OPEN FORUM REFERRING PATIENTS FOR GROUP PSYCHOTHERAPY: SOME GUIDELINES William
H.
Friedman,
Ph.D.
#{149}Often there is uncertainty about when to refer adult outpatients for group psychotherapy and when such referral is contraindicated. In the following discussion of some general guidelines for referral, two notions are implicit: that referral for group therapy is always preceded by an adequate diagnostic procedure performed by an individual therapist or a diagnostic team, and that the indications for group psychotherapy are somewhat different from those for individual psychotherapy. I will not consider such issues as whether a patient should be seen concurrently in individual and group therapy, or the indications for one type of group rather than another. The reasons an individual therapist refers a patient to a therapy group fall into three general categorieslegitimate, nonlegitimate, and illegitimate. A legitimate referral is one made because group therapy is the treatment of choice. Nonlegitimate referrals are those often made in teaching hospitals or training clinics: the patient may reasonibly be expected to benefit from group therapy, and in addition the referring therapist is aware of and influenced by the clinic’s need to provide its trainees with experience in leading groups. The referral is therefore at least partly for the convenience of the training institution. An illegitimate referral is one that is made primarily because of countertransference in individual therapy, and it constitutes rejection by the individual therapist. If the referral falls into the second or third category, it would be helpful if the referring therapist discussed the case directly with the group leader. The group leader is then alerted to the kind and vehemence of resistance that the patient is likely to bring to the pregroup screening interview and perhaps to the group itself. The next problem is trying to define criteria for a Dr. Friedman is associate professor and director of the group therapies program in the department of psychiatry, School of Medicine, University of North Carolina, Chapel Hill, North Carolina 27514.
good’ referral. Group therapy experiences have been offered to patients with diagnoses covering a wide range of psychopathology, as well as to individuals who did not define themselves as patients. There are, however, some general guidelines, and there is some research to support them,’ Those guidelines are not inviolable rules; there are always exceptions. The referring therapist’s clinical judgments and his private assessment of the competence of the group leaders are the most crucial determinants of whether or not a patient should be referred for group therapy. There are five general guidelines for referral of patients for group therapy: The patient defines his problem as interpersonal or emphasizes the interpersonal aspects of his problem. Note that this guideline refers to the patient’s conception of his problem, not the therapist’s. The therapist’s conception is reflected in the diagnostic labels, which are discussed later. Patients with organic brain syndromes and other neurological or organic deficits are not appropriate referrals for general outpatient groups. Also, a patient with a presenting complaint of depression or anxiety is likely to be more difficult to refer, and less likely tQ accept a referral, than one whose presenting complaint involves difficulty in interpersonal relationships. Patients whose presenting complaints connote intrapersonal, intrapsychic conflict should be retained in individual psychotherapy. ‘ ‘
‘
The
patient
is committed
to change
in interpersonal
behavior. Group therapy is contraindicated for patients who specify, spontaneously and tenaciously, that they seek understanding of motivation but no change in behavior. Patients who seek or who might readily benefit from the therapeutic development of insight usually should be referred for group therapy only if an opening is available in an insight-oriented, psychodynamic group. Patients who are able (perhaps as a result of a diagnostic procedure or a course of individual psychotherapy) to specify the problems or problem areas they want to work on will usually experience greater benefit from group therapy than patients whose complaints or symptoms are more vague and generalized.2 ‘M. Groups: 2
Ibid.
VOLUME
A. Lieherman, First Facts,
27
Basic
NUMBER
1. D. Yalom, and M. B. oks, New York City,
2
FEBRUARY
1976
Miles, 1973.
