The Promise of Group Therapy: How to Build a Vigorous Training and Organizational Base for
Group Therapy in Managed Behavioral Healthcare
CHAPTER 1: Organization Development and Group Therapy
Organization Development and Group Therapy
When I began my tenure as the first group psychotherapy coordinator for the Group Health Cooperative of Puget Sound in 1980, the first task I set for myself was to learn the structure of the organization and meet the decision makers. At the time, I was criticized by some of my peers for meddling in the affairs of management, which clinical professionals were supposed to ignore in order to focus on clinical responsibilities. Yet to practice group therapy in a cost-managed system, group clinicians must be aware of how the entire system works, because our success depends directly on how well the system refers people to groups.
PROMOTING GROUP THERAPY
Three factors are key to the rise of an organizational culture in which group therapy flourishes: (1) educating the consumer, (2) training the clinician, and (3) educating the organization.
Educating the Consumer
The organization must educate consumers to take an active role in their healthcare. In the field of group therapy, this begins by teaching the purposes of group and by giving a sense of what is possible to accomplish. Providing sufficient and realistic knowledge allows the consumer to choose group therapy—an important factor in helping a person become motivated to take part in a group therapeutic experience. This education includes information on the benefits that can be derived and the financial incentives that can be gained by participating in the group program.
For example, the prospective group candidate who has presented with symptoms of depression will want to know that her condition can be treated in a group, and a little about how that treatment proceeds. The candidate will also want to know that the group therapists are well trained and experienced in the treatment of the condition that afflicts her, and that the organization believes enough in this form of treatment not only to develop a special program for its delivery but also to provide a benefit package that makes it advantageous for the consumer to be treated in group. Providing information of this sort helps the potential group patient begin thinking of herself as a member of a therapy group prior to her entry.
Financial incentives to enter group can also be designed in a number of creative ways. At Puget Sound, we structured the patient benefit such that a group session “cost” one-half to one-third of a standard individual session. In that way, a person could receive two to three times as many treatment sessions under the same benefit package by choosing to enter group treatment. In systems that require co-payments, the co-payments for group can be reduced by one-half to one-third as an additional incentive for patients to use group therapy.
Training the Clinician
The clinical professional must be trained for competence in the treatment of patients in group psychotherapy. This training consists not just of instruction, in order to gain theoretical understanding of the complex processes of group, but also of emotional preparation for group leadership, which always involves a considerable amount of time devoted to learning about group as a participating member.
The goal of training for competency is to allow the group therapist to gain a dual perspective: that of an objectively trained eye for the abstract processes that underlie the content of group interaction, and a subjectively trained sensibility for empathizing with the pain and suffering of the individuals who seek help. In addition, the group therapist must possess excellent psychological boundaries that prevent the loss of self in the often bewildering array of projections and projective identifications that bombard an individual who enters a group; paradoxically, these boundaries also permit psychological intimacy with colleagues and people in treatment.
The group therapist must also be skilled at introducing the public to group therapy and educating the public as to the benefits and limitations of group treatment. This aspect of marketing or “selling” group therapy to consumers is a necessary component of group therapy practice, because only one in one hundred persons will seek group therapy on their own. We know from our experience in the HMO industry that forty in one hundred persons are both suitable and appropriate for group therapy treatment. Therefore, it falls to the group therapist to educate the other thirty-nine. Such education involves the sale of an intangible product that must be convincingly presented by therapists who truly believe that groups can improve people’s lives.
Educating the Organization
The managers and decision makers of the organization must understand the product they are promoting, because group therapy is a complex human service that matches skilled professionals with subscribers to the health plan who have specific, often pressing needs. For group therapy to be effective, the organization must clear the way so that clinicians can offer treatment and patients can choose treatment in group. Organization managers must learn how to create a context in which mental health services, and specifically group therapy programs, can be effectively used by patients.
First, the marketing division of the organization must bear fiscal responsibility not to sell more employer contracts than its clinical professionals can serve—nor to promise potential consumers services that the organization cannot deliver. To do so would undermine the morale of the treatment team and send a message to the consumer that the organization is not to be trusted—a chilling start for a service like group therapy, which for its successful completion requires basic trust, from initial contacts and clinical interventions to follow-up procedures.
