Supervising the Beginning Group Leader in Inpatient and Partial Hospital Settings

CE Information for ParticipantsPlease see front matter for Continuing Education Credit Details and Requirements.

Supervising the Beginning Group Leader in Inpatient and Partial Hospital Settings, by Marsha Vannicelli, Ph.d., cgP, FagPa

Estimated Time to Complete this Activity: 90 minutes

Learning Objectives:The reader will be able to:1. Assist the beginning group therapist in providing group structure.2. Describe specific moves to help group members interact to further group process.3. List clinical interventions that make groups therapeutic, over a range of different kinds of groups.

Author Disclosure:Marsha Vannicelli, Nothing to Disclose

INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 64 (2) 2014

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Marsha Vannicelli is Associate Clinical Professor of Psychology, Harvard Medical School in Boston and Teaching Faculty, Massachusetts School of Professional Psychology in New-ton, Massachusetts.

VANNICELLISUPERVISING GROUP LEADERS IN HOSPITAL SETTINGS

Supervising the Beginning Group Leader in Inpatient and Partial Hospital Settings

MARSHA VANNICELLI, PH.D., CGP, FAGPA

aBstract

This paper provides a guide for supervisors in inpatient and partial hospital settings who train beginning group therapists in a variety of group modalities. It addresses basic issues facing the neophyte therapist, including structural as-pects of the group, problematic member behaviors, and useful interventions that maximize member engagement and increase overall therapeutic effectiveness.

Much has been written describing the use of group therapy in inpatient and partial hospital programs (Emer, 2004; Klein, 1977; Radcliffe, Hajek, & Carson, 2010; Rice & Rutan, 1987; Ya-lom, 1983; Yalom & Lesczc, 2005), as well as specific kinds of group work in these settings (Beutel et al., 2006; Burlingame et al., 2007; Didonna, 2009; Druck, 1978; Gunn, 1978; Maxmen, 1978; Spielman, 1975; Springer & Silk, 1996). Attention has also been given to the paucity of training in group skills that is in-creasingly the norm for group leaders in hospital settings (Burl-ingame et al., 2007; Fuhriman & Burlingame, 2001; Nicholas & Klein, 2000; Weinstein & Rossini, 1998; Yalom & Lesczc, 2005).

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Sadly, the training deficit is not helped by the fact that in the past ten years, several otherwise excellent texts designed to train neo-phyte group therapists lack coverage of groups in such settings (Brandler & Roman, 2012; Corey, 2012; Corey, Corey, & Corey, 2010; Kleinberg, 2012; Motherwell & Shay, 2005; Rutan, Stone, & Shay, 2007). Moreover, little has been written specifically to pro-vide guidance to the group therapy supervisor who works with today’s trainees in inpatient and partial hospital programs.

Many of the basic principles that will be spelled out in this paper have been well documented in excellent generic texts on group therapy spanning more than three decades, beginning with early works by Yalom (1975), Rutan and Stone (1984), and Vannicelli (1992), as well as in specific texts on inpatient group therapy (cited above). The ideas are familiar to seasoned thera-pists—so much so that they are often taken for granted and over-looked when supervising the beginning therapist. The purpose of this paper is to organize the essentials in a succinct and us-able fashion, adding whenever possible language that may guide young therapists in knowing what to say when (and why) in order to provide a beginning repertoire of effective responses to situa-tions that they are likely to encounter.

cHallENgEs FaciNg tHE suPErVisor

The supervisor who trains beginning group therapists in these settings faces a number of challenges in terms of the trainees’ past experiences, as well as the nature and quality of the clini-cal setting. Some trainees may have led therapeutic groups in the past, but without training or supervision, their experiences merely reinforce ineffectual interventions that have now become habitual. Others come for training with no prior experience leading therapeutic groups, their knowledge of group leadership coming solely from watching the group leaders they are most familiar with—teachers and parents. In either case, much of the trainees’ “knowledge” is likely to run counter to effective leader-ship in therapeutic groups. The supervisor’s job is to help the student undo old learning and replace it with strategies that are more clinically useful. Jerome Gans (personal communication, 1998) put it well, stating, “Not all that comes naturally is useful

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and not all that is useful comes naturally.” The supervisor of be-ginning group leaders should take nothing for granted and make no assumptions about what the trainees would “naturally” know to do.

