Some Perspectives on Time-limited Group Psychotherapy Harold S. Bernard and Robert H. Klein
D
ESPITE a continuing core of opposition to psychotherapy groups,‘” group therapy has gained general acceptance among professionals at all levels. Though not all therapists utilize the group format themselves, it is an accepted tool in the professional’s armamentarium. A recent development in the evolution of new procedures to deal with the increasing demand for psychiatric/psychological services has been the emergence of short-term, time-limited therapeutic interventions. In the past several years there has been a burgeoning literature concerning such approaches to the therapeutic situation.‘“,” This paper represents an effort to review the literature on short-term, timelimited group psychotherapy. An attempt will be made to integrate several suggestions and guidelines for conducting such groups. THE DEVELOPMENT OF SHORT-TERM
PSYCHOTHERAPY GROUPS
One practical justification advanced for both the group approach and the shortterm, time-limited individual approach is that each makes it possible to reach more people in need of help with the same investment of professional time. Since societal needs require that mental health professionals develop new ways to respond to the ever-increasing demand for services, it is only logical to look at short-term, time-limited group psychotherapy as a therapeutic alternative. Various formats for short-term groups have been proposed.” Most frequently, the time-limited group approach is utilized with different specialized populations, such as acutely disturbed adolescent males,‘:’ neurotic and acting out boys,’ and prospective counselors.6 The implication is that shared problems or concerns make it possible to begin substantive work much more quickly. Several contributions support the notion that homogeneous groups do result in faster development of trust and empathy among members, and thus lead to useful therapeutic work at an earlier stage than heterogeneous groups.’ Wolf”’ argues strongly for homogeneity rather than heterogeneity in grouping patients for a short-term intervention. Much less has been written about time-limited group psychotherapy with a general out-patient population than with various specialized populations. A distinction may be drawn among the different formats for time-limited groups between short-term, time-limited groups and crisis groups. Crisis groups have been written about extensively in the literature.’ Such groups are exclusively for
From the Department of Psychiatry, University of Rochester Medical Center, Rochr.strr. .Yrw York. Harold S. Bernard. Ph.D.: Assistant Professor of Psychiatry tPsvchologyJ; Robert H. Klein, Ph.D.: .dssociate Professor of Psvchiatry (PsychologyL University of Rochester Medical Center, Rochester. New York. Reprint requests should be addressed to University Health Service.r, Clniver.vity of Rochester Medical Center, 601 Elmwood Avenue. Rochester, N. Y. 14642. ‘~51977 by Prune & Stratton, Inc. ISSN 0010 440X. Comprehensive Psychiatry, Vol. 18. No. 6 (November/December).
1977
579
BERNARD
580
AND KLEIN
patients who are in the midst of a crisis; the therapeutic work usually involves an effort to relieve the immediate distress. Helping the patient develop tools for dealing with such difficulties in the future is usually a secondary goal of such groups. Another kind of group which can be distinguished from the short-term timeThe marathon is most frequently limited group is the marathon group.2~Lo~‘1~L7 utilized in the encounter movement. Participants identify themselves as interested in growth and development rather than as patients interested in alleviating their psychological distress. Though there is more overlap between populations than this dichotomy would imply, the different orientations which encounter group members have from therapy patients, growth versus survival, make the respective groups enormously different.22 Marathons are at times used as a psychotherapy tool. They may be either adjuncts to ongoing therapeutic endeavors, or constitute the entire treatment procedure.17 Such techniques can be distinguished from time-limited group psychotherapy by examining the time distribution of therapeutic contact. There is a sense of continuity and working-over time (albeit relatively little time) that characterizes time-limited group psychotherapy in contrast to marathon psychotherapy. From a learning theory perspective, the marathon group represents a massed-practice strategy, while the time-limited group represents a series of distributed, more discrete trials. In marathons, the integration of therapeutic work takes place either virtually immediately or after the group has terminated. In time-limited psychotherapy, there is much more op~rtunity for the consolidation of therapeutic gains within the context of the group. Also, such groups permit examination and integration of interpolated experiences in everyday social reality. Frequently the therapist in time-limited groups will supplement the regular sessions of the group with other kinds of interventions.lg Sometimes these interventions require additional investment of professional time, and sometimes they do not. An example of the former is the frequent practice of interweaving individual therapy sessions with group meetings, while an example of the latter is the alternation of regular group sessions with leaderless meetings. However, if one of the goals of time-limited groups is to maximize therapeutic impact while conserving as much professional time as possible, then using supplements techniques which require significant amounts of additional professional time undermines the purpose. Supplementary interventions which do not require additional professional time are certainly consistent with the aforementioned goal. GUIDELINES
FOR TIME-LIMITED
GROUPS
Patient Selection Psychopathology. A number of guidelines can be proposed to maximize the effectiveness of the time-limited group approach. The first issue which must be addressed is that of patient selection. Clearly, there is not the same luxury of time as there is in more traditional psychotherapeutic modalities to deal with and thoroughly work through the variety of problems which arise in the clinical situation. Thus, the short-term group therapist must make a crucial clinical judgment before therapy begins as to which patients can benefit from a time-limited group experience.
