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Process-Oriented Inpatient Groups: Alive and Well?, by Catherine Gray Deering, Ph.D., ABPP Estimated Time to Complete this Activity: 90 minutes Learning Objectives: The reader will be able to: 1. Discuss the reasons for the current trend away from doing process-oriented inpatient groups. 2. Describe a model for conducting effective process-oriented groups on an inpatient unit. 3. Compare the benefits of process-oriented groups versus psychoeducational and cognitive-behavioral groups. Author Disclosure: Catherine Deering, Nothing to Disclose
INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 64 (2) 2014 DEERING PROCESS-ORIENTED INPATIENT GROUPS
Process-Oriented Inpatient Groups: Alive and Well? CATHERINE GRAY DEERING, PH.D., ABPP
ABSTRACT This paper explores the trend away from offering process-oriented groups on inpatient units, given decreasing lengths of stay, increasing acuity levels, and current biases toward psychoeducational groups and cognitive-behavioral treatments. A model for doing process-oriented groups that provides a structure while allowing a theme to emerge and maximal interaction to take place is presented. A case is made for the benefits of process-oriented inpatient groups as compared to, and complementary with, psychoeducational, cognitive, and behavioral approaches. Clinical vignettes illustrate typical themes and dynamics emerging in process-oriented inpatient groups. We are all the same it seems behind the eyes. Broken promises and dreams in good disguise. All we’re really looking for is somewhere safe and warm. The shelter of each other in the storm. —Beverly Darnall, Amy Grant, and Keith Thomas, “Turn This World Around”
Catherine Gray Deering is Professor of Psychology at Clayton State University in Morrow, Georgia, and Associate Clinical Professor in the Department of Psychiatry and Behavioral Sciences at the Emory University School of Medicine in Atlanta.
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n his classic book Inpatient Group Psychotherapy, Yalom (1983) noted that milieu therapy has become obsolete. In my experience this is, sadly, true. In my over 30 years on inpatient units, first as a psychiatric nurse and later as a psychologist, I have seen these units transform from cohesive, tightly designed, rich environments for change and growth to short way stations equipped only to provide crisis stabilization and medication evaluation. There is barely enough time for a few individual sessions, and groups are restricted to topic-oriented, psychoeducational, and cognitive-behavioral approaches. Given the paradigm shift toward crisis stabilization and brief evidence-based treatments, will process groups on inpatient units soon become obsolete, or are they still a vital part of the inpatient experience? In this article, I will make a case for keeping inpatient groups alive and well. Trends toward increasingly briefer inpatient stays have necessitated a shift in therapeutic approaches on inpatient units worldwide. A recent study reviewed data from 29 nations on inpatient treatment of unipolar depression and found that the average length of stay for depressed patients in the United States was 7.4 days (Holzel, Kriston, Weisner, & Harter, 2011). In the 20 years that I have done groups on an inpatient unit at a VA Medical Center, the average length of stay has dropped from roughly 30–60 days to less than 7 days. At the same time, the patient population has become more acute and heterogeneous such that, whereas I started out doing small homogeneous inpatient groups for male combat veterans with PTSD, I am currently doing larger groups with mixed diagnoses and genders. Throughout this time, the inpatient unit has continued to offer psychoeducational groups on topics such as discharge planning, anger management, medication, and the recovery model. As a part-time consulting psychologist on the unit who is there primarily in a training role, I have had the freedom to design and offer the kinds of groups that I thought would be most effective for treatment and training, while complementing those offered within the rest of the inpatient program. I continue to argue for process groups on the unit because I have seen them work; I believe they provide an opportunity for patients to share their most pressing concerns, to be heard, to
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learn how to utilize group therapy, and to solidify their alliance with the treatment process. SUPPORT FOR INPATIENT GROUPS
Research on the efficacy of inpatient groups has been hampered by innumerable confounding variables, including differences in treatment models, contextual factors, and difficulty isolating the effects of group from other concurrent treatments on the unit. Despite this, a meta-analysis of 70 studies (Kosters, Burlingame, Nachtigall, & Strauss, 2006) and a recent review article (Emond & Rasmussen, 2012) present evidence that inpatient groups have demonstrated effectiveness in controlled studies. Several have demonstrated the efficacy of process groups for inpatients with specific problems, such as trauma (Wright et al., 2003), grief (Rosner, Lumbeck, & Geissner, 2011), and personality disorders (Winship & Hardy, 2007). Some have argued that inpatient groups should be divided into subgroups, with patients assigned to groups based on their level of functioning (Emond & Rasmussen, 2012; Kahn, 1986; Yalom, 1983). Others maintain that inpatient process groups can be effective even for schizophrenic (Kanas & Barr, 1986) and other severely disturbed, low functioning patients (Radcliffe & Diamond, 2010; Weiss, 2010). For example, Weiss (2010) describes how inpatient groups can help seriously mentally ill patients to identify their cyclic maladaptive interpersonal patterns and work with them in vivo in the group. He argues that process groups are better able to address these patterns than more structured groups where patients follow an agenda or prescription. WHAT IS A PROCESS GROUP?