Second, the organization must learn to appreciate the complexity of the tasks of starting and maintaining treatment groups. It must not pressure providers to assume the leadership of groups before the providers have received adequate preparation and resources to accomplish the task. The organization must allocate the necessary and sufficient resources for providers to do their jobs well. These resources— in addition to in-service training—include meeting rooms, lighting fixtures, and comfortable chairs that create a positive and healing ambience for group members. I once consulted with a manager who seriously considered cutting back on tissue boxes, not realizing their importance in the therapeutic environment. Such false economizing sends a negative message to both patients and clinicians and should be avoided. Suitable co-therapists will also be required for certain high-stress groups involving people suffering from deep and acute traumas and losses.
Third, the performance goals that management sets for group ther- apists must reflect a realistic understanding of what is possible. For example, to establish an arbitrary goal that each clinician lead four groups each week—or that the percentage of group visits relative to overall patient visits be increased to 30 percent within one year—will have a demoralizing effect for staff who may truly believe they are not working hard enough. A wise manager will not want to induce resent- ment among staff for failing to meet unattainable production goals, but rather will set up rewards for incremental growth that fit both the sophistication of the providers and the needs of the patients. Some rewards and incentives for providers include paid time off for profes- sional enrichment and a reduction of clinical hours relative to time in the office.
CONSUMER TRUST IN THE ORGANIZATION
How the consumer views the organization as a whole reinforces either positively or negatively the outcomes of mental health treatment. This fact was brought home to me quite clearly when I completed a medical utilization review of selected group psychotherapy patients at the Group Health Cooperative of Puget Sound. We cover the study in detail as I consider the offset effect in Chapter Seven, but here I want to cite the relevant statistics that show the similarity in response between this experimental group of 115 group psychotherapy patients and a randomly selected sample of 5,664 consumers in two satisfaction surveys given independently during the same month by the Mental Health Service and the Administration of Puget Sound.
Overall Satisfaction with Treatment in Group Therapy N=115
Completely satisfied: 47 percent Somewhat satisfied: 43 percent Somewhat unsatisfied: 8.7 percent Completely unsatisfied: 1 percent
Overall Satisfaction with Services at the Medical Center N = 5,664
Completely satisfied: 48 percent Moderately satisfied: 46 percent Slightly unsatisfied: 4 percent Not satisfied: 2 percent
After studying the striking similarity between the cooperative-wide consumer survey and our own group therapy consumer survey, we concluded that we had tapped into the expression of a larger phenomenon. Satisfaction or dissatisfaction was being reported for the medical and health services at the Group Health Cooperative of Puget Sound at large, including the mental health services provided by the group therapy program. This finding seems to correlate with Saul Feldman’s observation: “More in mental health than in any other field, the way people feel about the organization in which they are receiving help has a major effect on the outcome of that help. In effect, the organization is an important part of the treatment.”
The side-by-side comparison of these two studies is worthwhile because it portrays an operational definition of trust as expressed by healthcare consumers. Trust in the operation of the larger organization transfers to the trust subscribers feel for the quality of treatment they have received and expect to receive from their group therapists. The trust the organization demonstrates in training their clinicians translates into the trust and willingness that subscribers show by entering a therapy group. Building this context of trust is essential because of the dynamic connection between the individual and the organization.
In terms of general systems theory, this connection is an example of isomorphy, a term derived from the joining of two Greek words, meaning “the same form.” Isomorphy means that in a complex system there are similar organizing structures that operate beneath the diverse contents of any system. The notion of isomorphy expresses the reciprocal relationships that exist between the organization and the individual within a specific context, the proper consideration of which is the work of organization development.
THE ROLE OF ORGANIZATION DEVELOPMENT
As we are beginning to see, the success of group therapy depends on organization development, which can be defined as the effort to understand and enhance the relationship between the individual and the organization in which he works or is a member. The individual always interacts with the organization within a specific context that includes historical, economic, sociological, political, philosophical, and psychological factors. Both the individual and the organization are embedded in the specific context, which becomes the matrix for all their interactions. The individual and the organization are influenced reciprocally by the context in which they interact. That context includes beliefs and values that are held by individuals personally, by the specific corporate culture as a whole, and by the nation, with its multifaceted and often contradictory social and cultural mores. A chief assumption of organization development is that attempts by the individual or the organization to change will always be facilitated or limited by the specific context in which they find themselves. Those who practice organization development help individuals and organizations make changes by analyzing the interactions between the organization and the individual to see what adaptations are possible given a specific context. Once a change is implemented, there must be a further effort to create a social and organizational context that supports and maintains that change over time.
