Psychotherapy Leaders: Dr. Molyn Leszcz on Group Therapy, Part 2 of 2

Dr. Leszcz is a world-renowned expert in group psychotherapy and an extraordinary leader in Canadian psychiatry. He is a Distinguished Fellow of the American Group psychotherapy Association among other prestigious recognitions. Amongst his many publications, Dr. Molyn Leszcz co-authored with Dr. Irvin Yalom the revised and updated 5th edition of The Theory and Practice of Group Psychotherapy (Basic Books), the incomparable guide to group therapy. In March of this year, Dr. Leszcz and his colleagues: Drs. Clare Pain, Jon Hunter, Robert Maunder and Paula Ravitz (also editor with Robert Maunder) published the book Achieving Psychotherapy Effectiveness in the “Psychotherapy Essentials To Go” series (W. W. Norton & Company).

We are extremely grateful to Dr. Leszcz for taking the time to talk to us about group psychotherapy for this series.

(Continued from Part 1)

PsychotherapyMatters.com (PM):
Thank you so much. You’ve described with great clarity the challenge of what a psychotherapist “must do” and what he or she “must be” in order to be effective in a group therapy setting. The group psychotherapist has to adapt the structure, process, and content of the group to maximize therapeutic value for each member of the group. You mentioned already some adaptations of group psychotherapy. Could you now dive into the topic of group psychotherapy adaptations to specific patient populations?

Dr. Molyn Leszcz (ML):
I think that it is wise to talk about the psychotherapies and the group psychotherapies, rather than thinking about group therapy as a single modality. As I mentioned earlier, a group on an inpatient unit, with acutely ill patients seeking relief, in a composition that changes every day, and a group of young women with genetic predisposition to breast cancer, are going to be very different.

The fundamental principle that I think is wise to follow is this: identify the clinical population, identify the clinical need, try to shape the group psychotherapy to meet those clinical needs and adapt to the logistical challenges of providing group therapy in that environment. Modify the model that you are using so that it fits within those parameters and then apply the intervention, study it, measure it, report on it, and try to improve on it.

We have used that approach in constructing models for group psychotherapies for patients on our inpatient unit, patients on a geriatric unit with depression, women with metastatic breast cancer, women with genetic predisposition to cancer, first episode psychosis, patients with personality disorders, and patients with co-morbid/concurrent depression and substance abuse. I’m pleased that we were able to publish on all those areas over time, demonstrating effectiveness of treatment and the ways in which treatment needed to be modified.

PM:
Can you give us an example?

ML:
Group therapy for women with metastatic breast cancer focuses enormously on creating an environment of support, and focuses on helping people cope. Anything that helps people cope is for the good. In traditional group psychotherapy, we don’t encourage extra-group contact because we want the work of therapy to occur within the session. But in our group psychotherapy for women with metastatic breast cancer, we actively encourage them to form a community, a network, outside of the group to support one another, in their homes, and in the hospital.

Unfortunately, many women die of metastatic breast cancer. Not infrequently, their co-group members would not only attend the funeral, but on occasion, speak a eulogy. The boundaries in that kind of group would be very different from the boundaries we would employ in a group intervention for people with depression and substance abuse, where we would be more concerned and focused on ensuring boundaries were well maintained, and there was not any acting out that was going on outside the group.

PM:
I see that so far in this interview you have alluded to the importance of evidence-based practice more than once. Can you elaborate further on evidence-based group psychotherapy?

ML:
One of the other areas that I am interested in with regard to group psychotherapy is helping people to practice in an evidence-based fashion. I work very closely with colleagues in the American Group Psychotherapy Association. We published several years ago a large document entitled “Clinical Practice Guidelines for the Practice of Group Psychotherapy.” This is a widely cited, widely used document that helps people to understand and employ the best evidence about effectiveness in the various domains and dimensions of group psychotherapy. The document describes how to set up a group psychotherapy program; how to select patients; how to prepare patients; how to deal with challenges; ethics and expectations of leaders; how to maximize the use of therapeutic factors; so on and so forth.