Encounter
121
In the pregroup screening interview, the referring therapist or the group leader may wish to help the patient become more specific about what he hopes to gain from the group therapy experience. In some types of groups, such as transactional analysis groups and some behavior modification groups, the definition or identification of specific problems or behaviors to be worked on may be a prerequisite for admission to the group. The patient is willing to become susceptible to the influence of the group. Patients who verbalize their independence from and indifference to the opinions of others are less likely to benefit from group therapy than patients who seek such information. Other things being equal, patients who are moderately approval-dependent and who are open to but not readily swayed by the opinions of others generally do well in groups. Highly approval-dependent patients may have a somewhat stormy course in group therapy, although this therapeutic modality may well be the treatment of choice when approval-dependence is a major problem for the patient. The patient is willing to report to the group his subjective experience of benefit. This and the following guideline are probably not as important as the first three since they refer more to issues of comfort than of effectiveness. The patient who is willing to report to the group that You have made a difference for me’ will have a more comfortable (but not necessarily more beneficial) time than the patient who regards such a statement as an admission of weakness. The patient is willing to be of help to others in the group setting. Commitment to help others can usually be handled easily in a therapy group without letting such commitment be carried to a pathological extreme. On the other hand, highly narcissistic patients, and those whose ability to form object cathexes is impaired, are best handled in individual psychotherapy. While a group may be able to tolerate and even to help one or two such individuals, a group made up largely or entirely of such patients will usually be difficult for even a highly experienced therapist to deal with. Because group therapy has been offered to patients with such a wide range of diagnoses, it is difficult to identify on the basis of diagnosis which patients will do well in group therapy, or to decide whether individual or group therapy is the treatment of choice when one of the psychotherapies does seem indicated. The following guidelines are intended for use in clinical settings in which training is a primary function and in which groups are often led by clinicians with little or no prior experience as group leaders. Actually we will be describing the sar#{241}e patients as in the preceding section, but from a different vantage point. Five guidelines related to diagnosis can be set forth:, ‘ ‘
‘
#{149} Schizophrenic or schizoid patients generally do not do well in group therapy, except over a long period of time in highly structured supportive groups followed by at least a brief course of individual psychotherapy. The complaints of such patients are often vague, their
122
HOSPITAL
& COMMUNITY
PSYCHIATRY
commitment to change uncertain, and their susceptibility to the influence of others minimal. There may be schizophrenic patients who are not like that; if they are not misdiagnosed, they are exceptional and may benefit from group therapy. Most group leaders prefer not to have actively psychotic, borderline, or prepsychotic patients in their groups, whether the diagnostic label includes schizophrenia or some other type of psychosis. A group that must walk on eggshells to avoid precipitating a psychotic break in one of its members is not likely to develop the emotional intensity that is at once cathartic and facilitative of behavior change. . Patients with diagnoses denoting likely to benefit from group therapy more severely disturbed. However, nature of the neurotic defenses, the cation, and the extent to which he problems as interpersonal have an appropriateness of referral for group
neurosis are more than those who are such factors as the patient’s sophisticonceptualizes his influence on the therapy.
. Patients with personality disorders appear to benefit more from group therapy than those with neuroses, within the general framework of the preceding guidelines. Exceptions include schizoid personalities, who may find it difficult to become susceptible to the influence of the group, and sociopathic personalities, who virtually by definition do not allow themselves such susceptibility. . Individuals with transient situational disturbances severe enough to warrant psychiatric intervention more often are offered crisis intervention therapy on an mdividual basis, rather than being referred for group therapy. However, group therapy may be an additional source of support or a postcrisis opportunity for the patient to examine and change the situation that is causing the disturbance.
. Suicidal ideation, tendencies, or gestures constitute a clear contraindication for referral for group therapy. Such impulses or behavior, if reported to the group by the suicidal patient, tend to be quite frightening to the other patients. If a group member attempts suicide, the other patients assume an unnecessary and unwarranted burden of guilt. If suicide is threatened, the group will be afraid of precipitating such behavioi’ arid at the same time be angry about having to tread gently. That anger intensifies the guilt, and the group spends a great deal of time, energy, and anguish on sorhething that is not likely to benefit anyone. The preceding discussion embodies the truism that the least distiithed patients are the ones who will ex.perience the greatest benefit from group therapy in the shortest period of time. Patients with greater, rather than less, psychological sophistication are more likely to do well in either individual or group psychotherapy. Patients whose defenses are strong enough to handle the intense emotional experiences that frequently characterize group therapy appear to need therapy less, but at the same time are more likely to benefit from it than more disturbed patients.