One of the factors that has impeded the growth of group therapy in the mental health industry to this point has been the failure to grasp and employ the concepts of organization development. Too often, mental health managers have assumed incorrectly that clinical providers alone are responsible for the effective delivery of care to patients, forgetting that the values and policies of the organization and the needs and expectations of subscribers play equally powerful parts. When managers conceive of group therapy in terms of organization development, they pay greater attention to the context in which the patient receives help.
Of Bagels and Mental Health
Just the other day I saw two newspaper headlines in rough juxtaposition. The first read, “Noah’s Bagels, Local Success Story, in Line for Corporate Buy Out.” The second read, “Regional Mental Health Care Provider Considers Merger with the Largest Insurance Company in the Industry.”
In both cases, the consumer has some reason to worry. She may wonder, Will my bagel taste as good as before? Will my neighbor who makes bagels lose his job? Will my healthcare dollar buy as much as it did before? Will my needs for mental healthcare be lost in the pursuit of bigness and efficiency?
These kinds of questions arise when changes occur that affect the context in which individuals and organizations interact. This is the meaning of organization development for me as an individual: How should I negotiate a path to getting what I want from an organization, given a particular set of opportunities and constraints?
It is ironic that mental health professionals, many of whom consider themselves “agents of change,” have been slow to embrace the notion that change is primarily a social phenomenon. Socially oriented change theorists have long perceived the group as a powerful instrument to effect change. For many years these theorists have found a home in the world of business and commerce, but not mental health. The joke has been: “If you want to study group interactions at the university level, enter the school of business, not psychology. Business knows that if you want to make money, you must learn how to function with people in groups.” That statement is no less true now than in the past.
Even the best-trained group therapists will fail to prosper in an organization that does not allow them to succeed. The most carefully structured organization will not sustain group practices over time unless it provides group therapists ongoing training and supervision that focuses on forming personal boundaries, exploring projective identification, and the working through of countertransference. In the absence of training in such preventive measures, group therapists face professional burnout and loss of productivity. Group therapists are highly exposed because they cannot hide their mistakes in the privacy of individual treatment. Group therapists are visible and vulnerable. It is imperative that the corporate culture establish and maintain organizational boundaries that conserve and nurture group therapists. Training and the positive incentives of appropriate organizational structure are inextricably linked, and together they create a practical alliance for success that must be thoughtfully crafted.
At both the level of the therapy group and the level of the corporation, the group is the social unit of change because in the group setting I can comprehend the context in which I as an individual interact with the organization. In a group, I will display the full range of my coping and defensive strategies in relation to others. I will obtain feedback from others about my own behavior and may quite often be surprised to learn that not all people experience me the same way. I may also be astonished to find that others perceive me in very similar ways. It becomes difficult for me to dismiss the characteristic ways that a number of observers see me, even if I am resistant to seeing myself that way. Their perceptions—whether positive or negative—reinforce the way I perceive myself. In the social unit of the group, I can also experience my own resistance to change and discover the organization’s limitations, traditions, and customs that circumscribe my efforts to change.
I believe that as educators we have done a good job changing the attitude of the public toward mental health treatment as a force for positive change in the quality of people’s lives. There is now a growing expectation that mental health coverage will be provided as part of the return for our healthcare dollar. Health planners and providers must come up with new ideas in the delivery of mental health services to meet the growing consumer demand. As part of this process, the organization must explore and adopt special strategies to champion group therapy.
NINE WAYS TO ENCOURAGE GROUP THERAPY
It might be helpful at this point to compare two organizations and how they constructed their group therapy programs. I intend this to be an object lesson in what to avoid and what actions to take in order to improve and expand group treatment delivery.