TIME-LIMITED
GROUP
PSYCHOTHERAPY
581
The nature and degree of the patients’ psychopathology must be assessed. Review of the literature suggests that the one clear area of agreement seems to be that “severely disturbed” people are not appropriate for this modality. Thus, activety psychotic, brain damaged, and severe character disordered patients (including drug abusers and alcoholics) should be ruled out. As discussed above, homogeneity of diagnostic category is also recommended. Motivation. An assessment of the patient’s motivation for treatment also must be addressed by both therapist and patient before an agreement to begin therapy is reached. Certainly these two issues are interactive, since the nature of the psychopathology is one factor affecting motivation. Sifneos’” is quite instructive in this regard, He lists seven criteria which can be used in evaluating motivation for short-term therapy: 1) Ability to recognize that symptoms are psychological; 2) tendency toward introspection and honesty; 3) willingness to participate actively in treatment; 4) willingness and curiosity to understand oneself; 5) willingness to explore and change; 6) realistic expectations of therapy: and 7) willingness to make sacrifices. Though it is difficult to make rapid assessments on all of these dimensions, a long and extensive evaluation would be contrary to the whole purpose of the timelimited approach. Resistance. Subsumed under the area of motivation is the issue of resistance. The therapist must make an assessment of the likelihood that resistances can be sufficiently resolved to permit meaningful progress to be made in the limited time available. Patients with relatively intractable resistances are not appropriate for short-term psychotherapy. The more pervasive, entrenched, and primitive the patient’s resistances, the less likely he is to benefit from a time-limited approach. In assessing motivation and resistance, the therapist must pay attention to the patient’s behavior during the interview. He needs to determine the likelihood of his being able to establish a therapeutic alliance with the patient’s healthy-ego at an early stage in the treatment. The patient’s ability to think and talk about himself objectively and critically is a crucial indicator that a therapeutic alliance can be established quickly. External Environment. A related area which must be assessed during the pretherapy screening procedure is the nature of the patient’s external environment. Essentially, the environment must be such that the patient can devote himself in a primary way to the therapeutic enterprise. The therapist must inquire into the nature and extent of the supports available to the patient, and the kinds of demands which are placed upon him. He must assess whether the external environment is stable enough to withstand the inevitable stress which the patient will experience in the therapeutic process. If the patient’s environment does not have suEicient supports and stability, he may not be an appropriate candidate for timelimited psychotherapy. Psychod.vnamic Conjicts and Treatment Goals. Assuming that the patient’s impairments in ego functioning are not so pervasive and debilitating that he is severely disturbed, all psychodynamic conflicts are potentially amenable to shortterm intervention. Our experience suggests that it is possible to make signi~cant impact in a short time whether the patient is having problems with dependency, authority, sexuality, intimacy, aggression, or any other conflict area. The issue is not what area or areas the patient is having difficulty with (though determining
BERNARD
582
AND
KLEIN
this is obviously necessary in order to formulate a treatment plan), but rather whether it is possible to formulate goals within that area of conflict which are attainable in the limited time available. For instance, a goal of fundamentally changing the characterologi~al style of a passive-dependent personality is not attainable in a short-term treatment program, but it may be possible to help such a person interact more successfully with a particularly important person in his life. Similarly, it would not be possible to work through all of the infantile rage which results in a patient’s inability to control aggressive outbursts, but it may be possible to formulate a more circumscribed goal within this area of concern which is achievable. Thus, the therapist must gather information in a number of different areas during the pretherapy evaluations: severity of psychopathology, motivation for treatment, resistance to treatment and change, support and stability of the external environment, area of psychodynamic concerns, and possi~ity of. formulating an achievable goal. If the patient is not excluded on any of these grounds, he may be regarded as a reasonable candidate for time-limited group psychotherapy. Patient Preparation
