Group Composition

I am part of a team opening our agency's newest satellite clinic. It includes a partial hospital program and intensive outpatient program for adults with eating disorders, and will eventually include some adolescent programs, with a separate staff. Tomorrow is the first day the adult programs are open to clients.

It's an exciting development, and has been months in the making. The biggest challenge left for us to tackle will be actually running a program in this opening period when our census is really low. Referrals are hard to predict no matter what, and even more so with a totally new program in a new location. It's great that we have as many as we have (3 in PHP, and 2 in IOP, with a few more slated for later in the week). However, when group therapy is the primary treatment modality, that kind of census is definitely challenging.

The program will definitely look a bit different this week than it will look later on. We may not be able to follow our group schedule exactly, especially since clinicians, dietitians, and psychopharmacologists have to take clients out of groups for individual meetings. A group of two, with one person pulled out, is no longer a group! We don't want people to get used to whatever adjustments we have to make for the low census, but it does offer an opportunity to think about what makes (or breaks) a group.

At these levels of care, groups look a little different than they do in standard outpatient care, where there is usually stable membership - a set number of people who attend a predetermined number of session, the same people each time. Even in long-term groups with rolling membership, there is a core of members who attend over time. As a result, we see groups develop their own character as a group, and move from disconnected people to a unified cohort.

Other levels of care, such as PHP and IOP, have a more fluid population, so group membership is constantly changing. Clients attend multiple groups with the same people each day, but various clients may be pulled out of various groups without warning. It's a constantly changing picture, and interpersonal connections that form tend to be to the program rather than to the group per se.

Nevertheless, group composition can drastically change the tone of the group, and therefore, of the treatment clients receive. In my ideal world, I like groups to have between 6-10 members, who have enough in common that they can relate to one another, and enough NOT in common to offer each other new perspectives. Our clients already have something in common by virtue of having an eating disorder, but when it's a mix of anorexia, bulimia, and binge eating disorder, that similarity may not go very far. We typically have all adults, and they tend to be similar functional levels, which helps...but in this beginning period, we've had to accept a few adolescents mixed in with the adults, which could make it harder for group members to relate to each other.

At these levels of care, people tend to be at varying stages of recovery, with varying degrees of motivation for change; I think that's an asset to groups, as people further along in recovery can serve as role models and exert some healthy peer pressure. Of course, the opposite process is also possible: when a majority of the group is early in recovery and/or unmotivated for change, they can bring the group as a whole down to their level. Part of the facilitator's job is to keep that from happening. Another challenge is when most group members are reluctant to speak; it can be pretty painful to get through an hour with a bunch of people who just stare at you, their feet, or the clock! I really hope that, with such a small group this week, they will at least be willing to talk.

What factors do you think make for a productive, or detrimental, group dynamic? How would you navigate this awkward period of low census, and the shifting census that will always be part of the equation at this level of care?

Laying the Groundwork

The kind of conversation one has in therapy is different from conversations one has in regular, day-to-day life. That's the point, after all - we think "talk therapy" helps people by engaging them in a unique form of dialogue in the context of a unique relationship. If just talking about something with a friend, or in one's own head, could solve the problem, people wouldn't be coming to see us to begin with!

For clients entering therapy for the first time, this new kind of interaction can feel very foreign. They may feel confused about what they're supposed to say or do, or why I am asking what I'm asking. They may feel awkward talking about themselves, or expressing feelings. They may not even know how to express feelings!

An important task for the therapist early in treatment is to introduce clients to the therapeutic process. Even if a client has been in therapy before, the previous therapist may have practiced from a different theoretical orientation, or have other stylistic differences from you. Clients want to know what to expect when they come to see you - and you want to set the stage for productive sessions.

Manualized CBT (e.g. Cognitive Behavior Therapy, Second Edition: Basics and Beyond) is quite structured, so it is fairly easy to establish a routine or agenda (addressing pressing concerns/crises, reviewing the last session and homework, identifying the next step based on outcomes). It's harder to orient clients to less directive approaches because they are, by definition, less concrete. To complicate matters further, the assessment process (often the first few sessions) is structured around the therapist asking quite specific questions. If clients come to expect that all sessions will be like that, it can lead to frustration all around.

Some clinicians (e.g. Becoming a Therapist: What Do I Say, and Why?) advocate taking a less directive approach in the first session, then doing the bulk of the assessment in sessions 2 and 3, as one way to both establish an alliance, and avoid establishing structured interviewing as the norm. Even then, the first treatment session post-assessment should begin with the therapist explaining the different structure and expectations for therapy vs. assessment.

A non-directive session structure may be particularly challenging for clients who are psychotic or otherwise cognitively disorganized. It can also be disappointing or frustrating for clients who have come in looking for an expert who will "fix" their problems. In some cultures and age groups, the image of therapy seems to be similar to the primary care doctor, and the role of the "patient" is to come to appointments and follow instructions - a more passive role than is actually expected of therapy clients!

So, given all these challenges, how do you set the stage for therapy with new clients - how do you orient them to the process, the roles of client and therapist, etc? What do you do during the first session, and later, to create a productive therapeutic environment?