It is equally important that the supervisor take nothing for granted about the clinical setting in which each supervisee is working, or the ways in which that setting supports effective group work. Increasingly, as funds for mental health care shrink and caseloads become overwhelming in inpatient and partial hos-pital settings, “doing groups” seems like a good solution. Unfor-tunately, as Yalom and Lesczc (2005) point out, administrators who set up group programs often know very little about groups or what it takes to makes them therapeutic; they may know only that groups are a cost-effective way of managing care when there are too many patients and too few staff. Basic parameters that the supervisor might well take for granted are often ignored, such as enough chairs for all group members, the ability to sit in a way that provides members and leaders visual access to one anoth-er, the ability to control sound and heat, and time and physical boundaries that are respected.

Even in programs which require that members participate in all groups, the groups themselves may be so fluid that patients can enter any time, without notifying leaders that they will be late, or leave any time—also without notice—to meet with doc-tors or caseworkers (the latter often entering freely to pull pa-tients out). Looking in on such groups, one could easily get the impression that they have been set up primarily as a “holding area” where patients wait for other things that might potentially be important. Often, little attention is given to what will actually happen in the groups, and little preparation or training is given to new leaders other than watching another leader who may be equally unprepared and untrained.

In addition, in many settings there is considerable concern about potential dangers in groups—the notion that groups are scary places, where, unless things are tightly controlled, bad things can happen. As such, safety concerns and “containment” often take on disproportionate importance, reflected in strong messages to trainees about not doing anything to “trigger” pa-tients. This often amounts to encouraging therapists to avoid the

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topics that may be most important for patients to talk openly about, such as sex, drugs, and thoughts about self-harm—clini-cal constraints that would rarely be imposed on an individual, couples, or family therapists, no matter how green.

The goal of this paper is to provide a guide for supervisors to assist the beginning group therapist in providing group struc-ture, helping group members to interact, and applying simple moves to further group process. It details clinical interventions that make groups therapeutic, regardless of whether they are interpersonal process groups, psychoeducational groups, discus-sion groups, community meetings, opening and closing groups (often referred to as check-in and check-out groups), or skills-based groups, including DBT and CBT. Basic essentials are out-lined that do not require knowledge of clients’ histories or the particular issues that bring them to treatment and are equally applicable to groups of any duration, from one-shot discussion groups to long-term therapy groups, and to both fixed member-ship and revolving membership groups.

Basic structural issuEs

It is important at the outset to attend to the following basic struc-tural issues.

the group room

The physical set-up of the room in which the group is to take place is an important topic to discuss with the trainee. Often what has been provided is inadequate—not enough chairs, poor lighting, distracting noise, chairs set around a huge rectangular table where members have difficulty seeing one another. Leaders should be encouraged to consider ways of modifying such im-pediments, for example moving a table out of the way or discuss-ing with hospital administrators the possibility of other modifica-tions in the physical space allocated for groups.

Trainees should be encouraged, whenever possible, to arrange chairs in a circle so that group members have maximum visual access to one another, with leaders, if co-led, sitting opposite one another. They should also be reminded of the importance of al-


lowing time before the group starts each week to prepare the room for maximal utility.

Leaders should also let patients know what time they should enter the group room, and when the door will be open and closed as a way of signaling the physical and time boundaries of the group.

Protecting the Boundaries of the group

It is important to help new leaders understand the utility of a boundaried space for making the group safe enough for patients to do meaningful therapeutic work. If leaders are in a setting where patients are routinely called out of group to meet with psychiatrists or case managers, group leaders should be encour-aged to talk to other members of the team about protecting the group boundaries as much as possible. At times this may mean only that the group will be informed about comings and goings, with group leaders announcing in advance if a patient will need to leave the group early or will be entering late because of an ap-pointment with a staff member. Even doing as little as providing these announcements will help signal the importance of main-taining the integrity of the group.

clear group Purpose

Leaders should have a clear sense of the purpose of their group. Without clarity on the part of the leaders, members have no idea what to expect or why they have been put into a room together. (Is it to get them out of the way or to give them something to keep busy?) It is important that the leaders clearly transmit specif-ic goals at the beginning of each group. Sadly, in many inpatient and partial hospital settings, the structure of the group consists of little more than a poorly conceived questionnaire tossed at group members at the start of the meeting, with the instruction to write out answers that will then be shared. It is not uncommon for the writing to take up most of the group time and the sharing to consist solely of members reading aloud what they have writ-ten one by one.