The question of whether or not a patient should be referred for group therapy can often be resolved by considering the guidelines presented here. The guidelines may also help to differentiate between those patients who should continue in individual therapy and those who should be referred for group therapy. If there is still uncertainty about referral to a group, it is entirely appropriate for the referring therapist to allow the group leader to make the decision. The group leader has considerably more information about the group than the referring therapist and is therefore in a better position to judge the probability that the patient will benefit from that specific group.
the ever-increasing demands of the Joint Commission on Accreditation of Hospitals, Medicare and Medicaid requirements, the courts, and the various publics with which facilities must deal. As the populations of public facilities have been reduced to a more manageable” size, institutions have increasingly been expected to function as do private facilities, even general hospitals with residential psychiatric programs. Yet private facilities (which generally reserve the right to exclude patients they feel they cannot cope with) operate with a staff-to-patient ratio of two or three to one. I therefore cannot feel any enthusiasm for reaching the one-to-one goal that has long since ceased to have any meaning in the field.
BPK
Reply
NIMH ANNOUNCEMENT OF ONE-TO-ONE RATIO IS QUESTIONED, DEFENDED
Charles
R. Nelson
UI would like to take exception to the enthusiasm with which Dr. Bertram Brown, director of the National Institute of Mental Health, apparently greeted the news that public mental hospitals had finally achieved a one-to-one ratio of staff to patients, reported in the September 1975 issue of Hospital & Community Psychiatry.’ While such news may indeed constitute a landmark’ in some historical sense, it hardly justified the good feeling’ of having achieved a “pipe dream.” In fact, the pipe dream of 1948 (the one-to-one ratio) has long been rendered obsolete by the explosion of expectations placed on mental health delivery systems in the 1960s and early 1970s. In addition, most patients in public mental health facilities are housed in older multiple-building institutions sprawled over many acres; 20 per cent or more of the staffs are tied up in totally non-patient-related tasks such as building and grounds maintenance, laundry, and purchasing. An additional 10 per cent of the staff, professional as well as nonprofessional, must devote their time to general administration, billing, utilization review, public relations, planning, labor negotiations, and similar activities. And staff must frequently support a ponderous statewide or regional bureaucracy preoccupied with budgeting, grants administration, and political maneuvering to gain fiscal support and pacify pressure groups. Even in those few favored programs in which the ratio of direct-care staff to patients approaches one to one, it is frequently very difficult or impossible to meet ‘ ‘
‘
“
‘
‘ ‘
From
Bertram
S. Brown,
M.D.
Mr. Nelson is quite right in pointing out that even a one-to-one patient-staff ratio in state mental hospitals is not necessarily adequate, and that private mental hospitals and general hospitals have a considerably higher ratio. I am also aware of the many significant changes in mental health legislation and in accreditation procedures that require state hospitals to perform new functions requiring even more staff than wads desirable at an earlier period. NIMH is concerned with these problems, and we are making every effort to improve the situation not only in the state mental hospitals but in the mental health delivery system as a whole. Mr. Nelson’s concerned interest and that of others is of considerable importance in accomplishing changes in this area. However, the fact that, on the average, state mental hospitals have reached a one-to-one patient-staff ratio does indicate that there has been a major change in the availability of staff in those hospitals. That the state hospitals have reached this goal certainly represents an achievement. But I agree wholeheartedly that the old goal of a one-to-one ratio is no longer as appropriate as it was in the past, and that new goals should be set. Summary indexes such as the patient-staff ratio are useful in showing over-all changes in the mental health system over the past decade. As Mr. Nelson implies, however, these indexes tend to oversimplify the situation and do not indicate the complexity of the changes taking place.U
Mr. Nelson is director of the acute treatment program at Elgin (Ill.) Mental Health Center. His mailing address is 1145 Florimond, Elgin, Illinois 60120. The views he expresses are his, nd not those of the Illinois Department of Mental Health. Dr. BrQwn’s address is 5600 Fishers Lane, Rockville, Maryland 20852. 1 “Patient-Staff Ratio Reaches One to One in Public Mental Hospitals,” Vol. 26, pp. 619 and 623.