The next area with which the therapist must be concerned is the preparation of the patient for the group experience. Once again, proper preparation assumes more than the normal importance because of the time that will be lost if such preparation is not carried out thoughtfully and thoroughly. Garrison5 asserts that, as well as providing practical details about the group’s operation, e.g., the number and length of group sessions, such preparation should include a discussion of what the patient realistically can hope to accomplish in the limited time available. In addition, the kinds of participation which will maximize the chances of his being able to accomplish his goal should be reviewed. Furthermore, as noted by Yalomz2 and by Klein8 the therapist should: attempt to deal with some of the fears and resistances which patients typically experience when entering therapy groups; provide some discussion of ground rules, such as confidentiality and contacts with other patients outside therapy; inform the patients about the therapist’s role in the group; discuss with the patient whether the group is to be observed or recorded. Therapeutic
Technique
There is substantial discussion in the literature as to what kinds of techniques are most useful in time-limited psychotherapy. Most of these techniques apply to group as well as individual work. Wolf 21stresses the importance of realistically limited goals, and suggests the utilization of ego-building techniques, that is, focusing on the growth of the repressed positive ego. He emphasizes the utilization of social and environmental resources whenever possible. In addition, he stresses the importance of addressing oneself to the patient’s immediate, rather than irrational and archaic needs, and notes that by strengthening rather than breaking the patient’s defenses down, the therapist can avoid inducing a transference
neurosis.
Thus, Wolf views the techniques employed in short-term group psychotherapy as being quite different from, and often diametrically opposed to, those adopted for the more traditional, time-unlimited approach. The concepts he emphasizes indicate the profound impact that time-limited model can have on therapeutic strategy.
TIME-LIMITED
GROUP
PSYCHOTHERAPY
583
Others have written about therapeutic strategy in short-term treatment as well. Weiner’” postulates three kinds of group psychotherapy: 1) didactic; patients are told directly how to change destructive patterns of behavior; 2) supportive; repression and the substitution of less pathological defenses are encouraged; 3) analytically oriented; the aim is recognition of unconscious patterns by the uncovering of transferences and the working through of resistances through the medium of interpretation. According to this scheme, Weiner argues that, in order to have a therapeutic impact, short-term groups must emphasize the didactic and supportive, and deemphasize the analytically oriented. There seems to be some consensus among therapists that short-term work is benefitted by direct interpretations, active efforts to isolate the main conflict, and direct explanation of the meaning of the patient’s symptoms. The picture that emerges is that of a therapist who is considerably more active than his time-unlimited counterpart. There is insufficient time to encourage the patient to come to an understanding and appreciation of his problems in his own way and at his own pace. The therapist, while never compromising his supportive stance, must move the therapeutic process along quite quickly. He needs to interpret more quickly and directly, and sometimes even offer behavioral prescriptions. He should remain aware of what can and cannot be accomplished in the limited time he has available, and fashion his efforts accordingly. In those areas in which he does not feel he can lay adequate groundwork so that the patient can make progress on his own after the group has terminated, he must actively seek to shore up defenses. This is not easy for many therapists, who find it difficult to aim for anything less than major characterological restructuring, but it is crucial for the therapist who utilizes the time-limited group approach. Termination
The issue of termination pervades a short-term group from the first session onward. Patients typically feel confused about why the number of sessions has been arbitrarily limited. They may feel cheated and angered by this decision. It is crucial for the therapist to recognize these feelings and encourage patients to vent them. Exploration of the dynamic significance of the anger can be undertaken with individual patients to the extent that it is consistent with their particular therapeutic goals. Furthermore, it may be useful to review in the group what treatment alternatives are available for patients at the conclusion of therapy. Finally, the therapist may wish to schedule follow-up individual evaluation sessions for group members. CONCLUSIONS