Since process groups on inpatient units have become rare (Deering, 2006; Emond & Rasmussen, 2012), I have often found it necessary to define and explain them. While taking my group therapy course in a master’s degree program, students are placed in practicum sites where they are all doing psychoeducational and cognitive-behavioral groups; very few of them are exposed
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to process-oriented groups. When I require them to participate in and lead process-oriented groups for the experiential component, they often try to impose a structure, assign topics or tasks, and assume a teaching or problem-solving role as the group leader. They do this even after I have led and modeled process-oriented groups and shown them videotapes of Yalom’s interpersonal process groups. It is hard for them to let go of the structure they have learned in their practicum settings. The same is often true for staff in these settings. For her classic article defining process groups, Nina Brown (2003) reviewed numerous group therapy textbooks and found that, “Most definitions and descriptions of process were sparse and none were in sufficient detail so that the beginning group leader could learn how to identify process, or understand when and how to make process commentary” (p. 226). She concluded that the wide variations in meaning for the words “process” and “group process” have led to confusion. Brown (2003) proposed the following definition: “Process is the here-and-now experience in the group that describes how the group is functioning, the quality of the relationships between and among the group members and with the leader, the emotional experiences and reactions of the group, and the group’s strongest desires and fears.” I embrace this definition, and Brown’s (2003) article is required reading for my group therapy students, as is her book, Psychoeducational Groups (2011). SETTING AND PARTICIPANTS
My process groups take place in a 32-bed locked inpatient unit, and I co-lead them as a training experience with a pre-doctoral psychology intern. There are broad inclusion criteria for my groups; I allow anyone who can sit in the circle and participate to attend the group. Like others (Kanas & Barr, 1986; Radcliffe & Diamond, 2010; Weiss, 2010), I believe that even acutely disturbed patients can benefit from a process-oriented group, and I am often astonished by the insights and contributions of some the seemingly lowest functioning patients. However, unlike some of the mandatory psychoeducation groups on the unit, my process groups are voluntary, and patients are free to leave the room
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if they become uncomfortable with the content or affect (which they rarely do and/or might do briefly but often return.) Attendance typically ranges from 12 to 18 patients for a one-hour group. MODEL FOR INPATIENT PROCESS GROUPS
The model I use for process groups is a blend of Youcha’s (1990) focal group therapy and Yalom’s (1983) single-session time frame approach. We start with an introduction and brief orientation to the group, where I say, “This is a group for veterans on the inpatient unit. We are here to talk about what brought you into the hospital, how you are coping now, and what changes you will be making when you leave the hospital.” I introduce myself and then review the basic ground rules. My introduction to the group mirrors Youcha’s (1990) focal group therapy model. It addresses the immediate precipitants to hospitalization and only addresses the past as it relates to present functioning. In Youcha’s model, there are two main goals: (1) to engage the members to identify (not resolve) the conflicts that they need to work on, and (2) to provide a positive experience with group therapy that will motivate the client to join a group or engage in therapy after discharge. As noted in the literature, many hospitalized patients have never been in a group before or even on a psychiatric unit. The experience of hospitalization can be traumatic in itself. Above all, any group experience must not be negative, upsetting, or overwhelming for inpatients, but one that feels safe, supportive, and manageable. In a setting like the VA, where much of the outpatient treatment is in groups, the goal is to help patients overcome resistance to joining a group on discharge. Greene et al. (2004) argue that inpatient groups that focus on the problems of immediate concern to the patients, such as the focal group therapy model, allow patients to “start where they are” and provide face validity for the group. Other inpatient group therapists note that many inpatients do not fully understand why they have broken down and may lack awareness of the impact of precipitating factors and ongoing stresses in their lives. Without an opportunity to discuss and identify what brought them into the hospital, they may pass through the experience
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without understanding what has gone wrong and why (Radcliffe & Diamond, 2010). I blend the focal group therapy model with Yalom’s single session time framework described in Inpatient Group Psychotherapy (1983). In this model, the therapist listens for a theme that evolves during the first ten minutes or so, and then helps the group as a whole to explore that theme. There are recurrent group themes on our VA unit, often involving existential issues of hope, despair, and suicidality. By focusing on these issues, the group can grapple with and contain ambivalence about struggling with chronic mental illness during life crises and repeated relapses. Content themes are easily generated in groups with veterans because they have strong mutual identifications, and the voicing of the themes further enhances the development of cohesiveness (Greene et al., 2004). Additional themes that arise in my groups include loss of control (coming into the hospital against one’s wishes), making the choice to continue to take control again, holding onto faith and hope, and finding the strength to make difficult choices. The third influence has been David Johnson’s (1997) existential model for inpatients and partial hospitalization programs for chronically mentally ill patients. Johnson argues that the existential approach helps patients to “acknowledge their immense strengths in tolerating their illness” (p. 227) and “motivates them to continue working in treatment by providing inspiration, hope, and greater appreciation of the human race” (p. 228). Studies show that combating demoralization and helping patients to pull together in their struggle is one of the most valuable purposes of inpatient groups (De Chavez et al., 2000; Maxmen, 1984). The following vignettes illustrate typical issues and themes in my inpatient groups. They are rough conglomerate examples, not verbatim or based on recordings, and are designed to conceal identifying information. Vignette #1
William: I broke down this morning because I couldn’t face the way I have hurt people in my family. My girlfriend died in bed with me a year ago on a cocaine binge. My family blames me for her death, and they’re right. I was supposed to send my daughter
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$50.00 for Christmas but I spent the money on drugs. I’ve messed everything up. Therapist: Does anyone else in the group feel like you have let someone down? Otis: I couldn’t forgive my wife for cheating on me. Now I don’t have anything left. I drove her from me. Mike: Well, at least you are facing up to your mistakes. You have to face up to it and move on. Therapist: It sounds like you are speaking from experience. Have you gone through something similar? Mike: My wife walked out on me 30 years ago after my son was born. She just used me. I realize now that I must not have been giving her what she needed. I know I have my own not really faults, but negatives. I’m trying to accept that about myself. Carl: I just got married and my wife has a teenage daughter who is out of control. I tried to put my foot down before, and my wife took my step-daughter’s side. I went for her throat—tried to choke my wife. That’s how I got here. She knows I have PTSD and I can’t take this. She promised me that she would take my side if it came to it! Therapist: It sounds like a lot of you are feeling betrayed by the women in your lives. Otis: I know my wife betrayed me, but I also let her down. I can’t go on without her. Mike: Do you still love her? Otis: Yes. Mike: Then you really are in a tough place. [Long silence] Therapist: Kevin, you look like you are having some reactions to what the group is discussing. Kevin: I can identify with a lot of it. My wife is divorcing me after 28 years of marriage. At least you [looks at Otis] had a chance to reconcile with your wife—you went for counseling. My wife didn’t give me any notice. She just walked out without warning. Don’t you think after 28 years she owed me more than that? Shouldn’t she have told me that she was thinking of ending the marriage? I have nothing now. I lost my four children—everything. And now I’m going home tomorrow—to nothing.
