeneous, cognitive-behavioral eating-disorders group. And keep in mind that some individuals may fail in their first interpersonal group, learn from that experience, and thrive in a later group.

Dropouts

There is evidence that premature termination from group therapy is bad for the client and bad for the group. A pioneering study of thirty-five clients who dropped out of long-term heterogeneous interactional outpatient groups in twelve or fewer meetings found that only three reported themselves as improved.26 Moreover, those three individuals had only marginal symptomatic improvement. None of the thirty-five clients left therapy because they had satisfactorily concluded their work; they had all been dissatisfied with the therapy group experience. Their premature terminations also had an adverse effect on the remaining members of their group, who were threatened and demoralized by the early dropouts. In fact, many group leaders report a contagion or “wave effect,” with dropouts begetting other dropouts. The proper development of a group requires membership stability; a rash of dropouts may delay or obstruct the maturation of a group for months.

Early group termination is thus a failure for the individual and a detriment to the therapy of the remainder of the group. Unfortunately, dropping out prematurely is common across the psychotherapies.27 Reviews of dropout rates in group therapy across a range of settings, from private practice to university hospital clinics to VA outpatient clinics, consistently demonstrate group therapy attrition ranges from 17 percent to 57 percent.28 Although this rate is no higher than the dropout rate from individual therapy, the dropout phenomenon is more concerning to group therapists because of the deleterious effects of dropouts on the rest of the group.

A study of early dropouts may help establish sound exclusion criteria and, furthermore, may provide an important goal for the selection process. If, in the selection process, we learn merely to screen out members particularly vulnerable to dropping out of therapy, that in itself would constitute a major achievement. It would allow us to direct these clients to other treatments, to invest much more in their pregroup preparation, or to be alert to our own countertransference contributions to their negative group experience. Although the early terminators are not the only failures in group therapy, they are unequivocal failures.29 We may dismiss as unlikely the possibility that early dropouts have gained something positive that will manifest itself later. As noted in an earlier outcome study of encounter group participants, those who reported a negative experience when they left the group continued to feel that way long after the group ended. When interviewed six months later, none of these participants reported having “put it all together” and enjoying a delayed benefit from the group experience.30 If they left the group shaken or discouraged, they were very likely to remain that way.

Keep in mind that the study of group dropouts tells us little about those who continued to attend. Group continuation is a necessary but insufficient factor in successful therapy, although consistent evidence exists that clients who continue in treatment and avoid a premature ending achieve the best therapy outcomes.31

Reasons for Dropouts and Premature Termination

A number of rigorous studies of group therapy in various settings have convergent findings on the characteristics of people who drop out prematurely from group therapy.32 These studies demonstrate that such clients are likely, at the initial screening or in the first few meetings, to have one or more of the following characteristics:

