How to Prepare Clients for Groups
Exploration of Resistance, Education, Reassurance
Louis Ormont’s article The Preparation of Patients for Group Psycho-Analysis* offers 3 approaches to introducing clients to group therapy.
Here are some tidbits gleaned from the article and an exploration of how all three of these approaches, education, reassurance and resistance exploration, can be used and interwoven to prepare a client for group therapy.
Ormont emphasizes using all three approaches to prepare a client for group therapy. The article highlights the value of exploring the client’s resistances to joining a group. When a client’s concerns are taken seriously, explored and not immediately solved or reassured the result can be a feeling of acceptance, respect and being heard.
When a client’s concerns are taken seriously, explored and not immediately solved or reassured the result can be a feeling of acceptance, respect and being heard.
The emphasis is on exploration not resolution. Focusing too much on resolving resistance increases the pressure to change and may give the client the feeling they should be feeling something else. If you start to feel like you have to convince or sell a client into joining a group slow down. Acknowledge they're experience and show interest in what they are feeling and thinking.
Exploring a client’s resistance to joining a group eases tension.
The article quotes another writer as diagnosing a client’s resistances to joining a group as “neurotic distortions,” the reality is that joining a group can be scary. Walking into a room or zooming onto an online meeting to explore your emotional world, relationship problems or eating disorder with a group of strangers is inherently full of risks. Acknowledge these risks, normalize caution and explore whatever concerns arise about joining a group if you want to cultivate trust.
Walking into a room or zooming onto an online meeting to explore your emotional world with a group of strangers is inherently full of risks.
Explicitly naming the risks upfront is a form of education, exploring the client’s specific reasons for not joining is addressing their resistances.
Exploring the resistance to joining a group is a doorway into the client’s relational history. Expressing curiosity about why someone would not like do something encourages them to speak their mind, establishes an atmosphere of inclusivity and acceptance. Explicitly and implicitly I work to communicate anything they say is worth being explored. Everyone feels safer if they know whatever they say will be considered. Exploring each individual’s resistances helps establish healthy rapport between the client and therapist.
Exploring the resistance to joining a group is a doorway into the client’s relational history.
Resistances are specific to the client, although clients may share similar resistances. Education is general, It provides information about the group structure and norms. Ormont’s article recommends a minimal amount of education when preparing clients for entering a group. Another way to word this is to keep it general, simple and consistent. Ormont’s perspective is that the less a client knows about what happens in group the less likely they will be performative. Ormont states “The more the patient enters the group free intellectual preconceptions, the freer from role-playing will be his activity.” Yet some structure about what to expect helps titrate the uncertainty of entering into a new community. In general less structure leads to more regression and too much structure can also lead to regression and/or rebellion. How can you give the new group member enough information to feel like they have sense of what to expect but not so much to tell them how to behave?
How can you give the new group member enough information to feel like they have sense of what to expect but not so much to tell them how to behave?
I require at least one individual session for clients interested in my groups so that I can get to know them, they can get a feel for how I work and what to expect in the group, they can tell me things that they might not be ready to bring up in the group and they can ask me anything.
When I am onboarding a client for my therapy groups along with reviewing basic group structure and norms, like time, place, cost, confidentiality and purpose. I make a point to suggest and address the following, that they could start off observing, ask if they prefer to be drawn in or speak up when they feel like it, inform them that if something happens in group they do not feel comfortable addressing in the group, they can contact me outside of the group, “I am always available for a 5-10 minute phone call if anything comes up in group and you leave having a lot feelings.”
I specifically address urges to quit and the preferred protocol around quitting the group. State that the preference is to talk about leaving before acting on it. I tell clients that often everyone at some point feels the urge to leave and if they are willing to explore that urge it can be very helpful even if they end up deciding to leave. I reassure them that I will always help them do what they want to do, but would like the opportunity to explore it first, ideally in the group, but at the very least one on one. This acknowledges the client can leave whenever they like, and that builds safety.
Ormont’s basic directions for new group members is “Talk about your troubles, complaints and dreams.” Educating the client on basic group structure, protocol and the general experience of being in the group can be reassuring. Too much education can limit the experience and lead to performative behavior.
Too much education can limit the experience and lead to performative behavior.
Some reassurance helps clients. Too much reassurance can back fire. At its worse reassurance cultivates a dependent relationship. Tracking client communication is important when providing reassurances. Are you reassuring the client or your self? Are you assuming something will cause anxiety or is the client actually communicating they feel anxious. I suggest explicitly checking it out with a client by asking if they have any concerns and then exploring those concerns before choosing to reassure.
One way to reassure that Ormont names is that: “The patient is informed that he can feel free to talk about what he wants, when he wants, the way he wants.” The benefit of such a statement is that it emphasizes autonomy which the opposite of what a cult does. Invite a client to participate, don’t make it a demand.
Invite a client to participate, don’t make it a demand.
Exploring a client’s resistances to joining a group can result in reassuring a client that you want to understand, see their predicament and are going address their concerns. When a client expresses a resistance it is reassuring when the therapist listens, reflects and validates what the client is experiencing.
As mentioned above normalizing the fears around joining a group strangers is helpful and naming the benefits of groups can balance out the concerns. Group members that have been in my groups tell me the biggest benefit for them is learning to tolerate the ebb and flow of groups, both the comings and goings of group members and the ups and downs of emotions. When conflict arises in the group the experience of witnessing the working thru the feelings of a group as a whole is very reassuring.
Conclusions
General education about the basic form of the group, protocol and expectations can be followed by exploring the clients specific desires, needs and concerns about joining a group.
Exploring the client’s resistances, their expectations and desires builds rapport, communicates acceptance and gives the therapist information about the client that can be used in the group, along with giving the client the feeling they are being seen and heard.
Reassurance is best woven in rather than addressed proactively. For example after providing some education it can be good to ask “Hows that sound?” or “Do you have any concerns?” In contrast to assuming the client is nervous or anxious. Pacing reassurance to the moments in which resistance is detected builds rapport and takes on a rhythm with each individual client that hopefully provides an example for the tone for the group.
The process and tone of how you describe the group and explore a clients feelings about joining the group can be more reassuring than what you actually say.
*Reference info. For Ormont Article: Ormont, L. R. (1957). "The Preparation of Patients for Group Psycho-Analysis." American Journal of Psychotherapy, 11(4), 841–848.