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Mike: What are you going to do when you go home? Kevin: I’m going to an apartment. I’ll live alone and try to get through the day. Is it even worth it? I tried to kill myself. I’m not sure things will ever get any better. Mike: That’s no place to be. [Long silence] Mike: You are going to have to start over, whether you want to or not. Don: I’m going to a halfway house tomorrow. Before I came into the hospital I was evicted from my apartment. I found out last night that they threw all of my possessions into a dumpster. All I have to my name is this pair of moccasins, a dirty pair of pants, and a jacket. I don’t even have any socks. Lewis: I don’t know what I’m going to do when I leave the hospital. I just finished a vocational rehab program. I’m an electrician. I just assumed when I finished the program I’d be able to get a job. I know it’s probably not a reasonable thing to expect, but it was a shock when it didn’t happen. I still feel suicidal. Therapist: You’re all struggling with what must seem like impossible obstacles. Is there any way in which you still feel like you are soldiers on a battlefield? Mike: Yes. I think we are all still soldiers and I respect everyone in this room. I got a lot from my military experience. Every soldier accomplished something. I know there are no stupid or lazy people in this room. It helps me just to be around other soldiers. [All group members nod in silent agreement.] Vignette #2
Tony: I’m a junkie and I’m homeless. I’ve been trying to get into a treatment program for a couple of weeks now but I have no insurance. I drove my truck into a tree—not because I wanted to kill myself, but because I wanted to be injured so I could have a place to stay. That didn’t even work. Then I realized I forgot I was a veteran. I was in the navy. So I came to the VA and they took me in. And since I’ve been here, some of you have really helped me out [points to three different veterans and calls them by name].
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Therapist: You forgot you were a veteran? How does it feel to remember that again? Tony: It feels good [tears streaming down his face]. [Silence] David: I’m a junkie too. I’ve anaesthetized myself for so long I don’t know what it’s like to be alive. I tried to get into a treatment program but they turned me away so I had to take matters into my own hands. I made them listen to me. I made them take me. And when I finally got off drugs, I was watching TV and something sad came on. I realized I was crying like a baby. Over something stupid on TV. And I felt my face and my hands were covered with tears. And I started to laugh. And then I realized I was laughing with tears of joy because I could feel again. Therapist: So how are you doing now that you’re no longer anaesthetized? Richard [loudly from wheelchair]: What does anaesthetized mean? Therapist: He was numbed out from all of the drugs. John: You know—like when you have surgery. Richard: Oh. Jesse: You have to know about which programs to go to. There are programs out there but you have to find them. I was a homeless junkie too. Now I own a three-bedroom house. I’ve been through a bunch of programs. They’ll help you if you’re a homeless vet. [Starts naming and describing different programs.] Therapist: Jesse, that’s very valuable information. Would you be willing to share more about these programs with the other group members after the meeting today? Jesse: Sure. Just see me after the group. Therapist: So it sounds like some of you have sort of hit a brick wall and found yourself having to do something different. But it’s hard to find the strength to do something different when you’re feeling terrible. How do you find the strength? Jesse: You find it outside yourself. You can’t get it from inside. If it weren’t for my mother, I wouldn’t be here right now. She’s the one person who still believes in me, and when I’m at my worst, she scoops me up and brings me to the hospital. Sam: I know that’s right. I came here kicking and screaming. My daughter brought me and I tried to jump out of the car when
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we got to a stoplight. My son-in-law pushed me back in the car. I didn’t want any of it, but now that I’m here I know they were right. I’m grateful to them for caring about me. Therapist: It’s a very fortunate thing to have someone there for you when you really need them. I bet you’re not the only one who came here kicking and screaming. And I bet there are others in the group who didn’t have anyone to help them get here. [Many patients’ heads nodding.] So how did you find the strength? Roland: I did it for my kids. I realized I was walking around with a blood pressure of 190/140. I can’t do that to my kids. Therapist: That’s pretty scary. You could have had a stroke. How old are your kids? Roland: 22, 10, and 7. Therapist: So they really depend on you. Roland: Yes, my oldest is in college but he still depends on me. Therapist: So you reached down inside yourself and found a way to make yourself come in. Roland: Yes. Bill: Nobody can do it for you. George: I tried to kill myself before I came in. I couldn’t even do that right. The plastic bag I was trying to put over my head had a hole in it. So I called my mother and she said, “Get your ass down to the VA right now.” So here I am. Still a loser. A mentally ill loser. This mental illness really sucks. I get tired of dealing with it. Therapist: When your mother told you to get your ass down to the VA, did that feel supportive to you? George [laughs]: Yeah, it did, actually. She tells it to me straight. Therapist: So she doesn’t mince words. She lets you know what you need to do. George: Yeah. She knows by now… Richard: You know, people don’t believe in mental illness. They think you’re just lazy or fucked up. But this stuff is real. It’s serious. Nobody wants to have it. Bernie: It is real, and I’ve been dealing with it for over 20 years now. I’ve finally come to a place where I have a treatment team that I know I can call when I’m really in trouble. It took years to get there. And there were a lot of bad times along the way.
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Therapist: It sounds like you really have faith that the people on your team will help you, and they have your best interests at heart, but it wasn’t easy to establish those relationships. How did you do it? Bernie: I do have faith. We have to have faith. We don’t have any other choice.