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clear Map of Each session

Group leaders should also have in mind a clear “map” of each ses-sion—how it will begin, what the session is to look like, and how it will end. For example, the beginning might involve announce-ments of who may be late or may have to leave early, introduc-tion of new members, as well as a statement of the purpose of the group and how time will be spent during the session. At the end, there might be reflections by group members about what has transpired and how well it has gone, or perhaps a brief re-view and summary by the leaders. In addition, if group members are attending their last meeting, this should at least be acknowl-edged.

division of leader tasks

When co-leaders are working together, it is useful for them to think in advance about what functions and interventions each of them will handle—who will begin the group and state the pur-pose; if there is a specific task, who will introduce it; if there is to be a midway check-in about how things are going or whether the direction in which the group is moving seems useful, who will do this; and who will be responsible for ending the group. (Further discussion about effective co-leadership and managing co-leader conflict can be found in Vannicelli, 1992 and 2006.)

HElPiNg tHE traiNEE WitH oNgoiNg sKill dEVEloPMENt

The supervisor will also need to help new leaders metabolize specific interventions that may be useful in a variety of group contexts, independent of the specific content of the group. The beginning group leader needs to have a toolbox of useful interventions that are applicable across a wide range of group situations—ways to enhance member engagement, increase inter-action among members, attend to group process, deal with prob-lem behaviors, and create a psychodynamic orientation. These are outlined in the material that follows.


Enhancing Member Engagement

Encourage free flow of discussion. Encouraging the free flow of discussion involves welcoming, but not requiring, participation by all members, and avoiding circular “go-rounds” where group members must talk in turn and where everyone is required to speak. Instead, the group leader should be encouraged to invite group members to speak by saying, for example, “What reactions do you have to the handout you just completed (to the film we just showed, to the community issues that have been raised, etc.)?” After the first person speaks, the leader can encourage further in-teraction by saying, “What other reactions are there?” The leader should also invite those who have not spoken by noting, “Some folks have not yet had an opportunity to speak,” or by saying, “We have not yet heard from some of you.” Those who have not spoken up might also be asked, “For those of you who have not yet spoken up, I’m wondering what may be making it difficult.”

avoid rote “check-ins.” Often in day and evening treatment set-tings, each group member going around the circle in turn is ex-pected to “report” on what has happened since the last meeting. Though circular participation is easier on the leader, it tends to interfere with group members interacting with one another. Even worse, many patients pay no attention, anxiously rehearsing what they will say as they await their turn. Such check-ins are frequently done to guarantee material for a note in each individual’s chart.

There are, however, better alternatives. For example, global questions can be asked of the group such as, “Since our last meet-ing, I’m wondering what people have done that feels as if it is moving them closer to the goals they have set for themselves.” Or, “I’m wondering how things have gone for group members since our meeting yesterday.” Then, when some people have vol-unteered but others have not, leaders can ask, “For those of you who have not yet spoken, I’m wondering whether what’s been said so far pretty much covers the territory for you as well, or whether there are some additional things that we have not yet heard about.”

