International Journal of Group Psychotherapy
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Inpatient Group Psychotherapy: Practical Considerations and Special Problems Robert H. Klein To cite this article: Robert H. Klein (1977) Inpatient Group Psychotherapy: Practical Considerations and Special Problems, International Journal of Group Psychotherapy, 27:2, 201-214, DOI: 10.1080/00207284.1977.11492293 To link to this article: https://doi.org/10.1080/00207284.1977.11492293
Published online: 29 Oct 2015.
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Date: 07 January 2018, At: 09:16
Inpatient Group Psychotherapy: Practical Considerations and Special Problems
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ROBERT H. KLEIN, PH.D.
in contrast to work with outpatients, generally takes place within the context of a complex, multilevel, and highly influential social system: the inpatient psychiatric ward. An examination of the context in which the group exists is critical to an understanding of the formation, structure, and function of a given inpatient group. Astrachan, Harrow, and Flynn (1968) point out that the treatment offered a patient, and the goals of his therapy, derive from an interaction of social and psychological variables that include: the character of the clinical setting in which treatment is provided; the patient's economic and social status, his expectations of therapy, and his presenting symptoms; and the training and treatment values of the clinician. A recent series of experimental studies of group therapy (Astrachan et al., 1967a, 1967b; Becker et al., 1968; Harrow et al., 1967a, 1967b) has provided evidence that the social system of the ward, with its norms, expectations, and values, plays a particularly important role in determining patient behavior in group meetings and has a significant impact on the therapeutic process. Studies of therapeutic communities as social systems indicate certain defined ways of thinking, feeling, and behaving which INPATIENT GROUP PSYCHOTHERAPY,
Dr. Klein is Associate Professor of Psychiatry and Psychology, University of Rochester, Rochester, N .Y.
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are preferred by the community, and the community's values are effectively communicated through various group methods to new members of the community (Astrachan et al., 1968). The overall ward values can be regarded as background factors which influence all types of group meetings . One inpatient group may develop in a ward which enthusiastically endorses the application of group methods, may be led by a senior member of the teaching faculty, may be open for obser vation, and may serve as a stimulus for training and research. In contrast , another psychotherapy group may emerge in opposition to the culture of the ward, as an expression of defiance and rebellion on the part of staff lower in the ward social hierarchy, and may be a clandestine operation. Awareness of the social context in which each of these two types of groups emerge would obviously be invaluable for understanding and assessing the nature and process of the group itself and might also be used in the service of predicting "successful" outcomes from the group experience . While it seems almost too obvious to mention that the social setting in which a person finds himself has some effect on the way he behaves , mental health professionals who treat hospitalized psychiatric patients often appear to be operating on the assumption that patients and those who treat them are somehow immune from influence by the world around them (Trick et al. , 1974). It is not unusual to discover that disordered behavior is perceived entirely as the patient's response to his own internal events , as if treatment is provided for behavioral disorders occurring in a social vacuum . Little attention is paid to the role of the hospital environment as a behavioral determinant . Only with the development of therapeutic milieus or therapeutic communities have we witnessed an attempt to channel the social aspects of a psychiatric setting so as to yield the most effective forces leading to therapeutic change. Even here , however, the more specific dynamic considerations which characterize the ward are often unexplored and their influence remains somewha t mysterious. It is clear, for example, that to understand the role of a patient or a staff member in a group requires some understanding of their roles as defined more broadly within the social system of the ward. If roles are narrowly defined within the traditional model -the patient is sick , the doctor heals, the student learns , and the
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nurse assists-what takes place in the inpatient psychotherapy group will reflect these values. Furthermore , an inpatient psychiatric ward may well be part of a university teaching hospital and may have responsibilities not only for providing competent clinical care but also for providing training, teaching, and for generating research and patient income. Thus, one might question whether a given inpatient group is being conducted primarily to generate patient income , to serve as an opportunity to teach group dynamics, to provide therapeutic intervention , etc. The answers to these questions will have a direct bearing upon group formation , norms, dynamics , and outcomes.
Multiple Roles and Relationshtps for Staff and Patients The therapist and his supervisor must understand the social context in which the group takes place and the relationships among the group therapist and other members of the ward community, especially if the group therapist is a formal member of the ward staff. Thus, the therapist needs to be aware of his relationship to the nursing staff, residents, administrative staff, and attending physicians. Questions of his responsibility and authority are critical in this regard. His decision-making role in clinical situations, his responsibilities for record-keeping and for communication with other staff members , etc ., all need to be spelled out. The situation becomes even more complicated when the patients in the group are working with other therapists who have assumed primary responsibility for their care. Opportunities for splitting, acting out of jealous and rivalrous feelings, and competition for status and power exist in abundance for both staff and patients. We have often found it helpful to ask the individual and group therapists how they intend to handle such matters as: decisions about medication and discharge ; meetings with the family; who should be contacted in the event that there is an emergency situation involving the patient. In order to answer such questions it becomes necessary for the therapists to define their roles more carefully. Yet another complication may arise from the fact that a cotherapy format is often adopted in group work with inpatients. This derives not only from the fact that this may serve as an opportunity for teaching, training, and personal growth but also because
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of therapist anxie ty, needs for support , problems with limit-setting, lack of experience, and fears of physical harm (Block, 1961; Heil fron , 1969; Gans , 1962) . The special problems, assets, and liabili ties of cotherapy (e .g., Davis and Lohr, 1971 ; Mac Lennan , 1965; McGee and Schuman , 1970; Benjamin, 1972; Mintz, 1963, 1965) will not be considered here except insofar as it should be noted that the cotherapy relationship requires careful attention, as does the relationship of the cotherapists as a team to other members of the ward , both staff and patients. In particular , it can be helpful to encourage cotherapists to examine the various roles which each of them plays in the overall social context of the ward and to consider these roles in rel ation to their behavior as cotherapists in the group. Are the roles , responsibilities, and authority each assumes in different clinical and managerial contacts with patients consistent with each other , and if not, what possible sources of confusion or conflict are there ? How do they propose to deal with these in order to avert potentially disruptive consequences? It is not atypical to find a nurse who occupies a relatively low position in the social hierarchy of the ward acting as a cotherapist with the chief resident who enjoys considerably higher status and whose general clinical responsibilities and visibility on the floor are quite different from those of the nurse. In such circumstances the nurse is often perceived by the group members , and perhaps by her cotherapist as well , as relatively unimportant , a person who is easily relegated to the role of assistant or novice. On the other hand , wha t are the implications for both cotherapists and patients involved in the group if this same nurse is in fact a more experienced and / or competent group therapist who assumes a leadership role within the group ? Such issues warrant careful assessment by the participating therapists. Special problems and considerations also arise with regard to the patient members of inpatient psychotherapy groups because patients live together on the ward in much the same way as an extended family. Apart from the hours they spend together in actual group psychotherapy sessions, patients often have a variety of other personal contacts with each other. It is not uncommon for members of the same group to form close relationships outside of the group setting . In such circumstances, patient pairing , subgrouping, and