• Lower psychological-mindedness

• Tendency to act out

• Lower motivation

• More reactive and less reflective

• Less positive emotion

• Greater denial of distress or need for therapy

• Higher somatization

• Abuse of substances

• Greater anger and hostility

• Lower socioeconomic status

• Lower social effectiveness

• Lower intelligence

• Lack of understanding of how group therapy works

• The experience or expectation of cultural insensitivity

• Poorer social skills

• Very high levels of emotional or psychological distress

• In acute crisis and unable to turn attention to the group

• Strong preference for individual therapy

• Early dissatisfaction with the group or group leader

TABLE 8.1 Group Therapy Dropout Rates

Type of Group: University outpatient clinic

Length of Group: General, open-ended

Number of Sessions: 12 or fewer

Percent Dropping Out: 50%1

Type of Group: University outpatient clinic

Length of Group: Bereavement, closed

Number of Sessions: 12 or fewer

Percent Dropping Out: 28%2

Type of Group: University outpatient clinic

Length of Group: Short-term

Number of Sessions: 8 or fewer

Percent Dropping Out: 39%3

Type of Group: University outpatient clinic

Length of Group: Open-ended

Number of Sessions: 3 or fewer

Percent Dropping Out: 57%4

Type of Group: VA outpatient clinic

Length of Group: Open-ended

Number of Sessions: 9 or fewer

Percent Dropping Out: 51%5

Type of Group: VA outpatient clinic

Length of Group: Open-ended

Number of Sessions: 16 or fewer

Percent Dropping Out: 50%6

Type of Group: University outpatient clinic

Length of Group: Open-ended

Number of Sessions: 12 or fewer

Percent Dropping Out: 35%7

Type of Group: Private and clinic

Length of Group: Open-ended

Number of Sessions: 3 or fewer

Percent Dropping Out: 30%8

Type of Group: Clinic and hospital

Length of Group: Inpatient and outpatient

Number of Sessions: 20 or fewer

Percent Dropping Out: 25%9

Type of Group: Private practice

Length of Group: Long-term, analytic

Number of Sessions: 12 months or less

Percent Dropping Out: 35%10

Type of Group: Outpatient clinic

Length of Group: Open-ended

Number of Sessions: 12 or fewer

Percent Dropping Out: 17%11

Type of Group: Outpatient clinic

Length of Group: Short-term

Number of Sessions: 5 or fewer

Percent Dropping Out: 17%12

Type of Group: Private and clinic

Length of Group: Analytic

Number of Sessions: 10 or fewer

Percent Dropping Out: 24%13

Type of Group: Clinic

Length of Group: Dynamically oriented

Number of Sessions: 6 months or less

Percent Dropping Out: 17%14

Type of Group: Private practice

Length of Group: Dynamic/analytic

Number of Sessions: 6 months or less

Percent Dropping Out: 27% therapist A

38% therapist B15

Type of Group: Private practice

Length of Group: Analytic/long-term

Number of Sessions: 1 year or less

Percent Dropping Out: 55%16

Type of Group: University counseling center

Length of Group: Interactional/ interpersonal

Number of Sessions: 12 or fewer

Percent Dropping Out: 31% therapist A

45% therapist B17

Type of Group: Outpatient clinic

Length of Group: Complicated grief

Number of Sessions: 8 or fewer

Percent Dropping Out: 23%18

Type of Group: Outpatient clinic

Length of Group: CBT for depression

Number of Sessions: 12 or fewer

Percent Dropping gOut: 48%19

Sources:

1. R. Klein and R. Carroll, “Patient Characteristics and Attendance Patterns in Outpatient Group Psychotherapy,” International Journal of Group Psychotherapy 36 (1986): 115–32.

2. M. McCallum and W. Piper, “A Controlled Study for Effectiveness and Patient Suitability for Short-Term Group Psychotherapy,” International Journal of Group Psychotherapy 40 (1990): 431–52.

3. M. McCallum, W. Piper, and A. Joyce, “Dropping Out from Short-Term Group Therapy,” Psychotherapy 29 (1992): 206–13.

4. E. Nash et al., “Some Factors Related to Patients Remaining in Group Psychotherapy,” International Journal of Group Psychotherapy 7 (1957): 264–75.

5. B. Kotkov, “The Effects of Individual Psychotherapy on Group Attendance,” International Journal of Group Psychotherapy 5 (1955): 280–85.

6. S. Rosenzweig and R. Folman, “Patient and Therapist Variables Affecting Premature Termination in Group Psychotherapy,” Psychotherapy: Theory, Research and Practice 11 (1974): 76–79.

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

8. E. Berne, “Group Attendance: Clinical and Theoretical Considerations,” International Journal of Group Psychotherapy 5 (1955): 392–403.

9. J. Johnson, Group Psychotherapy : A Practical Approach (New York: McGraw-Hill, 1963).

10. M. Grotjahn, “Learning from Dropout Patients: A Clinical View of Patients Who Discontinued Group Psychotherapy,” International Journal of Group Psychotherapy 22 (1972): 306–19.

11. L. Koran and R. Costell, “Early Termination from Group Psychotherapy,” International Journal of Group Psychotherapy 24 (1973): 346–59.

12. S. Budman, A. Demby, and M. Randall, “Short-Term Group Psychotherapy: Who Succeeds, Who Fails,” Group 4 (1980): 3–16.

13. M. Weiner, “Outcome of Psychoanalytically Oriented Group Therapy,” Group 8 (1984): 3–12.

14. W. Piper, E. Debbane, J. Blenvenu, and J. Garant, “A Comparative Study of Four Forms of Psychotherapy,” Journal of Consulting and Clinical Psychology 52 (1984): 268–79.

15. W. Stone and S. Rutan, “Duration of Treatment in Group Psychotherapy,” International Journal of Group Psychotherapy 34 (1984): 93–109.

16. K. Christiansen, K. Valbak, and A. Weeke, “Premature Termination in Analytic Group Therapy,” Nordisk-Psykiatrisk-Tidsskrift 45 (1991): 377–82.

17. R. MacNair and J. Corazzini, “Clinical Factors Influencing Group Therapy Dropouts,” Psychotherapy: Theory, Research, Practice and Training 31 (1994): 352–61.