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The leader can then use as part of his clinical note for the silent patient the general themes discussed in the group. The leader might write, for example, “Bill, like others in the group, seems to feel that overall he was doing a bit better, despite lingering disap-pointment about the ways life still seemed untenable.” Notes on individual patients can also include whether they were actively engaged, and if so, whether this was verbal or non-verbal, and whether they stayed for the whole session. Often trainees think that it is only the content of what is discussed that is important, when in fact the process may be even more so—that is, whether the patient was engaged, argumentative, or reluctant, and what his mood and attitude were like in the group.

add life to “check-out groups.” Check-out groups, at the end of the day, are often equally dry, serving relatively little clinical pur-pose. Like check-in groups, their primary function is to provide material for a requisite clinical note. Generally, this involves ask-ing each person to say what she got out of that day’s experience—a question that is often less than productive, as an honest answer for many patients would likely be, “not much.” Instead, group members might be asked, “Who has some conviction about some-thing proactive that they have done or still plan to do today?” or, “Who has a wish for something they might do, but little convic-tion about their ability to do so?” If there are some members who have not responded, a third question might be whether there are “some folks who are feeling so low that they are having a hard time even coming up with a goal.” This might be followed by a brief summary of the various places members are at psychologi-cally and group members’ thoughts and reactions to this. These questions can also be useful for check-in groups.

For longer groups, the initial material gathered might be used as fodder for further group discussion, with questions such as, “What makes for the conviction, lack of conviction, or total dis-couragement?” or, “What is the difference between those who feel they have some conviction and those who don’t?” Such ques-tions will hopefully help those with conviction to also empathize with those who lack it, bringing hope that change may be pos-sible even for those who are currently feeling discouraged.

In check-out or “closing groups,” it is useful to give patients a place to talk about discouragement, skepticism, and ambivalence,


as well as positive experiences that occurred during the day. In one partial hospital setting, the trainee was told that a requisite for each group member’s discharge at the end of the day was to come up with something positive to say about the day’s expe-rience. Unfortunately, pressure to give a “rosy” comment even when a patient feels awful—something that is often encouraged by novice group leaders—leads to a lack of authenticity, the an-tithesis of good group process.

Make handouts and worksheets relevant and use them effectively. Handouts can be beneficial in providing structure when they are thoughtfully used. Group members, having been told the pur-pose of the group, should also be given some idea of how the handout fits with that purpose. Such use of handouts is quite different from the all-too-common scenario in which the group leader flies into the room to distribute handouts, saying, “Fill these out and then we will talk about them.” Insecure new group leaders may have members spend considerable time writing out detailed responses and then ask all members to read verbatim what they have written. This produces an extremely dry group in which there is room for little interaction among members.

Rather than this deadening approach, it is more useful to pro-vide “bullet points” for patients to “think about.” After taking a few minutes to do this, group members can then be asked to pick one or two items that they find “especially hard,” “especially in-teresting,” or “especially relevant to your situation.” Having done this, they can then be encouraged to talk about the thoughts and feelings that came up as they looked over the handout.

It is useful for the trainee to practice ways of acknowledging patient responses with comments such as, “That does seem hard, and I suspect that one might be hard for others, as well.” Or, “Your sense about what is hard sounds similar to the reaction that Bob had to that item,” thus, bridging the connection between two individuals. Or, “Yes, and I’m wondering who else might have also found that one hard (or interesting)?” Then, to mem-bers who have not spoken up, the leader might say, “I noticed that a few folks have not yet joined in, and wonder if others have already raised the issues that you would have addressed. Is that so?”

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increasing interaction among Members

Skills for creating group interaction among members are essen-tial to any group, even if it is largely educational or skills based, in order to create a group experience that feels personally relevant to participants and in which they have the valuable experience of human connection so critical for effective therapeutic work. Often group members, unschooled about what is to take place in a therapeutic group, respond as if they were in a classroom—di-recting all responses to the leader and interacting minimally with one another. The novice leader may inadvertently reinforce this by responding herself to each comment that is made. Instead, what is needed are simple strategies for helping group members to interact with one another, including the following:

Creating connections among members. Fostering connection in the group occurs initially by helping members join with one another around shared experiences and feelings. This kind of bonding can be facilitated by the leader’s active effort to make links when-ever possible between members by underscoring similarities. This occurs with simple leader interventions such as, “It sounds like what Bill is saying is similar in some ways to what Mary is talk-ing about.” Or, “What’s it like to have heard something similar from Mary?” (It is important that leaders avoid the word “same,” as it takes away individuality and may create a diversion, as indi-viduality along with connection is a universal need.) Another way to underscore similarities is to say, “My guess is that others also know something about that.”