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clique formation can lead to the dissipating of anxiety and to acting out, which often become pressing problems if the therapist does not anticipate these potential difficulties and take appropriate measures to curtail them. Therapeutic norms which stress confidentiality and the importance of reporting extra-group contacts are often helpful in this regard. A related issue is that patients who are participants in the group often have frequent contact with patients who are not group members. Apart from confidentiality and related matters, the public nature of the membership of the therapy group often results in mobilization of rivalries between patients. Some patients may regard themselves as members of a special inner circle which enjoys augmented status on the ward. Some patients may feel left out, while others may feel relieved at not having to attend still another meeting on the ward. Some may regard themselves as persecuted and pursued by persons in authority who insist that they participate in a form of therapy in which they have no interest. Regardless of their attitudes, the fact that patients are being treated publicly in different ways frequently elicits questions and provokes fantasies regarding the patient's sense of acceptance and belongingness on the ward and his capacity to trust the staff. Furthermore, staff decisions to include some patients while excluding others may result in considerable controversy, when, perhaps unwittingly, these decisions serve to disrupt the cohesion of a subgroup of patients which has formed on the floor. If a member of such a sentient group is inadvertently or purposely left out of a therapy group, it has been our experience that the members of the therapy group will call this to the attention of the therapist in a variety of ways, some quite disruptive in nature . Protest and upheaval often accompany such staff decisions.
Practz'cal Constraints From a practical point of view, a therapist who wishes to conduct an inpatient psychotherapy group is confronted from the outset with a variety of constraints . Critical in this connection are issues of time and money. The increasing costs of inpatient care, the growing use of hospitalization as a transient refuge from the problems of living, the rapidly expanding availability of day care and other transitional
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clinical facilities, plus changes in the philosophy of inpatient care diverging from custodial care models , have resulted in increasingly shorter lengths of hospit alization. The average stay in a university hospital inpatient ward is less than twenty-one days . Since any newly admitted patient is unlikely to enter group psychotherapy until he has been in the hospital for several days and has had a period of evaluation , diagnosis , and therapeutic planning, it is unlikely that a given patient will attend group meetings for much beyond the period of two to three weeks. Given this rapid turnover in patient population , problems of membership attrition can become disabling for the group. The format devised for a given inpatient group should take into consideration an awareness of the patient population to be served and the nature of the therapeutic goals to be pursued . At a practical level , however, in the process of thinking through an appropriate form at for the group , one must consider the length of time required for each session and the overall length of time the group will remain in existence as originally constituted. In this connection the therapist needs to take into account the practicality and feasibility of patients returning for group therapy sessions after they have been discharged from the hospital. Experience indicates that this is the point at which the incidence of dropouts is highest , and when patients drop out of a group this threatens the commitment of those who remain. The adverse effects upon enthusiasm , morale , viability, and cohesion are experienced by the therapists as well as by the patients. Also , the therapist must decide whether a given group will be time-limited or not , and whether it will be closed or open . Maintaining a closed group runs the risk of significant shrinkage in group size , while operating with an open group tends to result in increased patient turnover, with the group remaining at the early stages of development. In an effort to deal with these considerations , we have foun d it helpful to formulate a contract which invites patients to consider joining a short-term, time-limited , closed group . Such a group typically meets for one hour per session, two or three times per week , for three to six weeks. Furthermore , it has proven helpful to examine , from a broader perspective, the norms of the ward regarding attendance at group meetings and the social and therapeutic value attributed to such meetings. Specifically, do the norms
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and values endorsed by the social milieu increase or decrease the likelihood of full and active patient participation in the therapy group?
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Se lection and Composition of the Group The selection of patients and the composition of the group are also matters which must be accomplished within the constraints imposed by the ward and the patient population served by the hospital. In attempting to form a therapeutic group from among the patients on a 28-bed inpatient ward, for example, it has been our experience that it is not unusual to find that among the patients currently residing on the ward, several are undergoing ECT, several are newly admitted and not yet evaluated, several are acutely disturbed and disruptive in their behavior, several are quite elderly, delirious , or demented, others are so heavily medicated that productive social interaction is limited, and still others are on the verge of d ischarge from the hospital. Thus , out of the original 28 patients on the floo r, rel atively few may appear suitable for even a shortterm supportive group . Despite its recognized teaching value, the whole m atter of "composing" a therapy group is frequently regarded by inpatient staff as a somewhat luxurious and irrelevant concern which only has meaning in relation to outpatient groups. Apar t from these constraints , the actual matter of patient selection and recruitment is complicated by a number of other issues. For example, many of the more severely disturbed patients on an in patient floor are regarded by aspiring neophyte therapists as "unattractive" for a variety of reasons. Such patients are frequently labeled "inappropriate" for various forms of therapeutic intervention , and this can result in the limited number of more appealing patients being sought after by multiple staff members. The problem is exacerbated when competition for patients takes place in the context of various educational requirements to which the house staff and nurses are subject. For example, in a university hospital, psychiatric residents may be required to gain certain minimum experience in working with families, conducting intensive psychotherapy, learning various behavioral approaches, etc. Despite these training requirements, the ward often does not control who is admitted for treatment on that particular floor. If the ward has
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beds available, the boundary is often regulated by the emergency department through which patients are admitted to the hospital. Thus , it may be difficult for the ward to alter the nature of its patient composition in a particular direction in response to the training needs of its personnel. What is experienced at the ward level , then , is the simultaneous pursuit of multiple primary tasks by the hospital as a system, with service and training being tasks which, at a given point, may not be entirely compatible . In an effort to deal with the issue of suitable therapy patients often being in short supply, we have found it useful to encourage the therapist who wishes to begin a new group to become involved at the boundary of the ward system where patients are admitted. If he is involved in the intake and admission procedures, the chances of his obtaining some more psychologically minded patients as potential group members increase. One drawback against participating in the ward at this level , however, is that therapists often rapidly accumulate quite a number of patients in their efforts to screen and recruit group m embers. If the ward determines that the therapist must assume primary clinical responsibility for all patients seen at the time of admission, even those not accepted into the therapy group , it can indirectly but effectively regulate the likelihood of a therapy group's being established. Potential group candidates can come via referral from colleagues, but when this occurs on the ward, it often engenders a suspicious attitude. Since the competition for patients is frequently keen, therapists are alert to the prospect that a less attractive patient is more likely to be referred to them . Even if it turns out that the patient is in fact a good candidate for some form of inpatient group psychotherapy, we have found it instructive to examine the nature of the referral process , including the referring therapist's motives and the patient's understanding of the referral. In addition, it has proved useful to try to do some educational work with house staff and other therapists (including supervisors) to provide them with a set of descriptions of various types of group therapies as well as a description of the kinds of patients who might be suitable for each.