Time-limited group psychotherapy is a distinctive therapeutic modality. It is qualitatively different from the more traditional time-unlimited approach on several important dimensions: patient selection, patient preparation, therapeutic technique, and termination. While it is now possible to advance some preliminary guidelines for conducting short-term group therapy, the results from research regarding the therapeutic value of short-term interventions in general, and shortterm groups in particular, are predictably mixed. Although there is substantial literature to support the efficacy of time-limited interventionsi some studies have called into question the desirability of the time-limited group approach. McGee
584
BERNARD
AND KLEIN
and Williams9 found that members of short-term groups made some positive changes, but concluded that time-unlimited groups tend to be less forced, more natural, and thus provide a wider and more flexible framework within which change can occur. Thus, the data concerning the efficacy of time-limited group efforts remain ambiguous. Because of the pressing need to find modalities which will conserve professional time, and yet still make substantial therapeutic impact on participants, different time-limited approaches should continue to be utilized on an experimental basis until more is learned about their utility and their limitations. REFERENCES 1. Allgeyer J: Using groups in a crisis-oriented outpatient setting. Int J Group Psychother 231211-222, 1913 2. Bach GR: The marathon group: intensive practice of intimate interaction. Psycho1 Rep 18:995-1002,1972 3. Barten HH (ed): Brief Therapies. New York, Behavioral, 1971 4. Furst W: Homogenous vs heterogeneous groups, in Rosenbaum M, Berger M (eds): Group Psychotherapy and Group Function. New York, Basic Books, 1963, p 407 5. Garrison JE: Effects of systematic preparation of patients for group psychotherapy. Dissert Abst Int 33:2808, 1960 6. Gazda G, Ohlsen M: The effects of shortterm group counseling on prospective counselors. Pers Guid J 39:634-638, 1961 7. Karson S: Group psychotherapy with latency age boys. Int J Group Psychother 1581-89, 1965 8. Klein RH: Inpatient group psychotherapy: practical considerations and special problems. Int J Group Psychother (in press) 9. McGee TF, Williams M: Time-lirn~t~ and time-unlimited group psychotherapy: A comparison with schizophrenic patients. Compr Group Stud 2:7 i-84, 197I 10. Mintz EE: Time-extended marathon groups. Psychoth Theory Prac 4:65-69, 1967 I I. Mintz EE: Marathon groups: reality and symbol. New York, Appleton-Century-Crofts, 1971 12. Papanek H: Group psychotherapy in-
terminable. Int J Group Psychother 20~219-223, 1970 13. Sadock B, Gould RE: A preliminary report on short-term group psychotherapy on an acute adolescent male service. Int J Group Psychother 14:465--473, 1964 14. Sadock B, Newman L, Normand WC: Short-term group psychotherapy in a psychiatric walk-in clinic. Am J Orthopsychiatr 38:624-632, 1968 15. Sifneos PE: The motivational process: a selection and prognostic criterion for psychotherapy of short duration. Psychiatr Q 42~271-279, 1968 16. Small I,: The Briefer Therapies. New York, Brunner-Mazel, 1971 17. Staller FH: Accelerated interaction: a time-limited approach based on the brief, intensive group. Int J Group Psychother 18:220--258, 1968 18. Strupp HH: The experiential group and the psychotherapeutic enterprise. Int J Group Psychother 23:115~124,1973 19. Trakas DA, Lloyd G: Emergency management in a short-term open group. Compr Psychiatr 12170~175, 1971 20. Weiner MF: Levels of intervention in group psychotherapy. Group Proc 3:67-81, 1970-7 1 21. Wolf A: Short-term group psychotherapy, in Wolberg L (ed): Short-term Psychotherapy. New York, Grune & Stratton, 1965, p 245 22. Yalom I: The Theory and Practice of Group Psychotherapy. New York, Basic Books, 1970, p 365
D
ESPITE a continuing core of opposition to psychotherapy groups,‘” group therapy has gained general acceptance among professionals at all levels. Though not all therapists utilize the group format themselves, it is an accepted tool in the professional’s armamentarium. A recent development in the evolution of new procedures to deal with the increasing demand for psychiatric/psychological services has been the emergence of short-term, time-limited therapeutic interventions. In the past several years there has been a burgeoning literature concerning such approaches to the therapeutic situation.‘“,” This paper represents an effort to review the literature on short-term, timelimited group psychotherapy. An attempt will be made to integrate several suggestions and guidelines for conducting such groups. THE DEVELOPMENT OF SHORT-TERM
PSYCHOTHERAPY GROUPS