These vignettes convey the urgency and complexity of issues facing hospitalized psychiatric patients. Despite the uniqueness of each situation, the patients quickly come to see similarities, and existential themes of loneliness, despair, and responsibility emerge. ADVANTAGES OF PROCESS GROUPS
Patients come into the hospital in crisis, often suicidal and at a turning point in their lives. They are feeling isolated, misunderstood, or alienated by others. In a process group, they are able to give voice to their current experience and find others with whom they can identify. This is a powerful antidote against the loneliness and hopelessness they feel. In a process group, patients can connect with each other in an intimate way and find moments of poignant silence together that arise in stark contrast to the stimulation of living in close quarters in what can seem like a depersonalizing environment. When done effectively, an inpatient process group can provide a holding environment where powerful emotions are adequately maintained and supported (Reaves & Maxwell, 1987). The group often feels like a spiritual experience, and patients linger afterward or walk out of the room together arm in arm or patting each other on the back. They have made contact with others whom they can continue to get to know on the unit, people who are struggling with similar dilemmas and can sit with them when they awaken in the middle of the night or wait for loved ones who may or may not come to visit. In the group, they feel heard and seen as individuals, and this helps to build upon their often tenuous alliance with the treatment process, particularly if they have come into the hospital involuntarily. While psychoeducational and cognitive behavioral groups have an important role in educating and challenging the beliefs of people with mental illness, they do not often create a space
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where patients can be seen as individuals. In the interview on Volume III of Yalom’s video series, Understanding Group Psychotherapy (Wyatt & Seid, 2006), he makes the bold and controversial statement that today’s therapists are making an error by overemphasizing cognitive and behavioral treatment methods because they objectify patients and do not promote an authentic healing relationship. There is truth in this, especially when groups use a lecture format and patients are talked to rather than heard. In a process group, the therapist meets the group from a position of receptiveness, beginning in a place of silence. To my knowledge, the process groups that I do are the only ones on the inpatient unit in which the patients sit in a circle with no barriers between them. It takes a few minutes to move all of the furniture, and the patients often seem confused by the need to rearrange the room, but the very act of doing so creates a paradigm shift that allows for a different kind of experience. Rather than being in what feels like a classroom and what may evoke teacher-student transferences, we are all in the circle together and ready to listen to each other. My leadership style is by necessity more active than it would be in another setting because I want to be sure each person feels supported and acknowledged. This may be their only chance to be in a therapy group while on the unit, and I want them to seek out group experiences when they leave. Despite this, my goal is to help the patients act as therapeutic agents with each other and to maximize interaction. FACTORS FACILITATING AND DETRACTING FROM PROCESS GROUPS
Alonso, Alonso, and Piper (2003) point out that an inpatient group can never be understood apart from the unit in which it functions. The unit structure, length of stay, type of population, unit philosophy, and overall culture are paramount factors in determining the type of model one can use and the effectiveness of the experience. Inpatient groups are done in the trenches. They are notoriously difficult to run, and patients are sometimes heavily medicated, making therapeutic engagement a challenge (Hajek, 2007). Patients may fluctuate in and out of psychosis, fall asleep, bring food or reading material into the group, and walk
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in and out of the room. Staff may differ in their willingness to respect the boundaries of the group; some open the door to ask patients to come and get their blood sugar checked or give a urine specimen. Staff turnover on these stressful units necessitates ongoing communication, consultation, and teamwork with supervisory clinicians to keep the groups running as smoothly as possible. Emond & Rasmussen (2012) go as far as saying that current inpatient units are typically characterized by chaos, yet they argue that daily group therapy can act as a much needed anchoring point for patients and staff. Inpatient group therapists must be flexible and willing to tolerate the less than ideal conditions for creating successful groups. We must be willing to modify long-term dynamic models of traditional outpatient therapy and provide more structure and a higher leader activity level for groups with higher patient acuity and rapid turnover (Leszcz, 1986; Weiss, 2010). The therapist must be transparent, ready to answer questions about his/her emotional reactions, willing to acknowledge and appreciate every patient’s contribution, no matter how small, and capable of producing a feeling of achievement and success by the end of each group (Hajek, 2007). Most importantly, the therapist must maintain a belief that the groups are worth doing and can heal.
REFERENCES Alonso, A., Alonso, S., & Piper, W. (2003). Group psychotherapy. In G. Stricker (Ed.), Handbook of psychology: Clinical psychology (Vol. 8, pp. 347–366). Hoboken, NJ: Wiley. Brown, N. W. (2003). Conceptualizing process. International Journal of Group Psychotherapy, 53(2), 225-244. Brown, N. W. (2011). Psychoeducational groups: Process and practice (3rd ed.). New York: Routledge/Taylor & Francis. De Chavez, M. G., Guitierrez, M., Ducaju, M., & Fraile, J. C. (2000). Comparative study of therapeutic factors of group therapy in schizophrenic inpatients and outpatients. Group Analysis, 33, 251–264. Deering, C. G. (2006). Inpatient groups in an age of brief treatment: Is there time for a group in the house? Open session presented at Healing a House Divided: American Group Psychotherapy Association Annual Meeting, San Francisco, California.
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Emond, S., & Rasmussen, B. (2012). The status of psychiatric inpatient group therapy: Past, present, and future. Social Work with Groups, 35, 68-91. Greene, L. R., Meisler, A. W., Pilkey, D., Alexander, G., Cardella, L. A., Sirois, B. C., & Burg, M. M. (2004). Psychological work with groups in the Veterans Administration. In J. L. Delucia-Waak, D. A. Garrity, C. R. Kalodner, & M. T. Riva, M.T. (Eds.), Handbook of group counseling and psychotherapy (pp. 322-337). London: Sage. Hajek, K. (2007). Interpersonal group therapy on acute inpatient wards. Groupwork, 17(1), 7-19. Holzel, L. P., Kriston, L., Weisner, A. K., & Harter, M. (2011). Crossnational differences in inpatient depression treatment. European Psychiatric Review, 4(1), 32-34. Johnson, D. R. (1997). An existential model of group therapy for chronic mental conditions. International Journal of Group Psychotherapy, 47(2), 227-250. Kahn, E. M. (1986). Symposium discussion: Inpatient group psychotherapy: Which type of group is best? Group, 19, 27-33. Kanas, N., & Barr, M. A. (1986). Process and content in a short-term inpatient schizophrenic group. Small Group Behavior, 17, 355-363. Leszcz, M. (1986). Interactional group therapy with non-psychotic patients. Group, 10, 13-30. Kosters, M., Burlingame, G. M., Nachtigall, C., & Strauss, B. (2006). A meta-analytic review of the effectiveness of inpatient group psychotherapy. Group Dynamics: Theory, Research, and Practice, 10(2), 146163. Maxmen, J. (1984). Helping patients survive theories: An educative model. International Journal of Group Psychotherapy, 34, 355–368. Radcliffe, J., & Diamond, D. (2010). A psychodynamic inpatient group. In J. Radcliffe, K. Hajek, J. Carson, & O. Manor (Eds.), Psychological groupwork with acute psychiatric inpatients. London: Whiting & Birch. Reaves, M. E., & Maxwell, M. J. (1987). The evolution of a therapy group for Vietnam veterans on a general psychiatry unit. Journal of Contemporary Psychotherapy, 17(1), 22-33. Rosner, R., Lumbeck, G., & Geissner, E. (2011). Effectiveness of an inpatient group therapy for comorbid complicated grief disorder. Psychotherapy Research, 21(2), 210-218. Weiss, P. A. (2010). Time-limited dynamic psychotherapy as a model for short-term inpatient groups. Journal of Contemporary Psychotherapy, 40, 41-49. Winship, G., & Hardy, S. (2007). Perspectives on prevalence and treatment of personality disorder. Journal of Psychiatric and Mental Health Nursing, 14, 148-154.