The Initial Patient Contact If the therapist begins to assemble a group by surveying the available patient population on the ward and is able to select a number
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of patients who he thinks may be suitable for some form of group psychotherapy, he is then faced with the task of contacting the patient and negotiating his participation. Often a group therapist selects a patient as a desirable candidate for the group but learns that another staff member is functioning as his primary therapist. In such circumstances, we have found it helpful to encourage the group therapist to speak with the patient's primary therapist before contacting the patient directly. Our experiences suggest that if the primary therapist is not consulted at the outset, he may feel offended and may well respond in a competitive, undermining fashion. The patient then feels caught between two powerful adversaries, a situation which may well replicate traumatic early life experiences . In addition, the patient may experience enormous opportunities for manipulation. In either event, we have found that in the long run the patient nearly always suffers. When the patient himself is approached, it is important to consider whether he perceives the prospect of entering a psychotherapy group as voluntary or coercive. Patients in a university hospital are often aware that training needs are afforded high priority, sometimes even higher priority than patient care and service, and they may correctly identify some not so subtle underlying pressure to join the group . A newly admitted patient, dependent and upset about the issue of hospitalization, may find it quite difficult to refuse an ostensibly therapeutic offer made by a staff member. How the patient perceives his own entrance into the group will, of course, have implications for his treatment. Furthermore, if he is being followed on an individual basis, it will be necessary to consider with the patient how his participation in the group will interact with his individual therapy. At a broad level , will his participation in the group replace or be in addition to his individual therapy? Furthermore, the question of how the various therapists involved will coordinate their efforts needs to be discussed with the participating patient.
Patient Preparation and the Therapeutic Contract The preparation of the patient for group psychotherapy and the articulation of a clear therapeutic contract merit further discussion. Less experienced therapists operating on an inpatient floor are often unclear about these issues. From a systems point of view, the negoti-
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ation of a therapeutic contract may be conceptualized as one step in the process by which a complementarity of roles is established. In addition to examining the patient's expectations , fears, misconceptions , and any previous preparation he has received from his individual therapist, we have found it helpful to: (l) spell out the number and length of therapy sessions; (2) discuss with the patient the general goals and objectives of the psychotherapy group ; (3) summarize any discussions which have been held with his primary therapist ; (4) consider with him the roles of staff in the group ; (5) review what is expected of patient members; (6) discuss the ground rules for the group's operation, i.e., confidentiality, extra ·group contacts , etc .; (7) spell out the nature of the group therapist 's re sponsibility and authority for decisions affecting the patient's care and hospital stay ; (8) encourage a commitment to attend the group on a regular basis even after discharge; (9) discuss with the patient whether the group is to be observed or recorded . If the group is to be observed, observers should be identified for the patients. We have generally found it to be less disruptive if observers watch the group through a one-way screen rather than sit in the group room , as is also the case with videotaping. Furthermore, it has proved useful to discuss the purpose and use of the tapes with patients , and to permit them to examine the tapes , either during the course of the session itself or at other scheduled times.
Supervzsion Rather than provide a comprehensive review of the typic al functions which supervision can serve, we would prefer here to underscore some issues which seem especially relevant to inpatient group work . Supervision can be particularly helpful in : (l) enabling the therapist to assume a broader view of the group in relation to the ward as a social system of which he and the patients are members; (2) assisting the therapist to define his responsib ility and authority
with regard to the patients in the group and in relation to other staff members on the ward ; (3) encouraging the therapist to remain alert to the fact that patients live together on the ward and have extensive contact outside of group sessions; (4) alerting the therapist as to whether his goals , methods , level, and pace of therapy are consistent with the realistic constraints of inpatient work; (5) reviewing the
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procedures the therapist has followed in the selection, preparation, and contract formation processes ; (6) encouraging the therapist to examine any special fears and anxieties he may have about working with a more disturbed patient population. Because of the nature of the patient population involved, we have found it useful , as group psychotherapy supervisors, to examine the therapist's capacity to work effectively with severely disturbed patients in a group in terms of his cognitive and his emotional skills and preparation. At a cognitive level , it is absolutely essential to assist the therapist in formulating realistic objectives concerning the na tu re and intensity of the therapeutic engagement he wishes to promote in the group. Some neophyte therapists behave as if they were engaged in a long-term , intensive , psychoanalytically oriented exploration aimed at major personality reconstruction. Others act as if they are custodians faced with controlling unmanageable, regressed or dangerous patients with emotionally contagious illnesses. Both postures are antitherapeutic and obviously require thorough discussion . Specifically, we have found it helpful to encourage group therapists on the inpatient service to formulate a supportive treatment approach which emphasizes focused exploration of patients' concerns, a here- and -now orientation , an active posture on the part of the therapist , and the development of a modest set of realityoriented goals which aim toward the development of increased individual and social responsibility among patients. The therapist is encouraged to keep the group's task clearly before it , to address himself to the patients' immediate , rather than irrational and archaic , needs, to try to strengthen defenses and reality testing, and to avoid transference interpretations . At a personal and emotional level , sitting in a small room for an hour with six to eight psychotic persons can be a frightening experience. T he therapist may be faced with intense and conflicting demands on the part of various group members. Amidst a sea of seemingly unrelated and at times frankly psychotic productions , the therapist m ay well have to struggle to maintain his allegiance to reality. The internal sense of fragmentation experienced by individual group members is often replicated on a larger scale in the group . T he resulting loss of focus tends to mobilize concerns about
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control and survival for the therapist. Beginning therapists frequently feel buffeted about and fear being overwhelmed by the incongruous , disturbing elements in the group process . The relative lack of experience on the part of the professionals conducting the group can itself become a source of serious confusion and disruption, particularly since patients frequently perceive and respond to therapist anxiety and ineptness. Unfortunately, it is not uncommon to find a poorly prepared, inexperienced , first-year resident co-leading an inpatient group with a young, inexperienced , but attractive member of the nursing staff. The fact that a training program and a ward system may permit and even encourage such persons to assume the therapist roles in an inpatient group is itself worthy of examination. In addition, however, it is clear that the wishes, fears , security operations, and training needs of these neo phyte therapists require careful consideration (Berger, 1958; Williams , 1966 ; Yalom, 1966).