One practical justification advanced for both the group approach and the shortterm, time-limited individual approach is that each makes it possible to reach more people in need of help with the same investment of professional time. Since societal needs require that mental health professionals develop new ways to respond to the ever-increasing demand for services, it is only logical to look at short-term, time-limited group psychotherapy as a therapeutic alternative. Various formats for short-term groups have been proposed.” Most frequently, the time-limited group approach is utilized with different specialized populations, such as acutely disturbed adolescent males,‘:’ neurotic and acting out boys,’ and prospective counselors.6 The implication is that shared problems or concerns make it possible to begin substantive work much more quickly. Several contributions support the notion that homogeneous groups do result in faster development of trust and empathy among members, and thus lead to useful therapeutic work at an earlier stage than heterogeneous groups.’ Wolf”’ argues strongly for homogeneity rather than heterogeneity in grouping patients for a short-term intervention. Much less has been written about time-limited group psychotherapy with a general out-patient population than with various specialized populations. A distinction may be drawn among the different formats for time-limited groups between short-term, time-limited groups and crisis groups. Crisis groups have been written about extensively in the literature.’ Such groups are exclusively for
From the Department of Psychiatry, University of Rochester Medical Center, Rochr.strr. .Yrw York. Harold S. Bernard. Ph.D.: Assistant Professor of Psychiatry tPsvchologyJ; Robert H. Klein, Ph.D.: .dssociate Professor of Psvchiatry (PsychologyL University of Rochester Medical Center, Rochester. New York. Reprint requests should be addressed to University Health Service.r, Clniver.vity of Rochester Medical Center, 601 Elmwood Avenue. Rochester, N. Y. 14642. ‘~51977 by Prune & Stratton, Inc. ISSN 0010 440X. Comprehensive Psychiatry, Vol. 18. No. 6 (November/December).
1977
579
BERNARD
580
AND KLEIN
patients who are in the midst of a crisis; the therapeutic work usually involves an effort to relieve the immediate distress. Helping the patient develop tools for dealing with such difficulties in the future is usually a secondary goal of such groups. Another kind of group which can be distinguished from the short-term timeThe marathon is most frequently limited group is the marathon group.2~Lo~‘1~L7 utilized in the encounter movement. Participants identify themselves as interested in growth and development rather than as patients interested in alleviating their psychological distress. Though there is more overlap between populations than this dichotomy would imply, the different orientations which encounter group members have from therapy patients, growth versus survival, make the respective groups enormously different.22 Marathons are at times used as a psychotherapy tool. They may be either adjuncts to ongoing therapeutic endeavors, or constitute the entire treatment procedure.17 Such techniques can be distinguished from time-limited group psychotherapy by examining the time distribution of therapeutic contact. There is a sense of continuity and working-over time (albeit relatively little time) that characterizes time-limited group psychotherapy in contrast to marathon psychotherapy. From a learning theory perspective, the marathon group represents a massed-practice strategy, while the time-limited group represents a series of distributed, more discrete trials. In marathons, the integration of therapeutic work takes place either virtually immediately or after the group has terminated. In time-limited psychotherapy, there is much more op~rtunity for the consolidation of therapeutic gains within the context of the group. Also, such groups permit examination and integration of interpolated experiences in everyday social reality. Frequently the therapist in time-limited groups will supplement the regular sessions of the group with other kinds of interventions.lg Sometimes these interventions require additional investment of professional time, and sometimes they do not. An example of the former is the frequent practice of interweaving individual therapy sessions with group meetings, while an example of the latter is the alternation of regular group sessions with leaderless meetings. However, if one of the goals of time-limited groups is to maximize therapeutic impact while conserving as much professional time as possible, then using supplements techniques which require significant amounts of additional professional time undermines the purpose. Supplementary interventions which do not require additional professional time are certainly consistent with the aforementioned goal. GUIDELINES
FOR TIME-LIMITED
GROUPS
Patient Selection Psychopathology. A number of guidelines can be proposed to maximize the effectiveness of the time-limited group approach. The first issue which must be addressed is that of patient selection. Clearly, there is not the same luxury of time as there is in more traditional psychotherapeutic modalities to deal with and thoroughly work through the variety of problems which arise in the clinical situation. Thus, the short-term group therapist must make a crucial clinical judgment before therapy begins as to which patients can benefit from a time-limited group experience.