Group psychotherapy is very effective but there are things that we can do to make it more effective. There are also things that if we don’t do, or if we do incorrectly, will make therapy not only ineffective, but potentially damaging. So as a field we have to hold ourselves accountable on that front.

PM:
What about the selection of patients for group psychotherapy, what is the current evidence on particular characteristics that would make someone most likely to benefit from certain modalities of group psychotherapies?

ML:
Well, it depends on how you are structuring the group and what the goals of therapy are. This relates to my earlier comments about finding the population, identify the goals, and modify the structure. People who would benefit from one modality of group might be contraindicated in another kind of group. The identifying characteristic that might block you from being suitable for one group might make you very suitable for another kind of a group.  So selection is tied to the question of whether people can do the work of the group; whether they can develop a therapeutic alliance; or whether we can re-structure the group so we can offset their inability to form a therapeutic alliance.  For example, we provide highly structured groups on the inpatient unit, where each group session is an entire chapter in and of itself. In this setting, one need not worry about the fact that the composition of the group is going to be different from one group to the next.

Let me give you another example, women with breast cancer, you would think “well that’s a pretty homogeneous population.” In fact, it is not because women with primary breast cancer have very good prognoses, and so have different issues than women with metastatic breast cancer, by virtue of the fact that their illness is likely going to be fatal. When we were doing our metastatic breast cancer research, we found that there were women who would come into our research trial eager to be part of this group because they had gone to other groups, and had felt that they were ostracized. They felt that they scared the other members of the group because they had a much worse prognosis. So that is an example of the kind of nuance with regard to selection.

If I had to answer that question is in a brief way, I would say: selection is about whether the person can make use of the group; whether they have the psychological wherewithal to benefit from the group; whether they have the logistical wherewithal to make use of the group; and whether group structure can offset whatever limitations they may have in regard to that.

PM:
Thank you for your explanations. Let’s switch gears now and talk about the practice of group psychotherapy in Ontario and Canada as a whole. As a leader and authority in the practice of psychotherapy, how would you describe the practice currently?

ML:
In Ontario, I think that group psychotherapy is not being practiced as widely in private practice as I think it should. I think its home is much more in organizations, institutions, agencies, and hospitals, which is very good because group therapy is an efficient and effective form of treatment. I think that you would see in every hospital, in every organization, and in every community agency, different kinds of groups. My concern sometimes is that people lead groups without fully appreciating the power of the group. It’s important to, in every instance, practice in a way that is evidence-based.

The history of group psychotherapy in Canada is quite significant. There have been many leaders in the field based in Canada, holding very prominent international roles. Some of the best research in group psychotherapy has emerged from the work of people like Dr. William (Bill) Piper, Dr. Anthony (Tony) Joyce and Dr. John Ogrodniczuk. Dr. John Salvendy, who is based in Toronto, and does some very important work in culture and group therapy. Before her untimely passing, Dr. Fern Cramer-Azima did some very important work in adolescent group psychotherapy. And of course, I’m obviously very proud of my own work in the field.

PM:
We are grateful for your contributions and those of your colleagues to the field of group psychotherapy. For this next question I want to highlight a quote from the 5th edition of the Theory and Practice of Group Psychotherapy: “The intimacy developed in a group may be seen as a counterforce in a technologically-driven culture that, in all ways—socially, professionally, residentially, recreationally—inexorably dehumanizes relationships.” For residents in remote rural regions of Northern Ontario, social isolation is the norm of everyday life and internet technology is thought to connect—humanize—rather than dehumanize. Is it at all possible to adapt group therapy, put in into a virtual environment, to accommodate people living in far remote regions of Northern Ontario? Has it been done?

ML:
Absolutely, and I appreciate that quote, but I would probably rewrite that now. I would say that quote captures the truth but doesn’t capture the complete or whole truth, in that more and more, we are using the internet as a forum to create group psychotherapy opportunities and to deliver group psychotherapy opportunities. We do both through a kind of technological platform that allows people to meet at a set time in a video conference link, or to interact in an asynchronous fashion, where group members can post their thoughts, and others can comment, creating a dialogue within a community. These things have been shown to be very effective for people in remote communities, for people who may have physical or psychological barriers to leaving their home or other psychological barriers to engagement. There are situations where people feel marginalized or stigmatized and are more willing to make a foray toward engagement based upon a certain kind of anonymity that an internet-based group provides. This wasn’t the case before.