A Social Systems Perspectz"ve In our work as supervisors with mental health trainees we have found it necessary to return periodically to the notion that the behavior of individual group members may be interpreted from a variety of perspectives. Most often, beginning group therapists tend to fall back upon their understanding of individual psychodynamic theory and direct their interventions in the group toward elucidation of a given individual's functioning. This tendency is particularly evident among psychiatric residents who have been exposed primarily to a one-to-one model of clinical care beginning with their medical school training. As a result, it is often difficult to teach therapists to think in interpersonal and relational terms , and harder still to develop among therapists the capacity to view the group as a whole, i.e., an integrated system whose structure , function, and organization can be identified and understood. The social context of the therapy, though often instrumental in determining the therapeutic response, is frequently overlooked as a behavioral determinant. In order to enlarge the trainee's perspective, we focus on developing his awareness of the ward as a complex and highly influential social system. As noted by Astrachan (1970-71) , "Without an appre-
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ciation of the impact of the structure of the therapy on patient behavior, the temptation is to perceive the patient's behavior as individually determined, be it either conscious or unconscious, and to ignore the m anner in which the setting facilitates or inhibits feelings and actions" (p. 114). Moreover, we encourage the trainee to view the therapy group itself as a complex social system which will be affected by and will in turn affect its environment. In our opinion, the therapist ideally should be familiar with the social system within which he is conducting his group. In addition to his awareness of individual psychodynamics, he should be able to examine the group in terms of its structure and function as an entity and relate that to the broader social system context in which the group is taking place. Finally, the therapist who plans to conduct group psychotherapy on an inpatient ward needs to learn about groups and other social systems to understand the n ature and extent to which the institutional setting is congruent wi th his therapy. In working toward certain goals, the therapist needs to examine whether he is in fact assisting his patients to function more adequately or whether his therapeutic goals serve to inhibit functioning as a result of being at variance with the dominant social values of the broader context.
REFERENCES Astrachan, B. M. (1970 -1 971), Towards a Social Systems Model of Therapeutic Groups. Soc. Psychiat., 5- 6:1 10-119. _ _ , Flynn, H . R ., Geller , J D., and H arvey, H . H . (1970), A Systems Approach to Day Hospital iza tion . A rch. Gen. Psvchiat ., 22 :550-559. ___ , Harrow, M. , Becker, R . E., Schwartz, A. H ., and Miller, ]. C . (1967a), The Unled Patient Group as a Therapeutic T ool. Thisjournal, 17:178-191. ___ , Schwartz , A. H ., Becker, R. E., and Harrow , M. B. (1 967b) , The Psychiatrist's Effect on the Behavior and Inte raction of Therapy Groups. A m er. ]. Psychiat., 12:1379- 1387. ___ , Harrow , M., and Flynn , H. R . (1968), Influence of the Value System of a Psychiatric Setting on Behavior in Group Therapy Meetings. Soc. Psychiat .. 3:165-172. Becker, R. E., Harrow, M., Astrach an, B. M., Detre, T ., and Miller, J C. (1 968) , Influence of the Leader on the Activity Level of Therapy Groups.]. So c. Psycho[., 74:39 -51. Benjamin, S. E. (1972), Co-Therapy: A Growth Experience for Therapists. This journal, 22: 199-209. Berger, M. M. (195 8), Problems of Anxiety in Group Psychotherapy Trainees. A mer.]. Psychother., 12:3-13.
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Block , S. (1961 ), Multileadership as a Training and Therapeutic Tool in Group Practice. Comprehensive Psychiat ., 2: 21 1-218. Davis, B., and Lohr, N. E. (1971), Special Problems with the Use of Co-Therapists in Group Psychotherapy. Thisjournal, 2:143-1 58. Cans , R. W . (1962) , Group Co-Therapists and the Therapeutic Situation: A Critical Evaluation . Thisjournal, 12:82-88 . Harrow, M. E. , Astrachan , B . M ., Becker, R. E., Detre , T ., and Schwartz , A. H. (1967 a) , An Investigation into the Nature of the Patient-Family Therapy Group . A mer.]. Psychiat. , 37 :888 -899 . _ _ _ , _ _ _ , _ _ _ , Miller ,]. C ., and Schwartz , A. H. (1 967b), Influence of the Psychotherapist on the Emotional Climate in Group Therapy. Human R elations, 20:49-64. Heilfron , M. (1969) , Co-Therapy: The Relationship between Therapists. This journal, 19:366-381. MacLennan, B. W. (1965 ), Co-Therapy . This journal, 15:154-1 66 . McGee , T . F ., and Schuman, P . N . (1970), The Nature of the Co-Therapy Relationship. Thisjou rnal, 20 :25-36. Mintz , E. E. (1963) , Special Values of Co-T herapists in Group Psychotherapy . Thisjournal, 13:127 -132. _ _ _ (19 65) , Male-Female Co-Therapy: Some Values and Some Problems . A mer. j. Psychother., 19:293-301. Trick , 0. L. , J acobs, M. K., and Spradlin , W . W. (1974), An Inpa tient Teachi ng Laboratory as a Milieu Force. In: Th e Group as Agent of Change, ed. A . Jacobs and W. Spradlin. New York: Behaviora l Publica tions. W illiams, M. (1 966), Limitations, Fantasies and Security Operations of Beginning Group Psychotherapists . Thisjournal, 16:150-162 . Yalom , I. (1966), Problems of Neophyte Group Therapists. Int ernat . ]. Soc. Psychiat., 12:52-59.