TIME-LIMITED
GROUP
PSYCHOTHERAPY
581
The nature and degree of the patients’ psychopathology must be assessed. Review of the literature suggests that the one clear area of agreement seems to be that “severely disturbed” people are not appropriate for this modality. Thus, activety psychotic, brain damaged, and severe character disordered patients (including drug abusers and alcoholics) should be ruled out. As discussed above, homogeneity of diagnostic category is also recommended. Motivation. An assessment of the patient’s motivation for treatment also must be addressed by both therapist and patient before an agreement to begin therapy is reached. Certainly these two issues are interactive, since the nature of the psychopathology is one factor affecting motivation. Sifneos’” is quite instructive in this regard, He lists seven criteria which can be used in evaluating motivation for short-term therapy: 1) Ability to recognize that symptoms are psychological; 2) tendency toward introspection and honesty; 3) willingness to participate actively in treatment; 4) willingness and curiosity to understand oneself; 5) willingness to explore and change; 6) realistic expectations of therapy: and 7) willingness to make sacrifices. Though it is difficult to make rapid assessments on all of these dimensions, a long and extensive evaluation would be contrary to the whole purpose of the timelimited approach. Resistance. Subsumed under the area of motivation is the issue of resistance. The therapist must make an assessment of the likelihood that resistances can be sufficiently resolved to permit meaningful progress to be made in the limited time available. Patients with relatively intractable resistances are not appropriate for short-term psychotherapy. The more pervasive, entrenched, and primitive the patient’s resistances, the less likely he is to benefit from a time-limited approach. In assessing motivation and resistance, the therapist must pay attention to the patient’s behavior during the interview. He needs to determine the likelihood of his being able to establish a therapeutic alliance with the patient’s healthy-ego at an early stage in the treatment. The patient’s ability to think and talk about himself objectively and critically is a crucial indicator that a therapeutic alliance can be established quickly. External Environment. A related area which must be assessed during the pretherapy screening procedure is the nature of the patient’s external environment. Essentially, the environment must be such that the patient can devote himself in a primary way to the therapeutic enterprise. The therapist must inquire into the nature and extent of the supports available to the patient, and the kinds of demands which are placed upon him. He must assess whether the external environment is stable enough to withstand the inevitable stress which the patient will experience in the therapeutic process. If the patient’s environment does not have suEicient supports and stability, he may not be an appropriate candidate for timelimited psychotherapy. Psychod.vnamic Conjicts and Treatment Goals. Assuming that the patient’s impairments in ego functioning are not so pervasive and debilitating that he is severely disturbed, all psychodynamic conflicts are potentially amenable to shortterm intervention. Our experience suggests that it is possible to make signi~cant impact in a short time whether the patient is having problems with dependency, authority, sexuality, intimacy, aggression, or any other conflict area. The issue is not what area or areas the patient is having difficulty with (though determining
BERNARD
582
AND
KLEIN
this is obviously necessary in order to formulate a treatment plan), but rather whether it is possible to formulate goals within that area of conflict which are attainable in the limited time available. For instance, a goal of fundamentally changing the characterologi~al style of a passive-dependent personality is not attainable in a short-term treatment program, but it may be possible to help such a person interact more successfully with a particularly important person in his life. Similarly, it would not be possible to work through all of the infantile rage which results in a patient’s inability to control aggressive outbursts, but it may be possible to formulate a more circumscribed goal within this area of concern which is achievable. Thus, the therapist must gather information in a number of different areas during the pretherapy evaluations: severity of psychopathology, motivation for treatment, resistance to treatment and change, support and stability of the external environment, area of psychodynamic concerns, and possi~ity of. formulating an achievable goal. If the patient is not excluded on any of these grounds, he may be regarded as a reasonable candidate for time-limited group psychotherapy. Patient Preparation