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Wright, D. C., Woo, W. W., Muller, R. T., Fernandes, C. B., & Kraftcheck, E. R. (2003). An investigation of trauma-centered inpatient treatment for adult survivors of abuse. Child Abuse & Neglect, 27, 393-406. Wyatt, R. C., & Seid, E. L. (2006). Instructor’s manual for understanding group psychotherapy, volume III: An interview with Irvin Yalom. San Francisco, CA, psychotherapy.net. Yalom, I. D. (1983). Inpatient group psychotherapy. New York: Basic Books. Youcha, I. Z. (1990). The short-term inpatient group: Formation and beginnings. In B. E. Roth, W. Stone, & H. D. Kibel (Eds.), The difficult patient in group: Group psychotherapy with borderline and narcissistic disorders (pp. 265-281). Madison, CT: International Universities Press. Department of Psychology Clayton State University 2000 Clayton State Blvd. Morrow, GA 30260 E-mail: [email protected]
Process-Oriented Inpatient Groups: Alive and Well?, by Catherine Gray Deering, Ph.D., ABPP Estimated Time to Complete this Activity: 90 minutes Learning Objectives: The reader will be able to: 1. Discuss the reasons for the current trend away from doing process-oriented inpatient groups. 2. Describe a model for conducting effective process-oriented groups on an inpatient unit. 3. Compare the benefits of process-oriented groups versus psychoeducational and cognitive-behavioral groups. Author Disclosure: Catherine Deering, Nothing to Disclose
INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 64 (2) 2014 DEERING PROCESS-ORIENTED INPATIENT GROUPS
Process-Oriented Inpatient Groups: Alive and Well? CATHERINE GRAY DEERING, PH.D., ABPP
ABSTRACT This paper explores the trend away from offering process-oriented groups on inpatient units, given decreasing lengths of stay, increasing acuity levels, and current biases toward psychoeducational groups and cognitive-behavioral treatments. A model for doing process-oriented groups that provides a structure while allowing a theme to emerge and maximal interaction to take place is presented. A case is made for the benefits of process-oriented inpatient groups as compared to, and complementary with, psychoeducational, cognitive, and behavioral approaches. Clinical vignettes illustrate typical themes and dynamics emerging in process-oriented inpatient groups. We are all the same it seems behind the eyes. Broken promises and dreams in good disguise. All we’re really looking for is somewhere safe and warm. The shelter of each other in the storm. —Beverly Darnall, Amy Grant, and Keith Thomas, “Turn This World Around”
Catherine Gray Deering is Professor of Psychology at Clayton State University in Morrow, Georgia, and Associate Clinical Professor in the Department of Psychiatry and Behavioral Sciences at the Emory University School of Medicine in Atlanta.
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n his classic book Inpatient Group Psychotherapy, Yalom (1983) noted that milieu therapy has become obsolete. In my experience this is, sadly, true. In my over 30 years on inpatient units, first as a psychiatric nurse and later as a psychologist, I have seen these units transform from cohesive, tightly designed, rich environments for change and growth to short way stations equipped only to provide crisis stabilization and medication evaluation. There is barely enough time for a few individual sessions, and groups are restricted to topic-oriented, psychoeducational, and cognitive-behavioral approaches. Given the paradigm shift toward crisis stabilization and brief evidence-based treatments, will process groups on inpatient units soon become obsolete, or are they still a vital part of the inpatient experience? In this article, I will make a case for keeping inpatient groups alive and well. Trends toward increasingly briefer inpatient stays have necessitated a shift in therapeutic approaches on inpatient units worldwide. A recent study reviewed data from 29 nations on inpatient treatment of unipolar depression and found that the average length of stay for depressed patients in the United States was 7.4 days (Holzel, Kriston, Weisner, & Harter, 2011). In the 20 years that I have done groups on an inpatient unit at a VA Medical Center, the average length of stay has dropped from roughly 30–60 days to less than 7 days. At the same time, the patient population has become more acute and heterogeneous such that, whereas I started out doing small homogeneous inpatient groups for male combat veterans with PTSD, I am currently doing larger groups with mixed diagnoses and genders. Throughout this time, the inpatient unit has continued to offer psychoeducational groups on topics such as discharge planning, anger management, medication, and the recovery model. As a part-time consulting psychologist on the unit who is there primarily in a training role, I have had the freedom to design and offer the kinds of groups that I thought would be most effective for treatment and training, while complementing those offered within the rest of the inpatient program. I continue to argue for process groups on the unit because I have seen them work; I believe they provide an opportunity for patients to share their most pressing concerns, to be heard, to
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learn how to utilize group therapy, and to solidify their alliance with the treatment process. SUPPORT FOR INPATIENT GROUPS
Research on the efficacy of inpatient groups has been hampered by innumerable confounding variables, including differences in treatment models, contextual factors, and difficulty isolating the effects of group from other concurrent treatments on the unit. Despite this, a meta-analysis of 70 studies (Kosters, Burlingame, Nachtigall, & Strauss, 2006) and a recent review article (Emond & Rasmussen, 2012) present evidence that inpatient groups have demonstrated effectiveness in controlled studies. Several have demonstrated the efficacy of process groups for inpatients with specific problems, such as trauma (Wright et al., 2003), grief (Rosner, Lumbeck, & Geissner, 2011), and personality disorders (Winship & Hardy, 2007). Some have argued that inpatient groups should be divided into subgroups, with patients assigned to groups based on their level of functioning (Emond & Rasmussen, 2012; Kahn, 1986; Yalom, 1983). Others maintain that inpatient process groups can be effective even for schizophrenic (Kanas & Barr, 1986) and other severely disturbed, low functioning patients (Radcliffe & Diamond, 2010; Weiss, 2010). For example, Weiss (2010) describes how inpatient groups can help seriously mentally ill patients to identify their cyclic maladaptive interpersonal patterns and work with them in vivo in the group. He argues that process groups are better able to address these patterns than more structured groups where patients follow an agenda or prescription. WHAT IS A PROCESS GROUP?