Dr. Klein's address: Department of Psychiatry School of Medicz'ne and Dentistry University of Rochester 601 Elmwood Avenue Rochester, N. Y. 14642
ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20
Inpatient Group Psychotherapy: Practical Considerations and Special Problems Robert H. Klein To cite this article: Robert H. Klein (1977) Inpatient Group Psychotherapy: Practical Considerations and Special Problems, International Journal of Group Psychotherapy, 27:2, 201-214, DOI: 10.1080/00207284.1977.11492293 To link to this article: https://doi.org/10.1080/00207284.1977.11492293
Published online: 29 Oct 2015.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 19 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujgp20 Download by: [ECU Libraries]
Date: 07 January 2018, At: 09:16
Inpatient Group Psychotherapy: Practical Considerations and Special Problems
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ROBERT H. KLEIN, PH.D.
in contrast to work with outpatients, generally takes place within the context of a complex, multilevel, and highly influential social system: the inpatient psychiatric ward. An examination of the context in which the group exists is critical to an understanding of the formation, structure, and function of a given inpatient group. Astrachan, Harrow, and Flynn (1968) point out that the treatment offered a patient, and the goals of his therapy, derive from an interaction of social and psychological variables that include: the character of the clinical setting in which treatment is provided; the patient's economic and social status, his expectations of therapy, and his presenting symptoms; and the training and treatment values of the clinician. A recent series of experimental studies of group therapy (Astrachan et al., 1967a, 1967b; Becker et al., 1968; Harrow et al., 1967a, 1967b) has provided evidence that the social system of the ward, with its norms, expectations, and values, plays a particularly important role in determining patient behavior in group meetings and has a significant impact on the therapeutic process. Studies of therapeutic communities as social systems indicate certain defined ways of thinking, feeling, and behaving which INPATIENT GROUP PSYCHOTHERAPY,
Dr. Klein is Associate Professor of Psychiatry and Psychology, University of Rochester, Rochester, N .Y.
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are preferred by the community, and the community's values are effectively communicated through various group methods to new members of the community (Astrachan et al., 1968). The overall ward values can be regarded as background factors which influence all types of group meetings . One inpatient group may develop in a ward which enthusiastically endorses the application of group methods, may be led by a senior member of the teaching faculty, may be open for obser vation, and may serve as a stimulus for training and research. In contrast , another psychotherapy group may emerge in opposition to the culture of the ward, as an expression of defiance and rebellion on the part of staff lower in the ward social hierarchy, and may be a clandestine operation. Awareness of the social context in which each of these two types of groups emerge would obviously be invaluable for understanding and assessing the nature and process of the group itself and might also be used in the service of predicting "successful" outcomes from the group experience . While it seems almost too obvious to mention that the social setting in which a person finds himself has some effect on the way he behaves , mental health professionals who treat hospitalized psychiatric patients often appear to be operating on the assumption that patients and those who treat them are somehow immune from influence by the world around them (Trick et al. , 1974). It is not unusual to discover that disordered behavior is perceived entirely as the patient's response to his own internal events , as if treatment is provided for behavioral disorders occurring in a social vacuum . Little attention is paid to the role of the hospital environment as a behavioral determinant . Only with the development of therapeutic milieus or therapeutic communities have we witnessed an attempt to channel the social aspects of a psychiatric setting so as to yield the most effective forces leading to therapeutic change. Even here , however, the more specific dynamic considerations which characterize the ward are often unexplored and their influence remains somewha t mysterious. It is clear, for example, that to understand the role of a patient or a staff member in a group requires some understanding of their roles as defined more broadly within the social system of the ward. If roles are narrowly defined within the traditional model -the patient is sick , the doctor heals, the student learns , and the
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nurse assists-what takes place in the inpatient psychotherapy group will reflect these values. Furthermore , an inpatient psychiatric ward may well be part of a university teaching hospital and may have responsibilities not only for providing competent clinical care but also for providing training, teaching, and for generating research and patient income. Thus, one might question whether a given inpatient group is being conducted primarily to generate patient income , to serve as an opportunity to teach group dynamics, to provide therapeutic intervention , etc. The answers to these questions will have a direct bearing upon group formation , norms, dynamics , and outcomes.
Multiple Roles and Relationshtps for Staff and Patients The therapist and his supervisor must understand the social context in which the group takes place and the relationships among the group therapist and other members of the ward community, especially if the group therapist is a formal member of the ward staff. Thus, the therapist needs to be aware of his relationship to the nursing staff, residents, administrative staff, and attending physicians. Questions of his responsibility and authority are critical in this regard. His decision-making role in clinical situations, his responsibilities for record-keeping and for communication with other staff members , etc ., all need to be spelled out. The situation becomes even more complicated when the patients in the group are working with other therapists who have assumed primary responsibility for their care. Opportunities for splitting, acting out of jealous and rivalrous feelings, and competition for status and power exist in abundance for both staff and patients. We have often found it helpful to ask the individual and group therapists how they intend to handle such matters as: decisions about medication and discharge ; meetings with the family; who should be contacted in the event that there is an emergency situation involving the patient. In order to answer such questions it becomes necessary for the therapists to define their roles more carefully. Yet another complication may arise from the fact that a cotherapy format is often adopted in group work with inpatients. This derives not only from the fact that this may serve as an opportunity for teaching, training, and personal growth but also because
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of therapist anxie ty, needs for support , problems with limit-setting, lack of experience, and fears of physical harm (Block, 1961; Heil fron , 1969; Gans , 1962) . The special problems, assets, and liabili ties of cotherapy (e .g., Davis and Lohr, 1971 ; Mac Lennan , 1965; McGee and Schuman , 1970; Benjamin, 1972; Mintz, 1963, 1965) will not be considered here except insofar as it should be noted that the cotherapy relationship requires careful attention, as does the relationship of the cotherapists as a team to other members of the ward , both staff and patients. In particular , it can be helpful to encourage cotherapists to examine the various roles which each of them plays in the overall social context of the ward and to consider these roles in rel ation to their behavior as cotherapists in the group. Are the roles , responsibilities, and authority each assumes in different clinical and managerial contacts with patients consistent with each other , and if not, what possible sources of confusion or conflict are there ? How do they propose to deal with these in order to avert potentially disruptive consequences? It is not atypical to find a nurse who occupies a relatively low position in the social hierarchy of the ward acting as a cotherapist with the chief resident who enjoys considerably higher status and whose general clinical responsibilities and visibility on the floor are quite different from those of the nurse. In such circumstances the nurse is often perceived by the group members , and perhaps by her cotherapist as well , as relatively unimportant , a person who is easily relegated to the role of assistant or novice. On the other hand , wha t are the implications for both cotherapists and patients involved in the group if this same nurse is in fact a more experienced and / or competent group therapist who assumes a leadership role within the group ? Such issues warrant careful assessment by the participating therapists. Special problems and considerations also arise with regard to the patient members of inpatient psychotherapy groups because patients live together on the ward in much the same way as an extended family. Apart from the hours they spend together in actual group psychotherapy sessions, patients often have a variety of other personal contacts with each other. It is not uncommon for members of the same group to form close relationships outside of the group setting . In such circumstances, patient pairing , subgrouping, and