Helping group members build on what others are saying. If members seem to address their comments mostly to the leader, it is fair to assume that they do not understand the importance in a thera-peutic group for members to interact with one another. Because the novice group leader may also not fully understand this, the supervisor should help the trainee to begin shaping expectations for a different kind of group behavior. Thus, he may suggest that the trainee intervene by saying something like, “There may be a notion in this group that members are supposed to talk only to the leader, rather than to one another. I wonder where that idea might have come from?” Then adding, “How do you think things might be different in here if people felt they could actively


respond to what others were sharing?” The leader is thus active-ly educating/coaching group members through his questions, thereby helping to shape effective group behavior.

Other comments useful in promoting group interaction might be the following, “I’ve had the sense that group members have gotten the idea that people should speak, in turn, directly to the leader. I have a hunch this comes from years of experience in the classroom. But in here we are trying to do something different by providing an opportunity to actively engage with one another. I will encourage you when you forget, to try to speak directly with one another.” Or, when somebody is directing a response to the leader, he or she might say, “I wonder, Bob, how it might feel, if instead of addressing me, you spoke directly to other members of the group?” And, “I also wonder for others how it would feel if there were more direct exchanges among you as we process things that are going on in response to our exercises?” Alterna-tively, the leader might say, “I wonder what it would be like for you, Bob, to direct that response to Mary?”

Making the speaker the spokesperson for others in the group. This is especially useful when a group member is taking the risk of say-ing something negative about the leader, the task, or how things are being run in the group, or is raising a taboo feeling about himself. In such situations, the leader might say, “Jane, I have a hunch that you may be speaking for others as well as yourself.” This helps the person who has taken the risk of expressing some-thing difficult to feel that she is not alone and also that the leader is able to hear her and does not judge her harshly for what she has said. As a follow-up, the leader might ask, “Who else may have had feelings or reactions that were similar in some ways to Jane’s?”

Making a person a spokesperson, however, should never be used to garner group support against a fellow group member—likely to be experienced by the latter as the leader goading the group to gang up against her. For example, if Bob says, “I find Jane’s way of putting me down incredibly annoying,” the group leader would be ill advised to say, “I think you may be speaking for others as well as yourself.”

Fostering interpersonal reflections. Interaction among group members can also be fostered by helping them to reflect on their

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own reactions as others are sharing their personal experiences, or working things out with one another. Simple questions get to this, such as: a) “Would it be useful to hear others’ reactions to what you were sharing”; b) “What was it like for you, Bob, to hear Martha’s reactions”; c) “What was it like for others in here as Martha and Dale where trying to work things out”; and d) “What were people experiencing as Mary was talking to me so directly about her disappointment with the way I’m running the group?”

Paying attention to group Process

Tracking changes in the group climate. General process interven-tions track the emotional climate of what is currently going on in the room and can be quite simple and content free. They may be as simple as asking, “What just happened?”—which might be asked when there has been a shift in topic or emotional tone, an interruption, a side conversation, or multiple people suddenly talking at once. Alternatively, the leader might ask, “How are things going right now?” or, if things seem to be stuck in some way, “What makes it hard to continue?” or “What’s happening in the room right now?”

Dealing with silence. Silence is an important behavior, not a problem to be avoided. Too often the beginning group leader is terrified of silence and fills it promptly, often with material of relatively little use. Instead, it is useful to honor silence as a behavior that can be informative about important reactions and feelings that are alive in the group. The group leader can find out about this by asking a number of simple questions, such as: (a) “What is going on for people during the silence?”; (b) “What is the silence like for people?”; (c) “What kind of silence is this?”—there are sad silences, empty silences, bored silences, and angry, withholding silences; (d) “What do you make of the silence?”; or (e) “I notice a change in energy in here in the past few minutes—perhaps it would be helpful to understand more about it.” Other ways of “tickling” the silence would be to ask questions such as: “What makes it hard to speak right now?” or, “What is getting in the way of people’s feeling that they can talk?”