The next area with which the therapist must be concerned is the preparation of the patient for the group experience. Once again, proper preparation assumes more than the normal importance because of the time that will be lost if such preparation is not carried out thoughtfully and thoroughly. Garrison5 asserts that, as well as providing practical details about the group’s operation, e.g., the number and length of group sessions, such preparation should include a discussion of what the patient realistically can hope to accomplish in the limited time available. In addition, the kinds of participation which will maximize the chances of his being able to accomplish his goal should be reviewed. Furthermore, as noted by Yalomz2 and by Klein8 the therapist should: attempt to deal with some of the fears and resistances which patients typically experience when entering therapy groups; provide some discussion of ground rules, such as confidentiality and contacts with other patients outside therapy; inform the patients about the therapist’s role in the group; discuss with the patient whether the group is to be observed or recorded. Therapeutic
Technique
There is substantial discussion in the literature as to what kinds of techniques are most useful in time-limited psychotherapy. Most of these techniques apply to group as well as individual work. Wolf 21stresses the importance of realistically limited goals, and suggests the utilization of ego-building techniques, that is, focusing on the growth of the repressed positive ego. He emphasizes the utilization of social and environmental resources whenever possible. In addition, he stresses the importance of addressing oneself to the patient’s immediate, rather than irrational and archaic needs, and notes that by strengthening rather than breaking the patient’s defenses down, the therapist can avoid inducing a transference
neurosis.
Thus, Wolf views the techniques employed in short-term group psychotherapy as being quite different from, and often diametrically opposed to, those adopted for the more traditional, time-unlimited approach. The concepts he emphasizes indicate the profound impact that time-limited model can have on therapeutic strategy.
TIME-LIMITED
GROUP
PSYCHOTHERAPY
583
Others have written about therapeutic strategy in short-term treatment as well. Weiner’” postulates three kinds of group psychotherapy: 1) didactic; patients are told directly how to change destructive patterns of behavior; 2) supportive; repression and the substitution of less pathological defenses are encouraged; 3) analytically oriented; the aim is recognition of unconscious patterns by the uncovering of transferences and the working through of resistances through the medium of interpretation. According to this scheme, Weiner argues that, in order to have a therapeutic impact, short-term groups must emphasize the didactic and supportive, and deemphasize the analytically oriented. There seems to be some consensus among therapists that short-term work is benefitted by direct interpretations, active efforts to isolate the main conflict, and direct explanation of the meaning of the patient’s symptoms. The picture that emerges is that of a therapist who is considerably more active than his time-unlimited counterpart. There is insufficient time to encourage the patient to come to an understanding and appreciation of his problems in his own way and at his own pace. The therapist, while never compromising his supportive stance, must move the therapeutic process along quite quickly. He needs to interpret more quickly and directly, and sometimes even offer behavioral prescriptions. He should remain aware of what can and cannot be accomplished in the limited time he has available, and fashion his efforts accordingly. In those areas in which he does not feel he can lay adequate groundwork so that the patient can make progress on his own after the group has terminated, he must actively seek to shore up defenses. This is not easy for many therapists, who find it difficult to aim for anything less than major characterological restructuring, but it is crucial for the therapist who utilizes the time-limited group approach. Termination