So as I said I stand by that quote but I would add to it now.

PM:
It sounds to me from everything you’ve said today, that group therapy is quite versatile and adaptable as a psychotherapeutic treatment modality. Its power is only limited by the knowledge, skill, integrity, imagination of the group psychotherapy provider, and by technological resource availability.

At the Canadian Psychiatric Association’s annual conference this year, I listened to talks by psychiatrists, like Dr. Paul Kurdyak and Dr. Elliot Goldner, who are interested in the problem of access to mental health services in Ontario and in Canada. A particularly interesting symposium on this topic was the one organized by Dr. Susan Abbey entitled “Psychiatry 3.0: Reinventing Psychiatry to Solve the Problem of Access.” I want to also refer more specifically to the talk by Dr. Jonathan Downar entitled “Toward a New Generation of Treatment for Mental Health.” He asked “Is there a way to do psychiatry so that everyone can get some?”

One of the solutions envisioned in his talk is using a psychiatrist-lead hierarchical model of group psychotherapy, in which the psychiatrist supervises a number of psychotherapist providers. Only when patients do not do well in a less intensive therapy group in the periphery, are they moved gradually to more intensive groups higher up the hierarchy. At the top of the hierarchy are limited intensive groups provided by the psychiatrist. Ultimately, if the patient also fails more intensive groups, they would go to individual psychotherapy. Because group therapy is efficient and effective and allows multiple individuals to be treated simultaneously, it is a way to solve the problem of access to therapists’ time and skill. What do you think about this?

ML:
I think that group therapy can play a very important role in the issue of access because of the factors you have cited. I think that the more that we are able to use the kind of stepped approach, the better. A lot of people might get a less intensive treatment, may be psychoeducation or bibliotherapy. Then we might go up the pyramid, where a smaller number of people get something more intensive, and an even smaller number get more intensive therapy yet. I think this could be a part of how we can address some of the issues of access and trying to fit the patients’ need to the treatment.

I think that there are instances where we can predict early on that someone is going to need something more intensive. We can often predict that certain people are not going to be making use of the group unless they are also in individual psychotherapy. That’s not uncommon at all. And the more we are able to predict these outcomes early, then the greater will be our ability to save people time and pain and to move them to the right spot on that pyramid, at the beginning, rather than after several months or years of less effective treatment.

PM:
Thank you Dr. Leszcz, this is our last question, tell us about your latest publication Achieving Psychotherapy Effectiveness and what else are you currently working on?

ML:
Along with my co-authors we have created an accessible guide for front line practitioners that synthesizes the key evidence based aspects of effective psychotherapy. The book comes with captioned DVDs that illustrate the link between theory and practice in simulated sessions. There are also self-reflective questions and it has a work book style.

My main work right now is focused on my administrative leadership roles around improving access, flow and equity. So I’ve been working on projects of improving access to care in our emergency rooms, and flow across the health care network. That’s part of my administrative responsibility.

I am part of a smaller project looking at the relationship between supervision and alliance. We are trying to look at the relationship between the supervisory experiences of our trainees and the therapeutic alliance experience of our patients with our trainees. I’m looking forward to having more time to focus on group psychotherapy research as some of these administrative responsibilities recede.

PM:
Thank you, Dr. Leszcz for this interview. It was a pleasure and an honour, a great honour in fact, to have had the opportunity to speak to you.

Vicky P.K.H. Nguyen
Vicky P.K.H. Nguyen

Vicky is a psychiatry resident at the Northern Ontario School of Medicine (NOSM). She completed her PhD and MD training at the University of Toronto. Her research interests are directed at promoting innovative practices and policies to address sub-optimal wait times, access, equity, and quality of health care services for disadvantaged populations in Ontario. She is certified to provide IPT and CBT. She is trained to provide other types of therapy including DBT, and Psychodynamic Psychotherapy.

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