It is important for the beginning leader to learn to tolerate si-lences, not indefinitely, but to allow room for them. I discourage


leaders from waiting so long to speak that their anxiety mounts to a point where they can barely think. My personal signal is to interrupt the silence when I feel myself getting uncomfortable in a specific physiological way—for example, when I begin to feel that I’m about to swallow. Just before that happens is the time for me to intervene and to find my voice, while I still can. (See Van-nicelli, 1992, for a fuller discussion of the meaning of silence and ways to effectively intervene.)

dealing with Problem Behaviors

There are a number of problematic member behaviors that, while challenging to the novice group leader, can be managed with relatively simple interventions detailed by Yalom and Lesczc (2005) and Vannicelli (1992). In addition, effective interventions for problem behaviors unique to dual diagnosis patients are de-scribed in Vannicelli (2012, 2014). Three of the most common problem behaviors arising in groups in inpatient and partial hos-pital settings are the following:

Dealing with excessive advice giving. Advice giving is often em-powering for the adviser, at times useful for the advisee, and it can also help to build a supportive group. However, advice giving can also feel patronizing to the one receiving the advice, especially if it is not solicited, or if the group ends up putting somebody in the “identified patient” role with all others being the healthy “teachers.” Often group members feel far more con-nected to those who share painful experiences that relate to those of the speaker than they do to advice givers who have presumably resolved the issue and are no longer in the same boat.

When the value of advice seems questionable to the leader, he can intervene by saying, “It seems that the group is really eager to help Bill. Lots of good solutions have been forthcoming. I’m wondering, Bill, if it would be useful to get further suggestions and advice or, if you would find it even more useful at this point, to hear about some of the experiences that others in the room have had that are similar to yours and have served as the basis for their advice.” (See Vannicelli, 1992, for a fuller discussion of the functions served by advice giving and ways to effectively intervene.)

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Dealing with the group (or group member) who is “off task”. Group members get off task for a variety of reasons. It may be a defen-sive, protective reaction to material that is too “hot,” or it may have to do with the level of functioning of group members and/or their lack of understanding about what is supposed to tran-spire in the group. It is important for the group leader to deci-pher which of these is going on in order to make appropriate interventions.

If the group is responding defensively to anxiety that is being generated, the leader may simply ask the group to reflect on this. Take, for example, a group that is now talking about the Red Sox when a few minutes earlier they were talking about losses that had considerable emotional impact. The leader can ask, “What does the group understand about the discussion at hand, and how might that relate to what group members were talking about a few minutes earlier?” The leader is thus helping the group to pay attention to its process and the ways that members may be taking care of themselves. The goal of the intervention is to foster reflective observation without criticizing or requiring the group to change course, although the discussion that follows may pro-vide an opportunity to return to the topic that the group was fleeing.

More difficult are groups in which members are off task be-cause they are cognitively impaired and need to be contained. For example, patients with dementia or in psychotic or pre-psychotic states may respond tangentially to whatever is happening in the group. Such patients, if not contained, siphon energy off the group and create a sense of hopelessness about whether anything meaningful can happen. With such patients, it may be useful in the group session itself to contract to limit their interactions so that they (and others) will be able to get more out of the group. Thus, the leader might say something like, “Mary, I have a sense that you are very much wanting to be with us today and are strug-gling to find a way to do that. I’d like to help you to find a way to be here that will be more useful to you. For today, I’d like to ask that you be with us by listening very carefully, and only listening. Can you agree to that?” The leader is thus making a contract with the group member for a different kind of participation that will


help him to remain in the group. If the patient declines (gener-ally that will not be the case), the leader might say, “In that case, perhaps today is not such a good day for you to be with us; we will look forward to seeing you tomorrow.” That individual is then, at least temporarily, being helped out of the group.

In my experience, however, most patients who are given a con-tract understand the commitment they have made. Though they may slip up one or two more times, each time it happens, the leader reminds her, “Mary, we had an agreement.” It should be noted that although such interventions are more frequent in in-patient settings and in settings with chronic mentally ill patients, they need to be mastered by all group therapists because a pa-tient can be compromised in almost any group due to aging ef-fects, trauma, drugs, or other events that may temporarily or per-manently leave him impaired.