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clique formation can lead to the dissipating of anxiety and to acting out, which often become pressing problems if the therapist does not anticipate these potential difficulties and take appropriate measures to curtail them. Therapeutic norms which stress confidentiality and the importance of reporting extra-group contacts are often helpful in this regard. A related issue is that patients who are participants in the group often have frequent contact with patients who are not group members. Apart from confidentiality and related matters, the public nature of the membership of the therapy group often results in mobilization of rivalries between patients. Some patients may regard themselves as members of a special inner circle which enjoys augmented status on the ward. Some patients may feel left out, while others may feel relieved at not having to attend still another meeting on the ward. Some may regard themselves as persecuted and pursued by persons in authority who insist that they participate in a form of therapy in which they have no interest. Regardless of their attitudes, the fact that patients are being treated publicly in different ways frequently elicits questions and provokes fantasies regarding the patient's sense of acceptance and belongingness on the ward and his capacity to trust the staff. Furthermore, staff decisions to include some patients while excluding others may result in considerable controversy, when, perhaps unwittingly, these decisions serve to disrupt the cohesion of a subgroup of patients which has formed on the floor. If a member of such a sentient group is inadvertently or purposely left out of a therapy group, it has been our experience that the members of the therapy group will call this to the attention of the therapist in a variety of ways, some quite disruptive in nature . Protest and upheaval often accompany such staff decisions.
Practz'cal Constraints From a practical point of view, a therapist who wishes to conduct an inpatient psychotherapy group is confronted from the outset with a variety of constraints . Critical in this connection are issues of time and money. The increasing costs of inpatient care, the growing use of hospitalization as a transient refuge from the problems of living, the rapidly expanding availability of day care and other transitional
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clinical facilities, plus changes in the philosophy of inpatient care diverging from custodial care models , have resulted in increasingly shorter lengths of hospit alization. The average stay in a university hospital inpatient ward is less than twenty-one days . Since any newly admitted patient is unlikely to enter group psychotherapy until he has been in the hospital for several days and has had a period of evaluation , diagnosis , and therapeutic planning, it is unlikely that a given patient will attend group meetings for much beyond the period of two to three weeks. Given this rapid turnover in patient population , problems of membership attrition can become disabling for the group. The format devised for a given inpatient group should take into consideration an awareness of the patient population to be served and the nature of the therapeutic goals to be pursued . At a practical level , however, in the process of thinking through an appropriate form at for the group , one must consider the length of time required for each session and the overall length of time the group will remain in existence as originally constituted. In this connection the therapist needs to take into account the practicality and feasibility of patients returning for group therapy sessions after they have been discharged from the hospital. Experience indicates that this is the point at which the incidence of dropouts is highest , and when patients drop out of a group this threatens the commitment of those who remain. The adverse effects upon enthusiasm , morale , viability, and cohesion are experienced by the therapists as well as by the patients. Also , the therapist must decide whether a given group will be time-limited or not , and whether it will be closed or open . Maintaining a closed group runs the risk of significant shrinkage in group size , while operating with an open group tends to result in increased patient turnover, with the group remaining at the early stages of development. In an effort to deal with these considerations , we have foun d it helpful to formulate a contract which invites patients to consider joining a short-term, time-limited , closed group . Such a group typically meets for one hour per session, two or three times per week , for three to six weeks. Furthermore , it has proven helpful to examine , from a broader perspective, the norms of the ward regarding attendance at group meetings and the social and therapeutic value attributed to such meetings. Specifically, do the norms
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and values endorsed by the social milieu increase or decrease the likelihood of full and active patient participation in the therapy group?
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Se lection and Composition of the Group The selection of patients and the composition of the group are also matters which must be accomplished within the constraints imposed by the ward and the patient population served by the hospital. In attempting to form a therapeutic group from among the patients on a 28-bed inpatient ward, for example, it has been our experience that it is not unusual to find that among the patients currently residing on the ward, several are undergoing ECT, several are newly admitted and not yet evaluated, several are acutely disturbed and disruptive in their behavior, several are quite elderly, delirious , or demented, others are so heavily medicated that productive social interaction is limited, and still others are on the verge of d ischarge from the hospital. Thus , out of the original 28 patients on the floo r, rel atively few may appear suitable for even a shortterm supportive group . Despite its recognized teaching value, the whole m atter of "composing" a therapy group is frequently regarded by inpatient staff as a somewhat luxurious and irrelevant concern which only has meaning in relation to outpatient groups. Apar t from these constraints , the actual matter of patient selection and recruitment is complicated by a number of other issues. For example, many of the more severely disturbed patients on an in patient floor are regarded by aspiring neophyte therapists as "unattractive" for a variety of reasons. Such patients are frequently labeled "inappropriate" for various forms of therapeutic intervention , and this can result in the limited number of more appealing patients being sought after by multiple staff members. The problem is exacerbated when competition for patients takes place in the context of various educational requirements to which the house staff and nurses are subject. For example, in a university hospital, psychiatric residents may be required to gain certain minimum experience in working with families, conducting intensive psychotherapy, learning various behavioral approaches, etc. Despite these training requirements, the ward often does not control who is admitted for treatment on that particular floor. If the ward has
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beds available, the boundary is often regulated by the emergency department through which patients are admitted to the hospital. Thus , it may be difficult for the ward to alter the nature of its patient composition in a particular direction in response to the training needs of its personnel. What is experienced at the ward level , then , is the simultaneous pursuit of multiple primary tasks by the hospital as a system, with service and training being tasks which, at a given point, may not be entirely compatible . In an effort to deal with the issue of suitable therapy patients often being in short supply, we have found it useful to encourage the therapist who wishes to begin a new group to become involved at the boundary of the ward system where patients are admitted. If he is involved in the intake and admission procedures, the chances of his obtaining some more psychologically minded patients as potential group members increase. One drawback against participating in the ward at this level , however, is that therapists often rapidly accumulate quite a number of patients in their efforts to screen and recruit group m embers. If the ward determines that the therapist must assume primary clinical responsibility for all patients seen at the time of admission, even those not accepted into the therapy group , it can indirectly but effectively regulate the likelihood of a therapy group's being established. Potential group candidates can come via referral from colleagues, but when this occurs on the ward, it often engenders a suspicious attitude. Since the competition for patients is frequently keen, therapists are alert to the prospect that a less attractive patient is more likely to be referred to them . Even if it turns out that the patient is in fact a good candidate for some form of inpatient group psychotherapy, we have found it instructive to examine the nature of the referral process , including the referring therapist's motives and the patient's understanding of the referral. In addition, it has proved useful to try to do some educational work with house staff and other therapists (including supervisors) to provide them with a set of descriptions of various types of group therapies as well as a description of the kinds of patients who might be suitable for each.