The issue of termination pervades a short-term group from the first session onward. Patients typically feel confused about why the number of sessions has been arbitrarily limited. They may feel cheated and angered by this decision. It is crucial for the therapist to recognize these feelings and encourage patients to vent them. Exploration of the dynamic significance of the anger can be undertaken with individual patients to the extent that it is consistent with their particular therapeutic goals. Furthermore, it may be useful to review in the group what treatment alternatives are available for patients at the conclusion of therapy. Finally, the therapist may wish to schedule follow-up individual evaluation sessions for group members. CONCLUSIONS
Time-limited group psychotherapy is a distinctive therapeutic modality. It is qualitatively different from the more traditional time-unlimited approach on several important dimensions: patient selection, patient preparation, therapeutic technique, and termination. While it is now possible to advance some preliminary guidelines for conducting short-term group therapy, the results from research regarding the therapeutic value of short-term interventions in general, and shortterm groups in particular, are predictably mixed. Although there is substantial literature to support the efficacy of time-limited interventionsi some studies have called into question the desirability of the time-limited group approach. McGee
584
BERNARD
AND KLEIN
and Williams9 found that members of short-term groups made some positive changes, but concluded that time-unlimited groups tend to be less forced, more natural, and thus provide a wider and more flexible framework within which change can occur. Thus, the data concerning the efficacy of time-limited group efforts remain ambiguous. Because of the pressing need to find modalities which will conserve professional time, and yet still make substantial therapeutic impact on participants, different time-limited approaches should continue to be utilized on an experimental basis until more is learned about their utility and their limitations. REFERENCES 1. Allgeyer J: Using groups in a crisis-oriented outpatient setting. Int J Group Psychother 231211-222, 1913 2. Bach GR: The marathon group: intensive practice of intimate interaction. Psycho1 Rep 18:995-1002,1972 3. Barten HH (ed): Brief Therapies. New York, Behavioral, 1971 4. Furst W: Homogenous vs heterogeneous groups, in Rosenbaum M, Berger M (eds): Group Psychotherapy and Group Function. New York, Basic Books, 1963, p 407 5. Garrison JE: Effects of systematic preparation of patients for group psychotherapy. Dissert Abst Int 33:2808, 1960 6. Gazda G, Ohlsen M: The effects of shortterm group counseling on prospective counselors. Pers Guid J 39:634-638, 1961 7. Karson S: Group psychotherapy with latency age boys. Int J Group Psychother 1581-89, 1965 8. Klein RH: Inpatient group psychotherapy: practical considerations and special problems. Int J Group Psychother (in press) 9. McGee TF, Williams M: Time-lirn~t~ and time-unlimited group psychotherapy: A comparison with schizophrenic patients. Compr Group Stud 2:7 i-84, 197I 10. Mintz EE: Time-extended marathon groups. Psychoth Theory Prac 4:65-69, 1967 I I. Mintz EE: Marathon groups: reality and symbol. New York, Appleton-Century-Crofts, 1971 12. Papanek H: Group psychotherapy in-
terminable. Int J Group Psychother 20~219-223, 1970 13. Sadock B, Gould RE: A preliminary report on short-term group psychotherapy on an acute adolescent male service. Int J Group Psychother 14:465--473, 1964 14. Sadock B, Newman L, Normand WC: Short-term group psychotherapy in a psychiatric walk-in clinic. Am J Orthopsychiatr 38:624-632, 1968 15. Sifneos PE: The motivational process: a selection and prognostic criterion for psychotherapy of short duration. Psychiatr Q 42~271-279, 1968 16. Small I,: The Briefer Therapies. New York, Brunner-Mazel, 1971 17. Staller FH: Accelerated interaction: a time-limited approach based on the brief, intensive group. Int J Group Psychother 18:220--258, 1968 18. Strupp HH: The experiential group and the psychotherapeutic enterprise. Int J Group Psychother 23:115~124,1973 19. Trakas DA, Lloyd G: Emergency management in a short-term open group. Compr Psychiatr 12170~175, 1971 20. Weiner MF: Levels of intervention in group psychotherapy. Group Proc 3:67-81, 1970-7 1 21. Wolf A: Short-term group psychotherapy, in Wolberg L (ed): Short-term Psychotherapy. New York, Grune & Stratton, 1965, p 245 22. Yalom I: The Theory and Practice of Group Psychotherapy. New York, Basic Books, 1970, p 365