Since process groups on inpatient units have become rare (Deering, 2006; Emond & Rasmussen, 2012), I have often found it necessary to define and explain them. While taking my group therapy course in a master’s degree program, students are placed in practicum sites where they are all doing psychoeducational and cognitive-behavioral groups; very few of them are exposed
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to process-oriented groups. When I require them to participate in and lead process-oriented groups for the experiential component, they often try to impose a structure, assign topics or tasks, and assume a teaching or problem-solving role as the group leader. They do this even after I have led and modeled process-oriented groups and shown them videotapes of Yalom’s interpersonal process groups. It is hard for them to let go of the structure they have learned in their practicum settings. The same is often true for staff in these settings. For her classic article defining process groups, Nina Brown (2003) reviewed numerous group therapy textbooks and found that, “Most definitions and descriptions of process were sparse and none were in sufficient detail so that the beginning group leader could learn how to identify process, or understand when and how to make process commentary” (p. 226). She concluded that the wide variations in meaning for the words “process” and “group process” have led to confusion. Brown (2003) proposed the following definition: “Process is the here-and-now experience in the group that describes how the group is functioning, the quality of the relationships between and among the group members and with the leader, the emotional experiences and reactions of the group, and the group’s strongest desires and fears.” I embrace this definition, and Brown’s (2003) article is required reading for my group therapy students, as is her book, Psychoeducational Groups (2011). SETTING AND PARTICIPANTS
My process groups take place in a 32-bed locked inpatient unit, and I co-lead them as a training experience with a pre-doctoral psychology intern. There are broad inclusion criteria for my groups; I allow anyone who can sit in the circle and participate to attend the group. Like others (Kanas & Barr, 1986; Radcliffe & Diamond, 2010; Weiss, 2010), I believe that even acutely disturbed patients can benefit from a process-oriented group, and I am often astonished by the insights and contributions of some the seemingly lowest functioning patients. However, unlike some of the mandatory psychoeducation groups on the unit, my process groups are voluntary, and patients are free to leave the room
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if they become uncomfortable with the content or affect (which they rarely do and/or might do briefly but often return.) Attendance typically ranges from 12 to 18 patients for a one-hour group. MODEL FOR INPATIENT PROCESS GROUPS
The model I use for process groups is a blend of Youcha’s (1990) focal group therapy and Yalom’s (1983) single-session time frame approach. We start with an introduction and brief orientation to the group, where I say, “This is a group for veterans on the inpatient unit. We are here to talk about what brought you into the hospital, how you are coping now, and what changes you will be making when you leave the hospital.” I introduce myself and then review the basic ground rules. My introduction to the group mirrors Youcha’s (1990) focal group therapy model. It addresses the immediate precipitants to hospitalization and only addresses the past as it relates to present functioning. In Youcha’s model, there are two main goals: (1) to engage the members to identify (not resolve) the conflicts that they need to work on, and (2) to provide a positive experience with group therapy that will motivate the client to join a group or engage in therapy after discharge. As noted in the literature, many hospitalized patients have never been in a group before or even on a psychiatric unit. The experience of hospitalization can be traumatic in itself. Above all, any group experience must not be negative, upsetting, or overwhelming for inpatients, but one that feels safe, supportive, and manageable. In a setting like the VA, where much of the outpatient treatment is in groups, the goal is to help patients overcome resistance to joining a group on discharge. Greene et al. (2004) argue that inpatient groups that focus on the problems of immediate concern to the patients, such as the focal group therapy model, allow patients to “start where they are” and provide face validity for the group. Other inpatient group therapists note that many inpatients do not fully understand why they have broken down and may lack awareness of the impact of precipitating factors and ongoing stresses in their lives. Without an opportunity to discuss and identify what brought them into the hospital, they may pass through the experience
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without understanding what has gone wrong and why (Radcliffe & Diamond, 2010). I blend the focal group therapy model with Yalom’s single session time framework described in Inpatient Group Psychotherapy (1983). In this model, the therapist listens for a theme that evolves during the first ten minutes or so, and then helps the group as a whole to explore that theme. There are recurrent group themes on our VA unit, often involving existential issues of hope, despair, and suicidality. By focusing on these issues, the group can grapple with and contain ambivalence about struggling with chronic mental illness during life crises and repeated relapses. Content themes are easily generated in groups with veterans because they have strong mutual identifications, and the voicing of the themes further enhances the development of cohesiveness (Greene et al., 2004). Additional themes that arise in my groups include loss of control (coming into the hospital against one’s wishes), making the choice to continue to take control again, holding onto faith and hope, and finding the strength to make difficult choices. The third influence has been David Johnson’s (1997) existential model for inpatients and partial hospitalization programs for chronically mentally ill patients. Johnson argues that the existential approach helps patients to “acknowledge their immense strengths in tolerating their illness” (p. 227) and “motivates them to continue working in treatment by providing inspiration, hope, and greater appreciation of the human race” (p. 228). Studies show that combating demoralization and helping patients to pull together in their struggle is one of the most valuable purposes of inpatient groups (De Chavez et al., 2000; Maxmen, 1984). The following vignettes illustrate typical issues and themes in my inpatient groups. They are rough conglomerate examples, not verbatim or based on recordings, and are designed to conceal identifying information. Vignette #1
William: I broke down this morning because I couldn’t face the way I have hurt people in my family. My girlfriend died in bed with me a year ago on a cocaine binge. My family blames me for her death, and they’re right. I was supposed to send my daughter
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$50.00 for Christmas but I spent the money on drugs. I’ve messed everything up. Therapist: Does anyone else in the group feel like you have let someone down? Otis: I couldn’t forgive my wife for cheating on me. Now I don’t have anything left. I drove her from me. Mike: Well, at least you are facing up to your mistakes. You have to face up to it and move on. Therapist: It sounds like you are speaking from experience. Have you gone through something similar? Mike: My wife walked out on me 30 years ago after my son was born. She just used me. I realize now that I must not have been giving her what she needed. I know I have my own not really faults, but negatives. I’m trying to accept that about myself. Carl: I just got married and my wife has a teenage daughter who is out of control. I tried to put my foot down before, and my wife took my step-daughter’s side. I went for her throat—tried to choke my wife. That’s how I got here. She knows I have PTSD and I can’t take this. She promised me that she would take my side if it came to it! Therapist: It sounds like a lot of you are feeling betrayed by the women in your lives. Otis: I know my wife betrayed me, but I also let her down. I can’t go on without her. Mike: Do you still love her? Otis: Yes. Mike: Then you really are in a tough place. [Long silence] Therapist: Kevin, you look like you are having some reactions to what the group is discussing. Kevin: I can identify with a lot of it. My wife is divorcing me after 28 years of marriage. At least you [looks at Otis] had a chance to reconcile with your wife—you went for counseling. My wife didn’t give me any notice. She just walked out without warning. Don’t you think after 28 years she owed me more than that? Shouldn’t she have told me that she was thinking of ending the marriage? I have nothing now. I lost my four children—everything. And now I’m going home tomorrow—to nothing.