The Initial Patient Contact If the therapist begins to assemble a group by surveying the available patient population on the ward and is able to select a number
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of patients who he thinks may be suitable for some form of group psychotherapy, he is then faced with the task of contacting the patient and negotiating his participation. Often a group therapist selects a patient as a desirable candidate for the group but learns that another staff member is functioning as his primary therapist. In such circumstances, we have found it helpful to encourage the group therapist to speak with the patient's primary therapist before contacting the patient directly. Our experiences suggest that if the primary therapist is not consulted at the outset, he may feel offended and may well respond in a competitive, undermining fashion. The patient then feels caught between two powerful adversaries, a situation which may well replicate traumatic early life experiences . In addition, the patient may experience enormous opportunities for manipulation. In either event, we have found that in the long run the patient nearly always suffers. When the patient himself is approached, it is important to consider whether he perceives the prospect of entering a psychotherapy group as voluntary or coercive. Patients in a university hospital are often aware that training needs are afforded high priority, sometimes even higher priority than patient care and service, and they may correctly identify some not so subtle underlying pressure to join the group . A newly admitted patient, dependent and upset about the issue of hospitalization, may find it quite difficult to refuse an ostensibly therapeutic offer made by a staff member. How the patient perceives his own entrance into the group will, of course, have implications for his treatment. Furthermore, if he is being followed on an individual basis, it will be necessary to consider with the patient how his participation in the group will interact with his individual therapy. At a broad level , will his participation in the group replace or be in addition to his individual therapy? Furthermore, the question of how the various therapists involved will coordinate their efforts needs to be discussed with the participating patient.
Patient Preparation and the Therapeutic Contract The preparation of the patient for group psychotherapy and the articulation of a clear therapeutic contract merit further discussion. Less experienced therapists operating on an inpatient floor are often unclear about these issues. From a systems point of view, the negoti-
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ation of a therapeutic contract may be conceptualized as one step in the process by which a complementarity of roles is established. In addition to examining the patient's expectations , fears, misconceptions , and any previous preparation he has received from his individual therapist, we have found it helpful to: (l) spell out the number and length of therapy sessions; (2) discuss with the patient the general goals and objectives of the psychotherapy group ; (3) summarize any discussions which have been held with his primary therapist ; (4) consider with him the roles of staff in the group ; (5) review what is expected of patient members; (6) discuss the ground rules for the group's operation, i.e., confidentiality, extra ·group contacts , etc .; (7) spell out the nature of the group therapist 's re sponsibility and authority for decisions affecting the patient's care and hospital stay ; (8) encourage a commitment to attend the group on a regular basis even after discharge; (9) discuss with the patient whether the group is to be observed or recorded . If the group is to be observed, observers should be identified for the patients. We have generally found it to be less disruptive if observers watch the group through a one-way screen rather than sit in the group room , as is also the case with videotaping. Furthermore, it has proved useful to discuss the purpose and use of the tapes with patients , and to permit them to examine the tapes , either during the course of the session itself or at other scheduled times.
Supervzsion Rather than provide a comprehensive review of the typic al functions which supervision can serve, we would prefer here to underscore some issues which seem especially relevant to inpatient group work . Supervision can be particularly helpful in : (l) enabling the therapist to assume a broader view of the group in relation to the ward as a social system of which he and the patients are members; (2) assisting the therapist to define his responsib ility and authority
with regard to the patients in the group and in relation to other staff members on the ward ; (3) encouraging the therapist to remain alert to the fact that patients live together on the ward and have extensive contact outside of group sessions; (4) alerting the therapist as to whether his goals , methods , level, and pace of therapy are consistent with the realistic constraints of inpatient work; (5) reviewing the
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procedures the therapist has followed in the selection, preparation, and contract formation processes ; (6) encouraging the therapist to examine any special fears and anxieties he may have about working with a more disturbed patient population. Because of the nature of the patient population involved, we have found it useful , as group psychotherapy supervisors, to examine the therapist's capacity to work effectively with severely disturbed patients in a group in terms of his cognitive and his emotional skills and preparation. At a cognitive level , it is absolutely essential to assist the therapist in formulating realistic objectives concerning the na tu re and intensity of the therapeutic engagement he wishes to promote in the group. Some neophyte therapists behave as if they were engaged in a long-term , intensive , psychoanalytically oriented exploration aimed at major personality reconstruction. Others act as if they are custodians faced with controlling unmanageable, regressed or dangerous patients with emotionally contagious illnesses. Both postures are antitherapeutic and obviously require thorough discussion . Specifically, we have found it helpful to encourage group therapists on the inpatient service to formulate a supportive treatment approach which emphasizes focused exploration of patients' concerns, a here- and -now orientation , an active posture on the part of the therapist , and the development of a modest set of realityoriented goals which aim toward the development of increased individual and social responsibility among patients. The therapist is encouraged to keep the group's task clearly before it , to address himself to the patients' immediate , rather than irrational and archaic , needs, to try to strengthen defenses and reality testing, and to avoid transference interpretations . At a personal and emotional level , sitting in a small room for an hour with six to eight psychotic persons can be a frightening experience. T he therapist may be faced with intense and conflicting demands on the part of various group members. Amidst a sea of seemingly unrelated and at times frankly psychotic productions , the therapist m ay well have to struggle to maintain his allegiance to reality. The internal sense of fragmentation experienced by individual group members is often replicated on a larger scale in the group . T he resulting loss of focus tends to mobilize concerns about
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control and survival for the therapist. Beginning therapists frequently feel buffeted about and fear being overwhelmed by the incongruous , disturbing elements in the group process . The relative lack of experience on the part of the professionals conducting the group can itself become a source of serious confusion and disruption, particularly since patients frequently perceive and respond to therapist anxiety and ineptness. Unfortunately, it is not uncommon to find a poorly prepared, inexperienced , first-year resident co-leading an inpatient group with a young, inexperienced , but attractive member of the nursing staff. The fact that a training program and a ward system may permit and even encourage such persons to assume the therapist roles in an inpatient group is itself worthy of examination. In addition, however, it is clear that the wishes, fears , security operations, and training needs of these neo phyte therapists require careful consideration (Berger, 1958; Williams , 1966 ; Yalom, 1966).