While employed as group psychotherapy coordinator at Puget Sound, in my capacity as an external consultant I had the opportunity to study the department of psychiatry for a large health maintenance organization in northern California, hereafter called Northern California. This gave me the unique opportunity to examine the Northern California system and compare it with the system at Puget Sound on the dimension of group therapy delivery. At the time of my comparative study, 40 percent of all patient visits at Puget Sound were group therapy visits, whereas fewer than 10 percent of all patient visits were group therapy visits at Northern California. My study is now dated, but the principles of sound organizational structure that promote group therapy apply as much today as they did then.
Let’s consider nine aspects of organizational structure and decision making that have a direct impact on the operation of a group therapy program.
1. The first aspect is differential pricing. In my study, Northern California allowed no differential pricing between the two modes of treatment—group therapy and individual therapy. One patient visit equaled one patient visit regardless of modality or length of time consumed by the provider. In contrast, Puget Sound allowed for pricing differences between modes of treatment. This became one of the cornerstones of the group program because it gave consumers an incentive to consider and consent to referrals to a therapy group.
We found differential pricing both ethical and consumer-conscious, because it passes along to the consumer savings that the provider enjoys. It conforms to the community standard of practice that has long recognized the cost savings of group compared to individual treatment. The practice also conveys a subtle and powerful message to the consumer: “Your wise choice of group therapy is acknowledged and appreciated.”
2. The second aspect is the inclusion of master’s level clinicians and nurses as practitioners of group therapy. The Northern California program at that time excluded master’s level clinicians (Marriage, Family, and Child Counselors and master’s degree in nursing) from conducting groups. Such a policy is misguided: it excludes some of the better trained and most-experienced group therapists, group therapy supervisors, and group therapy program managers from participating. In the absence of a doctorate in group psychotherapy, which has never been conferred by any university or college in the United States, the possession of a doctorate itself does not qualify a professional in the clinical practice of group psychotherapy.
As indicated earlier, a degree in business may in some respects better prepare group professionals than a degree in a mental health discipline. Only recently has an attempt been made by the American Group Psychotherapy Association to codify what constitutes a trained group therapist, and then only at a minimal standard of competence. The attempt is laudable: it embraces master’s level clinicians and cites the kind of training, experience, and supervision necessary to meet the minimum standard. In contrast to Northern California, Puget Sound welcomed master’s level nurses and family counselors, who brought diversity and breadth of experience, training, and organizational expertise to the group program.
3. The Northern California system adopted a strict hierarchical (vertical) organization that followed the medical model. In such a structure, psychiatric physicians dominated the organization’s decision making and resource allocation, such as utilization of space and support staff time, with psychologists and social workers bringing up the rear in descending order. Unfortunately, such hierarchies among clinicians stifle the free flow of referrals between therapists that is so necessary for the sustenance and replenishment of psychotherapy groups. Functional equivalence among the various clinical disciplines for most kinds of therapeutic care must be respected; this alone permits clinicians to refer with confidence to appropriate groups conducted by a variety of qualified clinicians. At Puget Sound, this meant that psychiatrists, psychologists, social workers, nurses, and other master’s level clinicians were considered equivalent for general treatment responsibility.
Such a practice does not deny the variety of expertise on staff or among members of a treatment team (knowledge of psychotropic medication and psychological testing being two examples). However, it does permit a collegial atmosphere in which group referrals can be made across the lines of the various professional disciplines without the prohibitions that exist in a hierarchical system. A doctor can refer in confidence to a master’s level clinician with the sure knowledge that competent care will be given. An organization can thereby avoid unnecessary division and conflict within the group program. Patients are sensitive to the attitudes and beliefs of their referring therapists to such an extent that patients’ expectations of help and positive outcomes can be built in or sabotaged depending on the degree of enthusiasm with which the referral is made.
4. Puget Sound adopted functional equivalence among clinicians because of its early dedication to democratic principles as a consumer cooperative. As a fourth aspect of organizational structure, it cannot be overstated that equality is one of the most important underlying values that permit the establishment of group therapy programs and the treatment of patients therein. We must always remember that at some level, the members of every viable therapy group seek to create a kind of fairness among themselves even in the face of severe pathology. In a system that keeps this principle at the forefront, the consumer remains the focus for satisfaction, not the provider nor the clinic manager.