18. M. McCallum, W. Piper, J. Ogrodniczuk, and A. Joyce, “Early Process and Dropping Out from Short-Term Group Therapy for Complicated Grief,” Group Dynamics: Theory, Research, and Practice 6 (2002): 243–54.

19. T. Oei and T. Kazmierczak, “Factors Associated with Dropout in a Group Cognitive Behavior Therapy for Mood Disorders,” Behaviour Research and Therapy 35 (1997): 1025–30.

These conclusions suggest that, all too often, the rich get richer and the poor get poorer. What a sad paradox! The clients who have the least skills and attributes needed for working in a group, who most need what the group has to offer, are the very ones most likely to fail! It is this irony that has stimulated attempts to modify the therapy group experience so that it accommodates more of these at-risk clients. We need to fit our groups to our clients rather than the other way around.33

Keep in mind that these characteristics should therefore be seen as relative cautions rather than absolute contraindications. The person who fails in one group may do well in a different one. We should aim to reduce, not eliminate, dropouts. If we create groups that never experience a dropout, then it may be that we are setting our bar for entry too high, thus eliminating clients whom we may be able to help.

We will discuss one final study here in great detail, since it has considerable relevance for the selection process and its findings have been replicated in other studies.34 I (IY) studied the first six months of nine therapy groups in a university teaching hospital outpatient clinic and investigated all clients who terminated in twelve or fewer meetings. A total of ninety-seven clients were involved in these groups (seventy-one original members and twenty-six later additions); of these, thirty-five were early dropouts. Considerable data were generated from interviews and questionnaire studies of the dropouts and their therapists and from observers of the groups.

An analysis of the data revealed nine major reasons for the clients dropping out of therapy:

1. External factors

2. Group deviancy

3. Problems of intimacy

4. Fear of emotional contagion

5. Inability to share the therapist

6. Complications of concurrent individual and group therapy

7. Early provocateurs

8. Inadequate orientation to therapy

9. Complications arising from subgrouping

Usually more than one factor is involved in the decision to terminate. Some factors are more closely related to external circumstances or to enduring character traits that the client brings to the group, and thus are relevant to the selection process, whereas others are related to therapist actions, or to problems arising within the group (for example, the therapist’s skill and competence).35 Most relevant to the establishment of useful selection criteria are the clients who dropped out because of external factors, group deviancy, and problems of intimacy.

External Factors. Logistical reasons for terminating therapy (for example, irreconcilable scheduling conflicts, or moving out of the geographic area) played a negligible role in decisions to terminate. When this reason was offered by the client, closer examination usually revealed that group-related stress was more pertinent to the client’s departure. Nevertheless, in the initial screening session, the therapist should always inquire about any pending major life changes, such as a move and the client’s capacity to commit to the group at the planned time. Although clients show variable rates of progress in treatment, there is considerable evidence that therapy aimed at both relieving a client’s symptoms and making major changes in his or her underlying character structure is not brief therapy—a minimum of six months is necessary.36 Hence, clients should not be accepted into such therapy if there is a considerable likelihood of forced termination within the next few months. Instead, these clients are better candidates for shorter-term, problem-oriented groups.

External stress was considered a factor in the premature dropout of several clients who were so disturbed by external events in their lives that it was difficult for them to expend the energy for involvement in the group. They could not explore their relationships with other group members while they were consumed with the threat of disruption of relationships with the most significant people in their lives. It seemed especially pointless and frustrating to them to hear other group members discuss their problems when their own problems seemed so compelling. Among the external stresses were severe marital discord with impending divorce, impending career or academic failure, disruptive relationships with family members, bereavement, and severe physical illness. In such instances, referrals should be made to groups explicitly designed to deal with such situations: acute grief, for example, is generally a time-limited condition, and the acutely bereaved client is best referred to a shorter-term bereavement group, particularly if the grief is complex and unremitting.37

Note an important difference! If the goal is specifically to ameliorate the pain of a breakup, then a brief, problem-oriented therapy is indicated. But for clients who wish to change something in themselves that causes them to thrust themselves repeatedly into painful situations (for example, repetitive involvement with people who invariably leave them), then longer-term group work is indicated.

The importance of external stress as a factor in premature group termination was difficult to gauge, since often it appeared secondary to internal forces. A client’s psychic turmoil may cause disruption of his or her life situation, so that secondary external stress occurs; or a client may magnify external problems to escape anxiety originating from the group therapy. Several clients considered external stress the chief reason f

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