VOLUME
27
NUMBER
2
FEBRUARY
1976
123
H.
Friedman,
Ph.D.
#{149}Often there is uncertainty about when to refer adult outpatients for group psychotherapy and when such referral is contraindicated. In the following discussion of some general guidelines for referral, two notions are implicit: that referral for group therapy is always preceded by an adequate diagnostic procedure performed by an individual therapist or a diagnostic team, and that the indications for group psychotherapy are somewhat different from those for individual psychotherapy. I will not consider such issues as whether a patient should be seen concurrently in individual and group therapy, or the indications for one type of group rather than another. The reasons an individual therapist refers a patient to a therapy group fall into three general categorieslegitimate, nonlegitimate, and illegitimate. A legitimate referral is one made because group therapy is the treatment of choice. Nonlegitimate referrals are those often made in teaching hospitals or training clinics: the patient may reasonibly be expected to benefit from group therapy, and in addition the referring therapist is aware of and influenced by the clinic’s need to provide its trainees with experience in leading groups. The referral is therefore at least partly for the convenience of the training institution. An illegitimate referral is one that is made primarily because of countertransference in individual therapy, and it constitutes rejection by the individual therapist. If the referral falls into the second or third category, it would be helpful if the referring therapist discussed the case directly with the group leader. The group leader is then alerted to the kind and vehemence of resistance that the patient is likely to bring to the pregroup screening interview and perhaps to the group itself. The next problem is trying to define criteria for a Dr. Friedman is associate professor and director of the group therapies program in the department of psychiatry, School of Medicine, University of North Carolina, Chapel Hill, North Carolina 27514.
good’ referral. Group therapy experiences have been offered to patients with diagnoses covering a wide range of psychopathology, as well as to individuals who did not define themselves as patients. There are, however, some general guidelines, and there is some research to support them,’ Those guidelines are not inviolable rules; there are always exceptions. The referring therapist’s clinical judgments and his private assessment of the competence of the group leaders are the most crucial determinants of whether or not a patient should be referred for group therapy. There are five general guidelines for referral of patients for group therapy: The patient defines his problem as interpersonal or emphasizes the interpersonal aspects of his problem. Note that this guideline refers to the patient’s conception of his problem, not the therapist’s. The therapist’s conception is reflected in the diagnostic labels, which are discussed later. Patients with organic brain syndromes and other neurological or organic deficits are not appropriate referrals for general outpatient groups. Also, a patient with a presenting complaint of depression or anxiety is likely to be more difficult to refer, and less likely tQ accept a referral, than one whose presenting complaint involves difficulty in interpersonal relationships. Patients whose presenting complaints connote intrapersonal, intrapsychic conflict should be retained in individual psychotherapy. ‘ ‘
‘
The
patient
is committed
to change
in interpersonal
behavior. Group therapy is contraindicated for patients who specify, spontaneously and tenaciously, that they seek understanding of motivation but no change in behavior. Patients who seek or who might readily benefit from the therapeutic development of insight usually should be referred for group therapy only if an opening is available in an insight-oriented, psychodynamic group. Patients who are able (perhaps as a result of a diagnostic procedure or a course of individual psychotherapy) to specify the problems or problem areas they want to work on will usually experience greater benefit from group therapy than patients whose complaints or symptoms are more vague and generalized.2 ‘M. Groups: 2
Ibid.
VOLUME
A. Lieherman, First Facts,
27
Basic
NUMBER
1. D. Yalom, and M. B. oks, New York City,
2
FEBRUARY
1976
Miles, 1973.