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Mike: What are you going to do when you go home? Kevin: I’m going to an apartment. I’ll live alone and try to get through the day. Is it even worth it? I tried to kill myself. I’m not sure things will ever get any better. Mike: That’s no place to be. [Long silence] Mike: You are going to have to start over, whether you want to or not. Don: I’m going to a halfway house tomorrow. Before I came into the hospital I was evicted from my apartment. I found out last night that they threw all of my possessions into a dumpster. All I have to my name is this pair of moccasins, a dirty pair of pants, and a jacket. I don’t even have any socks. Lewis: I don’t know what I’m going to do when I leave the hospital. I just finished a vocational rehab program. I’m an electrician. I just assumed when I finished the program I’d be able to get a job. I know it’s probably not a reasonable thing to expect, but it was a shock when it didn’t happen. I still feel suicidal. Therapist: You’re all struggling with what must seem like impossible obstacles. Is there any way in which you still feel like you are soldiers on a battlefield? Mike: Yes. I think we are all still soldiers and I respect everyone in this room. I got a lot from my military experience. Every soldier accomplished something. I know there are no stupid or lazy people in this room. It helps me just to be around other soldiers. [All group members nod in silent agreement.] Vignette #2
Tony: I’m a junkie and I’m homeless. I’ve been trying to get into a treatment program for a couple of weeks now but I have no insurance. I drove my truck into a tree—not because I wanted to kill myself, but because I wanted to be injured so I could have a place to stay. That didn’t even work. Then I realized I forgot I was a veteran. I was in the navy. So I came to the VA and they took me in. And since I’ve been here, some of you have really helped me out [points to three different veterans and calls them by name].
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Therapist: You forgot you were a veteran? How does it feel to remember that again? Tony: It feels good [tears streaming down his face]. [Silence] David: I’m a junkie too. I’ve anaesthetized myself for so long I don’t know what it’s like to be alive. I tried to get into a treatment program but they turned me away so I had to take matters into my own hands. I made them listen to me. I made them take me. And when I finally got off drugs, I was watching TV and something sad came on. I realized I was crying like a baby. Over something stupid on TV. And I felt my face and my hands were covered with tears. And I started to laugh. And then I realized I was laughing with tears of joy because I could feel again. Therapist: So how are you doing now that you’re no longer anaesthetized? Richard [loudly from wheelchair]: What does anaesthetized mean? Therapist: He was numbed out from all of the drugs. John: You know—like when you have surgery. Richard: Oh. Jesse: You have to know about which programs to go to. There are programs out there but you have to find them. I was a homeless junkie too. Now I own a three-bedroom house. I’ve been through a bunch of programs. They’ll help you if you’re a homeless vet. [Starts naming and describing different programs.] Therapist: Jesse, that’s very valuable information. Would you be willing to share more about these programs with the other group members after the meeting today? Jesse: Sure. Just see me after the group. Therapist: So it sounds like some of you have sort of hit a brick wall and found yourself having to do something different. But it’s hard to find the strength to do something different when you’re feeling terrible. How do you find the strength? Jesse: You find it outside yourself. You can’t get it from inside. If it weren’t for my mother, I wouldn’t be here right now. She’s the one person who still believes in me, and when I’m at my worst, she scoops me up and brings me to the hospital. Sam: I know that’s right. I came here kicking and screaming. My daughter brought me and I tried to jump out of the car when
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we got to a stoplight. My son-in-law pushed me back in the car. I didn’t want any of it, but now that I’m here I know they were right. I’m grateful to them for caring about me. Therapist: It’s a very fortunate thing to have someone there for you when you really need them. I bet you’re not the only one who came here kicking and screaming. And I bet there are others in the group who didn’t have anyone to help them get here. [Many patients’ heads nodding.] So how did you find the strength? Roland: I did it for my kids. I realized I was walking around with a blood pressure of 190/140. I can’t do that to my kids. Therapist: That’s pretty scary. You could have had a stroke. How old are your kids? Roland: 22, 10, and 7. Therapist: So they really depend on you. Roland: Yes, my oldest is in college but he still depends on me. Therapist: So you reached down inside yourself and found a way to make yourself come in. Roland: Yes. Bill: Nobody can do it for you. George: I tried to kill myself before I came in. I couldn’t even do that right. The plastic bag I was trying to put over my head had a hole in it. So I called my mother and she said, “Get your ass down to the VA right now.” So here I am. Still a loser. A mentally ill loser. This mental illness really sucks. I get tired of dealing with it. Therapist: When your mother told you to get your ass down to the VA, did that feel supportive to you? George [laughs]: Yeah, it did, actually. She tells it to me straight. Therapist: So she doesn’t mince words. She lets you know what you need to do. George: Yeah. She knows by now… Richard: You know, people don’t believe in mental illness. They think you’re just lazy or fucked up. But this stuff is real. It’s serious. Nobody wants to have it. Bernie: It is real, and I’ve been dealing with it for over 20 years now. I’ve finally come to a place where I have a treatment team that I know I can call when I’m really in trouble. It took years to get there. And there were a lot of bad times along the way.
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Therapist: It sounds like you really have faith that the people on your team will help you, and they have your best interests at heart, but it wasn’t easy to establish those relationships. How did you do it? Bernie: I do have faith. We have to have faith. We don’t have any other choice.