A Social Systems Perspectz"ve In our work as supervisors with mental health trainees we have found it necessary to return periodically to the notion that the behavior of individual group members may be interpreted from a variety of perspectives. Most often, beginning group therapists tend to fall back upon their understanding of individual psychodynamic theory and direct their interventions in the group toward elucidation of a given individual's functioning. This tendency is particularly evident among psychiatric residents who have been exposed primarily to a one-to-one model of clinical care beginning with their medical school training. As a result, it is often difficult to teach therapists to think in interpersonal and relational terms , and harder still to develop among therapists the capacity to view the group as a whole, i.e., an integrated system whose structure , function, and organization can be identified and understood. The social context of the therapy, though often instrumental in determining the therapeutic response, is frequently overlooked as a behavioral determinant. In order to enlarge the trainee's perspective, we focus on developing his awareness of the ward as a complex and highly influential social system. As noted by Astrachan (1970-71) , "Without an appre-
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ciation of the impact of the structure of the therapy on patient behavior, the temptation is to perceive the patient's behavior as individually determined, be it either conscious or unconscious, and to ignore the m anner in which the setting facilitates or inhibits feelings and actions" (p. 114). Moreover, we encourage the trainee to view the therapy group itself as a complex social system which will be affected by and will in turn affect its environment. In our opinion, the therapist ideally should be familiar with the social system within which he is conducting his group. In addition to his awareness of individual psychodynamics, he should be able to examine the group in terms of its structure and function as an entity and relate that to the broader social system context in which the group is taking place. Finally, the therapist who plans to conduct group psychotherapy on an inpatient ward needs to learn about groups and other social systems to understand the n ature and extent to which the institutional setting is congruent wi th his therapy. In working toward certain goals, the therapist needs to examine whether he is in fact assisting his patients to function more adequately or whether his therapeutic goals serve to inhibit functioning as a result of being at variance with the dominant social values of the broader context.
REFERENCES Astrachan, B. M. (1970 -1 971), Towards a Social Systems Model of Therapeutic Groups. Soc. Psychiat., 5- 6:1 10-119. _ _ , Flynn, H . R ., Geller , J D., and H arvey, H . H . (1970), A Systems Approach to Day Hospital iza tion . A rch. Gen. Psvchiat ., 22 :550-559. ___ , Harrow, M. , Becker, R . E., Schwartz, A. H ., and Miller, ]. C . (1967a), The Unled Patient Group as a Therapeutic T ool. Thisjournal, 17:178-191. ___ , Schwartz , A. H ., Becker, R. E., and Harrow , M. B. (1 967b) , The Psychiatrist's Effect on the Behavior and Inte raction of Therapy Groups. A m er. ]. Psychiat., 12:1379- 1387. ___ , Harrow , M., and Flynn , H. R . (1968), Influence of the Value System of a Psychiatric Setting on Behavior in Group Therapy Meetings. Soc. Psychiat .. 3:165-172. Becker, R. E., Harrow, M., Astrach an, B. M., Detre, T ., and Miller, J C. (1 968) , Influence of the Leader on the Activity Level of Therapy Groups.]. So c. Psycho[., 74:39 -51. Benjamin, S. E. (1972), Co-Therapy: A Growth Experience for Therapists. This journal, 22: 199-209. Berger, M. M. (195 8), Problems of Anxiety in Group Psychotherapy Trainees. A mer.]. Psychother., 12:3-13.
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Block , S. (1961 ), Multileadership as a Training and Therapeutic Tool in Group Practice. Comprehensive Psychiat ., 2: 21 1-218. Davis, B., and Lohr, N. E. (1971), Special Problems with the Use of Co-Therapists in Group Psychotherapy. Thisjournal, 2:143-1 58. Cans , R. W . (1962) , Group Co-Therapists and the Therapeutic Situation: A Critical Evaluation . Thisjournal, 12:82-88 . Harrow, M. E. , Astrachan , B . M ., Becker, R. E., Detre , T ., and Schwartz , A. H. (1967 a) , An Investigation into the Nature of the Patient-Family Therapy Group . A mer.]. Psychiat. , 37 :888 -899 . _ _ _ , _ _ _ , _ _ _ , Miller ,]. C ., and Schwartz , A. H. (1 967b), Influence of the Psychotherapist on the Emotional Climate in Group Therapy. Human R elations, 20:49-64. Heilfron , M. (1969) , Co-Therapy: The Relationship between Therapists. This journal, 19:366-381. MacLennan, B. W. (1965 ), Co-Therapy . This journal, 15:154-1 66 . McGee , T . F ., and Schuman, P . N . (1970), The Nature of the Co-Therapy Relationship. Thisjou rnal, 20 :25-36. Mintz , E. E. (1963) , Special Values of Co-T herapists in Group Psychotherapy . Thisjournal, 13:127 -132. _ _ _ (19 65) , Male-Female Co-Therapy: Some Values and Some Problems . A mer. j. Psychother., 19:293-301. Trick , 0. L. , J acobs, M. K., and Spradlin , W . W. (1974), An Inpa tient Teachi ng Laboratory as a Milieu Force. In: Th e Group as Agent of Change, ed. A . Jacobs and W. Spradlin. New York: Behaviora l Publica tions. W illiams, M. (1 966), Limitations, Fantasies and Security Operations of Beginning Group Psychotherapists . Thisjournal, 16:150-162 . Yalom , I. (1966), Problems of Neophyte Group Therapists. Int ernat . ]. Soc. Psychiat., 12:52-59.
Dr. Klein's address: Department of Psychiatry School of Medicz'ne and Dentistry University of Rochester 601 Elmwood Avenue Rochester, N. Y. 14642