Encounter
121
In the pregroup screening interview, the referring therapist or the group leader may wish to help the patient become more specific about what he hopes to gain from the group therapy experience. In some types of groups, such as transactional analysis groups and some behavior modification groups, the definition or identification of specific problems or behaviors to be worked on may be a prerequisite for admission to the group. The patient is willing to become susceptible to the influence of the group. Patients who verbalize their independence from and indifference to the opinions of others are less likely to benefit from group therapy than patients who seek such information. Other things being equal, patients who are moderately approval-dependent and who are open to but not readily swayed by the opinions of others generally do well in groups. Highly approval-dependent patients may have a somewhat stormy course in group therapy, although this therapeutic modality may well be the treatment of choice when approval-dependence is a major problem for the patient. The patient is willing to report to the group his subjective experience of benefit. This and the following guideline are probably not as important as the first three since they refer more to issues of comfort than of effectiveness. The patient who is willing to report to the group that You have made a difference for me’ will have a more comfortable (but not necessarily more beneficial) time than the patient who regards such a statement as an admission of weakness. The patient is willing to be of help to others in the group setting. Commitment to help others can usually be handled easily in a therapy group without letting such commitment be carried to a pathological extreme. On the other hand, highly narcissistic patients, and those whose ability to form object cathexes is impaired, are best handled in individual psychotherapy. While a group may be able to tolerate and even to help one or two such individuals, a group made up largely or entirely of such patients will usually be difficult for even a highly experienced therapist to deal with. Because group therapy has been offered to patients with such a wide range of diagnoses, it is difficult to identify on the basis of diagnosis which patients will do well in group therapy, or to decide whether individual or group therapy is the treatment of choice when one of the psychotherapies does seem indicated. The following guidelines are intended for use in clinical settings in which training is a primary function and in which groups are often led by clinicians with little or no prior experience as group leaders. Actually we will be describing the sar#{241}e patients as in the preceding section, but from a different vantage point. Five guidelines related to diagnosis can be set forth:, ‘ ‘
‘
#{149} Schizophrenic or schizoid patients generally do not do well in group therapy, except over a long period of time in highly structured supportive groups followed by at least a brief course of individual psychotherapy. The complaints of such patients are often vague, their
122
HOSPITAL
& COMMUNITY
PSYCHIATRY
commitment to change uncertain, and their susceptibility to the influence of others minimal. There may be schizophrenic patients who are not like that; if they are not misdiagnosed, they are exceptional and may benefit from group therapy. Most group leaders prefer not to have actively psychotic, borderline, or prepsychotic patients in their groups, whether the diagnostic label includes schizophrenia or some other type of psychosis. A group that must walk on eggshells to avoid precipitating a psychotic break in one of its members is not likely to develop the emotional intensity that is at once cathartic and facilitative of behavior change. . Patients with diagnoses denoting likely to benefit from group therapy more severely disturbed. However, nature of the neurotic defenses, the cation, and the extent to which he problems as interpersonal have an appropriateness of referral for group
neurosis are more than those who are such factors as the patient’s sophisticonceptualizes his influence on the therapy.
. Patients with personality disorders appear to benefit more from group therapy than those with neuroses, within the general framework of the preceding guidelines. Exceptions include schizoid personalities, who may find it difficult to become susceptible to the influence of the group, and sociopathic personalities, who virtually by definition do not allow themselves such susceptibility. . Individuals with transient situational disturbances severe enough to warrant psychiatric intervention more often are offered crisis intervention therapy on an mdividual basis, rather than being referred for group therapy. However, group therapy may be an additional source of support or a postcrisis opportunity for the patient to examine and change the situation that is causing the disturbance.
. Suicidal ideation, tendencies, or gestures constitute a clear contraindication for referral for group therapy. Such impulses or behavior, if reported to the group by the suicidal patient, tend to be quite frightening to the other patients. If a group member attempts suicide, the other patients assume an unnecessary and unwarranted burden of guilt. If suicide is threatened, the group will be afraid of precipitating such behavioi’ arid at the same time be angry about having to tread gently. That anger intensifies the guilt, and the group spends a great deal of time, energy, and anguish on sorhething that is not likely to benefit anyone. The preceding discussion embodies the truism that the least distiithed patients are the ones who will ex.perience the greatest benefit from group therapy in the shortest period of time. Patients with greater, rather than less, psychological sophistication are more likely to do well in either individual or group psychotherapy. Patients whose defenses are strong enough to handle the intense emotional experiences that frequently characterize group therapy appear to need therapy less, but at the same time are more likely to benefit from it than more disturbed patients.