In the Northern California plan at that time, physicians became the “customers” to be satisfied rather than the mental health consumers who came seeking relief of their sorrows and suffering. This is a hazard that cost management people can easily fall into when they think of mental health services only as a product. It is essential for them to remember that what is being delivered is a service and that the judgment of what is effective and satisfying treatment ultimately rests with the consumers themselves. In the corporate management of mental health, I believe cost managers have taken the place of physicians in many respects, creating a new kind of hierarchy that can also compromise group therapy programs if these managers refuse to recognize the people who receive the care as the first priority.
When I say that the dynamics of one system (functional equivalence of clinical staff at the provider level) influence the dynamics of another system (the capacity of clinical staff to communicate enthusiasm to a patient about a therapy group) and also influence the dynamics of a third system (the ability of therapy group members to form a group and relate to each other as peers), I am again speaking from the perspective of isomorphy, the concept of general systems theory and organization development introduced earlier. Isomorphy, often called parallel process, exists at many levels of the complex systems that make up a comprehensive group psychotherapy delivery program. I discuss this concept at greater length in Chapter Eleven, Phases of Group Therapy Development.5. In the Puget Sound system, highly skilled and trained entry personnel effected a triage of patients, discussed the treatment options— including group therapy when appropriate—and generally prepared the patient with the expectation that group therapy may be offered, and if it is, will probably be successful. The group therapy coordinator and other clinical professionals devoted many hours to the selection and training of entry staff so that they could carry out their mandate to introduce the first-time consumer to the Mental Health Service, reduce delays in service, facilitate the entry of some patients into immediate access groups, and build in an expectation of help at the initial point of contact with the patient.
Instruction in triage procedure allows entry personnel to separate callers into three categories: emerging crisis, manageable anxiety or conflict, and potential long-term care. Persons assigned to each of these categories are given an appointment with a therapist, with the exception of some patients in crisis who can be referred directly to a crisis-type group. As I have stated previously, trust is a behavior that finds isomorphic resonance at various levels of the complex systems that make up the group therapy program. Management and professional staff must trust the special training program for entry personnel and their ability to make skillful judgments in order to accept the entry staff’s referrals to psychotherapy groups. The group psychotherapists must trust the patients to follow through with the commitments and contracts they make in groups. And patients must trust that their clinicians have the skills needed to help them.
In contrast, the Northern California system provided no trained entry personnel to triage patients on the phone or in person. The expectation that group therapy might be offered was never discussed by the secretary who fielded all calls and set up individual appointments. Secretaries were untrained in the most basic of interview skills.
In order to reach the thirty-nine out of one hundred people who are appropriate for group but do not request it, those staffing the entry positions must have specific training. The training should be limited in scope but broad enough to encompass predictable situations that require a high degree of confidence to execute. A wise clinic manager will want some of her best and most adept people at the front desk to interface with the consumers as they enter the system.
6. Puget Sound embraced the co-therapy model for over 50 percent of its groups. The success of the group therapy program can be demonstrated by the successful collaboration and communication among staff members. The existence of highly competent co-therapy teams is an indication that this kind of cooperation is widespread within the entire mental health service and is further evidence of positive isomorphy at work.
Although seemingly paradoxical in a program that wants to be less labor intensive, co-therapy sets in motion a powerful reciprocal incentive for conducting psychotherapy groups. Co-therapists who like to work together look for opportunities to do so, and start more groups. The more groups the co-therapists do together, the more they learn to like each other and the more effective and productive they become as a team. This definition of productivity includes the variable of work environment, which includes facilities, climate for effective communication, and employee opportunities to find satisfaction and professional growth in collaboration with each other.
For example, if two therapists can manage only two groups each week on their own but can conduct six groups each week working together, the goal of higher output is served. This illustrates the way co-therapy allows synergy to flourish in the group therapy program. Synergy is here defined as a synthesis of the skills and knowledge of two persons and can be expressed as “one plus one equals more than two.” The combination of two therapists augments and expands the capabilities of both. A mature co-therapy team brings higher energy into group formation and new life to the leadership function.