Dealing with sequential soliloquies. Patients who speak one after another with no apparent connection between what one person and the other is saying may suffer from a lack of understanding of what is supposed to happen in a therapeutic group. For example, some patients may be used to self-help groups, which specifically eschew “crosstalk.” What they have learned in AA meetings is that one person speaks, then another, and so forth. Since interac-tion is not a desired part of the process, unconnected discourse may not seem problematic to them.

The job of the effective group leader, through the questions he asks, is to help shape appropriate behavior so group members understand more about what is supposed to happen. Thus, when Bill has commented in an irrelevant way after Bob has spoken, the leader might say, “Bill, I haven’t understood the connection between what you’ve just shared and what Bob had said.” To this Bill might respond, “There is no connection.” The leader in turn might then say, “I have a hunch that people would feel better about their experience here, and more connected with one an-other, if you do try to respond in some way to what the person before you has been talking about. And, if you want to change the subject, you let the group know that you have been in a different place and have something else that you’d like to contribute.”

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creating a “Psychodynamic” orientation

In addition to enhancing interaction among members, in groups that are predominantly process oriented, the leader’s job is to help group members understand something about the ways in which old templates from the past are being carried forward in the present. The psychodynamic orientation provides an oppor-tunity for each group member to come to understand something about “who I am and how I have come to be this way.” The leader fosters this kind of reflective position by asking relatively simple questions such as, “Is that familiar for you?” or, “In what way is this familiar?” Sometimes patients respond to the “familiarity question” by saying, “Yes, what is happening in the group right now (or what is happening with my boss) also happens with my husband.” To this response, the leader who wishes to go back farther into history might say, “Yes, and I was also thinking about something even older than that.” This pulls for the past, and hopefully material from one’s family of origin. I might say in ad-dition, “I was thinking of something even older—perhaps stuff that you knew before growing up, or stuff that played itself out in your family of origin.” (See Vannicelli, 1992, for a fuller discus-sion of the ways in which important aspects of a member’s in-teractions with others outside the group are replayed within the group itself, providing a lively forum for learning about oneself.)

There is of course more to a psychodynamic orientation, in-cluding more sophisticated connections to the past that may make unconscious aspects of behavior more conscious, and moves that focus more specifically on transference. However, these moves are not likely to be in the territory of the beginning group leader and will be addressed later in one’s training and supervision.

coNclusioN

The supervisor can help the new group leader attend to structur-al aspects of the group as well as useful interventions that maxi-mize member engagement and increase the overall therapeutic effectiveness of groups in inpatient and partial hospital settings.


This process involves active guidance, not only discussing the questions and issues that the trainee brings in, but also questions and structure that the supervisor imposes on the supervision. Thus, it is often useful to ask the new leader who is doing a psy-cho-educational or other structured group what he plans to do for the next week. It is also useful to get a report after each group meeting about how things went—the general tone of the group, the level of engagement of the clients, and what interventions the leader tried that went well and not so well. In addition, the trainee should be encouraged to talk about situations that came up in the group that he was not sure how to handle, or potentially difficult situations that he anticipates facing in the future.

It is also important that the supervisor help the group trainee recognize inadequate interventions of co-leaders, even if they are full-fledged staff members. Through no fault of their own, many staff members who lead groups in hospital settings have had little or no training and have minimal skill. Even in major teaching hospitals where documentation of training is required to obtain specific clinical privileges for individual therapy, couples ther-apy, and family therapy, privileges for group therapy are often dispensed with—adding weight to the misguided assumption that “anyone can lead a group.”

Finally, even though there will be structural limitations that trainees will be unable to change because of constraints imposed by the clinical setting, it is important that the supervisor help them to understand what good practices look like and the ways in which the current setting may fall short. Although not ideal, learning by observing what not to do can mitigate some of the negative aspects of a difficult group training setting. In the end, with the help of good supervision, today’s group trainees are tomorrow’s hope for improved group programs in hospital set-tings.

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rEFErENcEs

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Supervising the Beginning Group Leader in Inpatient and Partial Hospital Settings

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