The question of whether or not a patient should be referred for group therapy can often be resolved by considering the guidelines presented here. The guidelines may also help to differentiate between those patients who should continue in individual therapy and those who should be referred for group therapy. If there is still uncertainty about referral to a group, it is entirely appropriate for the referring therapist to allow the group leader to make the decision. The group leader has considerably more information about the group than the referring therapist and is therefore in a better position to judge the probability that the patient will benefit from that specific group.
the ever-increasing demands of the Joint Commission on Accreditation of Hospitals, Medicare and Medicaid requirements, the courts, and the various publics with which facilities must deal. As the populations of public facilities have been reduced to a more manageable” size, institutions have increasingly been expected to function as do private facilities, even general hospitals with residential psychiatric programs. Yet private facilities (which generally reserve the right to exclude patients they feel they cannot cope with) operate with a staff-to-patient ratio of two or three to one. I therefore cannot feel any enthusiasm for reaching the one-to-one goal that has long since ceased to have any meaning in the field.
BPK
Reply
NIMH ANNOUNCEMENT OF ONE-TO-ONE RATIO IS QUESTIONED, DEFENDED
Charles
R. Nelson
UI would like to take exception to the enthusiasm with which Dr. Bertram Brown, director of the National Institute of Mental Health, apparently greeted the news that public mental hospitals had finally achieved a one-to-one ratio of staff to patients, reported in the September 1975 issue of Hospital & Community Psychiatry.’ While such news may indeed constitute a landmark’ in some historical sense, it hardly justified the good feeling’ of having achieved a “pipe dream.” In fact, the pipe dream of 1948 (the one-to-one ratio) has long been rendered obsolete by the explosion of expectations placed on mental health delivery systems in the 1960s and early 1970s. In addition, most patients in public mental health facilities are housed in older multiple-building institutions sprawled over many acres; 20 per cent or more of the staffs are tied up in totally non-patient-related tasks such as building and grounds maintenance, laundry, and purchasing. An additional 10 per cent of the staff, professional as well as nonprofessional, must devote their time to general administration, billing, utilization review, public relations, planning, labor negotiations, and similar activities. And staff must frequently support a ponderous statewide or regional bureaucracy preoccupied with budgeting, grants administration, and political maneuvering to gain fiscal support and pacify pressure groups. Even in those few favored programs in which the ratio of direct-care staff to patients approaches one to one, it is frequently very difficult or impossible to meet ‘ ‘
‘
“
‘
‘ ‘
From
Bertram
S. Brown,
M.D.
Mr. Nelson is quite right in pointing out that even a one-to-one patient-staff ratio in state mental hospitals is not necessarily adequate, and that private mental hospitals and general hospitals have a considerably higher ratio. I am also aware of the many significant changes in mental health legislation and in accreditation procedures that require state hospitals to perform new functions requiring even more staff than wads desirable at an earlier period. NIMH is concerned with these problems, and we are making every effort to improve the situation not only in the state mental hospitals but in the mental health delivery system as a whole. Mr. Nelson’s concerned interest and that of others is of considerable importance in accomplishing changes in this area. However, the fact that, on the average, state mental hospitals have reached a one-to-one patient-staff ratio does indicate that there has been a major change in the availability of staff in those hospitals. That the state hospitals have reached this goal certainly represents an achievement. But I agree wholeheartedly that the old goal of a one-to-one ratio is no longer as appropriate as it was in the past, and that new goals should be set. Summary indexes such as the patient-staff ratio are useful in showing over-all changes in the mental health system over the past decade. As Mr. Nelson implies, however, these indexes tend to oversimplify the situation and do not indicate the complexity of the changes taking place.U
Mr. Nelson is director of the acute treatment program at Elgin (Ill.) Mental Health Center. His mailing address is 1145 Florimond, Elgin, Illinois 60120. The views he expresses are his, nd not those of the Illinois Department of Mental Health. Dr. BrQwn’s address is 5600 Fishers Lane, Rockville, Maryland 20852. 1 “Patient-Staff Ratio Reaches One to One in Public Mental Hospitals,” Vol. 26, pp. 619 and 623.
VOLUME
27
NUMBER
2
FEBRUARY
1976
123