As I indicated previously, therapists’ behavior and the possibility for change as they interact with their environment and each other are the most crucial factors in the enhancement of productivity. By comparison, the Northern California system generally eschewed the co- therapy model—either because it might threaten the vertical hierarchy of clinical disciplines, or, lacking a deeper understanding of the meaning of productivity, Northern California perceived co-therapy as wasteful, expending two therapists when only one would do. One of my most productive group experiments came about when I shared the leadership of a crisis group with an entry-level person who was in training with me. Although this is not co-therapy as we define it because the two persons are not equal in experience or knowledge, the formation of such teams, called nequipo teams, facilitated the training of staff in group therapy. In this particular case, my entry-level assistant helped us streamline the direct referral of patients from entry to a treatment group by efficiently bridging the two.
7. At Puget Sound, group psychotherapy was perceived as a primary form of psychotherapeutic treatment and the treatment of choice for many conditions. This perception was communicated both directly and indirectly to consumers, making referral to group highly desirable. The practices of clinical professionals and the attitude conveyed by the managers at the highest level of the healthcare system must embody this perception.
At Northern California, group psychotherapy was institutionalized as a secondary or “inferior” form of treatment. Once this notion is communicated to consumers, referral to group therapy becomes almost impossible once individual therapy has commenced.
Mental health delivery systems that adopt group therapy for economic reasons alone and continue to believe that group therapy is the inferior alternative to individual treatment will inevitably communicate that message to their patients, and the group therapy program will suffer as a result. I want to emphasize that differential pricing of individual and group modalities, as I recommended previously, does not convey unequal respect or regard for the cheaper mode of treatment. In other words, because group therapy costs less does not mean it is worth less. If the primacy of group therapy for many conditions becomes a value of the institution, consumers will believe they are getting as much or more quality service for less money when they are offered group therapy.
8. At Northern California, the group therapy program was structurally weakened by an unwillingness to put centralized decision making authority in the hands of a coordinator who had specialized in group treatment and was dedicated to teaching the principles of group process. In my experience, whenever I observed group therapy flowering either moderately or extravagantly in whatever setting, there was always one person committed on a daily basis to the organization, operation, and development of groups. A group therapy coordinator, who has the authority to allocate resources, train and supervise professionals, and organize and develop groups, is an essential component in the development of a group therapy program. A group therapy coordinator must organize the program with an eye to the entire system of delivery, being cognizant of how the system affects the formation of groups at every level. At Puget Sound, the group therapy coordinator not only assumed management responsibility for group development but became chief training officer for sixty clinicians in the field of group therapy. In that capacity, I organized seminars and training opportunities for my colleagues and made myself available to them as a supervisor.
9. Related to the functional role of the group therapy coordinator, a viable group program must provide for ongoing training and super- vision in the area of group psychotherapy. Quite simply, Northern California did not provide those learning opportunities in a comprehensive or systematic way, and Puget Sound did. The presence of ongoing training in group therapy for staff produced a salutary effect on the morale of my colleagues. A greater esprit de corps was in evidence. Training of this sort gave to therapists a powerful message of their importance to the system. Therapists were being told that their work was valued enough that resources were set aside for the enrichment of their skills, and this became a potent antidote against demoralization and burnout.
I have enumerated these nine aspects of organizational structure and decision making in order to demonstrate the scope of the comprehensive planning that must go into the creation of groups in any institution or system of referral that presumes to offer group psychotherapy to its subscribers. In subsequent chapters, I will return to these aspects to further elaborate their significance. Just as they establish a context for a group therapy delivery system, so other factors create a historical context that must be considered as well.
Why does it take so much time to put these aspects in place? Can the start-up time for a group program be condensed by skillful management, focused training, and external consultation? What are the forces that resist change in a system of mental health delivery? How do changes become a part of the culture of an organization? These subjects will be addressed next.
Feldman, Saul. “Leadership in Mental Health: Changing of the Guard for the 1980’s.” American Journal of Psychiatry, 1981, 138(9), 1152.
Roller, Bill. “Organization and Development of Group Psychotherapy Programs in an HMO.” Proceedings of the 1982 Group Health Institute, Detroit, Mich., June 20–23, 1982. Washington, D.C.: Group Health Association of America.
Roller, Bill, and Nelson, Vivian. The Art of Co-Therapy: How Therapists Work Together. New York: Guilford Press, 1991, p. 20.
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