These vignettes convey the urgency and complexity of issues facing hospitalized psychiatric patients. Despite the uniqueness of each situation, the patients quickly come to see similarities, and existential themes of loneliness, despair, and responsibility emerge. ADVANTAGES OF PROCESS GROUPS
Patients come into the hospital in crisis, often suicidal and at a turning point in their lives. They are feeling isolated, misunderstood, or alienated by others. In a process group, they are able to give voice to their current experience and find others with whom they can identify. This is a powerful antidote against the loneliness and hopelessness they feel. In a process group, patients can connect with each other in an intimate way and find moments of poignant silence together that arise in stark contrast to the stimulation of living in close quarters in what can seem like a depersonalizing environment. When done effectively, an inpatient process group can provide a holding environment where powerful emotions are adequately maintained and supported (Reaves & Maxwell, 1987). The group often feels like a spiritual experience, and patients linger afterward or walk out of the room together arm in arm or patting each other on the back. They have made contact with others whom they can continue to get to know on the unit, people who are struggling with similar dilemmas and can sit with them when they awaken in the middle of the night or wait for loved ones who may or may not come to visit. In the group, they feel heard and seen as individuals, and this helps to build upon their often tenuous alliance with the treatment process, particularly if they have come into the hospital involuntarily. While psychoeducational and cognitive behavioral groups have an important role in educating and challenging the beliefs of people with mental illness, they do not often create a space
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where patients can be seen as individuals. In the interview on Volume III of Yalom’s video series, Understanding Group Psychotherapy (Wyatt & Seid, 2006), he makes the bold and controversial statement that today’s therapists are making an error by overemphasizing cognitive and behavioral treatment methods because they objectify patients and do not promote an authentic healing relationship. There is truth in this, especially when groups use a lecture format and patients are talked to rather than heard. In a process group, the therapist meets the group from a position of receptiveness, beginning in a place of silence. To my knowledge, the process groups that I do are the only ones on the inpatient unit in which the patients sit in a circle with no barriers between them. It takes a few minutes to move all of the furniture, and the patients often seem confused by the need to rearrange the room, but the very act of doing so creates a paradigm shift that allows for a different kind of experience. Rather than being in what feels like a classroom and what may evoke teacher-student transferences, we are all in the circle together and ready to listen to each other. My leadership style is by necessity more active than it would be in another setting because I want to be sure each person feels supported and acknowledged. This may be their only chance to be in a therapy group while on the unit, and I want them to seek out group experiences when they leave. Despite this, my goal is to help the patients act as therapeutic agents with each other and to maximize interaction. FACTORS FACILITATING AND DETRACTING FROM PROCESS GROUPS
Alonso, Alonso, and Piper (2003) point out that an inpatient group can never be understood apart from the unit in which it functions. The unit structure, length of stay, type of population, unit philosophy, and overall culture are paramount factors in determining the type of model one can use and the effectiveness of the experience. Inpatient groups are done in the trenches. They are notoriously difficult to run, and patients are sometimes heavily medicated, making therapeutic engagement a challenge (Hajek, 2007). Patients may fluctuate in and out of psychosis, fall asleep, bring food or reading material into the group, and walk
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in and out of the room. Staff may differ in their willingness to respect the boundaries of the group; some open the door to ask patients to come and get their blood sugar checked or give a urine specimen. Staff turnover on these stressful units necessitates ongoing communication, consultation, and teamwork with supervisory clinicians to keep the groups running as smoothly as possible. Emond & Rasmussen (2012) go as far as saying that current inpatient units are typically characterized by chaos, yet they argue that daily group therapy can act as a much needed anchoring point for patients and staff. Inpatient group therapists must be flexible and willing to tolerate the less than ideal conditions for creating successful groups. We must be willing to modify long-term dynamic models of traditional outpatient therapy and provide more structure and a higher leader activity level for groups with higher patient acuity and rapid turnover (Leszcz, 1986; Weiss, 2010). The therapist must be transparent, ready to answer questions about his/her emotional reactions, willing to acknowledge and appreciate every patient’s contribution, no matter how small, and capable of producing a feeling of achievement and success by the end of each group (Hajek, 2007). Most importantly, the therapist must maintain a belief that the groups are worth doing and can heal.
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Emond, S., & Rasmussen, B. (2012). The status of psychiatric inpatient group therapy: Past, present, and future. Social Work with Groups, 35, 68-91. Greene, L. R., Meisler, A. W., Pilkey, D., Alexander, G., Cardella, L. A., Sirois, B. C., & Burg, M. M. (2004). Psychological work with groups in the Veterans Administration. In J. L. Delucia-Waak, D. A. Garrity, C. R. Kalodner, & M. T. Riva, M.T. (Eds.), Handbook of group counseling and psychotherapy (pp. 322-337). London: Sage. Hajek, K. (2007). Interpersonal group therapy on acute inpatient wards. Groupwork, 17(1), 7-19. Holzel, L. P., Kriston, L., Weisner, A. K., & Harter, M. (2011). Crossnational differences in inpatient depression treatment. European Psychiatric Review, 4(1), 32-34. Johnson, D. R. (1997). An existential model of group therapy for chronic mental conditions. International Journal of Group Psychotherapy, 47(2), 227-250. Kahn, E. M. (1986). Symposium discussion: Inpatient group psychotherapy: Which type of group is best? Group, 19, 27-33. Kanas, N., & Barr, M. A. (1986). Process and content in a short-term inpatient schizophrenic group. Small Group Behavior, 17, 355-363. Leszcz, M. (1986). Interactional group therapy with non-psychotic patients. Group, 10, 13-30. Kosters, M., Burlingame, G. M., Nachtigall, C., & Strauss, B. (2006). A meta-analytic review of the effectiveness of inpatient group psychotherapy. Group Dynamics: Theory, Research, and Practice, 10(2), 146163. Maxmen, J. (1984). Helping patients survive theories: An educative model. International Journal of Group Psychotherapy, 34, 355–368. Radcliffe, J., & Diamond, D. (2010). A psychodynamic inpatient group. In J. Radcliffe, K. Hajek, J. Carson, & O. Manor (Eds.), Psychological groupwork with acute psychiatric inpatients. London: Whiting & Birch. Reaves, M. E., & Maxwell, M. J. (1987). The evolution of a therapy group for Vietnam veterans on a general psychiatry unit. Journal of Contemporary Psychotherapy, 17(1), 22-33. Rosner, R., Lumbeck, G., & Geissner, E. (2011). Effectiveness of an inpatient group therapy for comorbid complicated grief disorder. Psychotherapy Research, 21(2), 210-218. Weiss, P. A. (2010). Time-limited dynamic psychotherapy as a model for short-term inpatient groups. Journal of Contemporary Psychotherapy, 40, 41-49. Winship, G., & Hardy, S. (2007). Perspectives on prevalence and treatment of personality disorder. Journal of Psychiatric and Mental Health Nursing, 14, 148-154.
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Wright, D. C., Woo, W. W., Muller, R. T., Fernandes, C. B., & Kraftcheck, E. R. (2003). An investigation of trauma-centered inpatient treatment for adult survivors of abuse. Child Abuse & Neglect, 27, 393-406. Wyatt, R. C., & Seid, E. L. (2006). Instructor’s manual for understanding group psychotherapy, volume III: An interview with Irvin Yalom. San Francisco, CA, psychotherapy.net. Yalom, I. D. (1983). Inpatient group psychotherapy. New York: Basic Books. Youcha, I. Z. (1990). The short-term inpatient group: Formation and beginnings. In B. E. Roth, W. Stone, & H. D. Kibel (Eds.), The difficult patient in group: Group psychotherapy with borderline and narcissistic disorders (pp. 265-281). Madison, CT: International Universities Press. Department of Psychology Clayton State University 2000 Clayton State Blvd. Morrow, GA 30260 E-mail: [email protected]
