This question-and-answer column appears regularly in NSGPeople and addresses complex dilemmas in group therapy. Featured are case vignettes presented by NSGP members, with responses by senior clinicians. If you have a question you would like considered for this column, please submit a case vignette of 400 words or less to Natasha Khoury, M.ED., M.A., LMHC through the NSGP office, or via email to natasha.nsgp@gmail.com. Please remember to preserve the confidentiality of any group members described.
Dear Analyze This,
Is starting a group with three members ever a good idea? Or am I setting myself, as well as my group, up for false hope and ultimate disappointment?
I began my first Internet-only group one month ago Friday. My plan had been to hold back, this time, until I recruited at least four members. Although I had, in the past, what I would consider a successful, but time limited “micro group” (my term for three or less), I had more instances, in which I learned to associate the number 3 with the letters E.N.D. Here again, though, that familiar voice from within pounding, “use it or lose it” won the day! It had taken me months to gather, assess, and ready this trio and I feared that if I waited any longer for new members I could kiss a-group-at-all goodbye.
The members’ names (fictitious), are Michelle, a dependent 29 year-old single woman, librarian, adopted at birth, who lives with her non-biological parents and is agoraphobic; Brad, a dependent 26 year-old bi-gender, part-time musician, also living with parents, with an extensive history of depression and anxiety; and Gary, a 32 year-old straight single male, full-time computer technician, living independently, who has never dated and has been in individual treatment for six years for depression and social phobia.
All three express a wish to feel accepted, calm, and valued in the company of others, to experience intimacy in relationships, and to become, at last, unstuck from the emotional quicksand of shame, isolation, and fear. They look around and see others, even younger, on their own, in relationships, earning a living—in essence, launched (or seemingly so).
The one thing I can say so far is that sparks are flying and it’s only meeting #5. One member pushed through their (3rd person pronoun) inner debris to express directly and honestly a fear that I was too old and out of touch to make it safe; another, moved by the moment, broke open his guilt at having a history of homophobic rage and aggression, and the third, cowering during the fray in a recess of her mind spoke finally of the terror yet intrigue observing herself sitting through conflict for the unimaginable length of 40 minutes.
How sweet is this, really. But will three hold? Was there some way to have stacked this short deck to last?
- Easy as 1-2-3?
Dear Easy as 1-2-3,
Thanks for your lively and clear description. Your dilemma is not uncommon. And the challenges you and your group face raise important issues I’m pleased to discuss.
First, I want to acknowledge that between when you wrote to the newsletter and when this answer will be printed, weeks (and probably many group meetings) have passed. I am sure that your group is in a different place now than when you wrote. However, since I have no follow-up information, I’m writing this response as if you and I were talking together right after Meeting #5. I hope what I say will still be useful to you!
Let me say a word about my own clinical experience with “micro groups.” I don’t think I’ve ever started a group with only three members, although I’ve certainly been tempted. My reason for wanting to was exactly why you decided to start this one: the fear that the window of opportunity would close. I’d add that the three members you do have sound like people who can benefit greatly from being in a therapy group, which may have intensified your wish to get started.
You pose two questions at the end of your letter. The first is, “But will three hold?” I’d paraphrase this question as, “What will happen to this group in the future?” Your second question is, “Was there some way to have stacked this short deck to last?”This could be loosely paraphrased as, “What would have happened if I’d done something different in the past?”
In general, I feel questions about the future and the past are less useful to clinicians than questions about the present. Predicting the future is difficult, especially about something as complicated as a psychotherapy group. And questions about the past can sometimes be even harder. As the writer C.S. Lewis wrote, the one question we can never answer is, “What would have happened if...?”
The most helpful questions to focus on in our work are usually about the present. I’d invite you to consider these two:
What is happening in the group right now?
What can I do as a leader to be helpful to the group in its current struggles?
What is happening in the group now? I think your group has arrived on schedule at Tuckman’s second stage, Storming. Members have navigated the first stage, Forming, and they are feeling scared that things will get deeper and harder in the group. So they are attacking the leader, sharing inflammatory feelings, and in other ways testing to make sure it is safe to do the important work they came to do. As you know, this is a necessary and difficult stage in the life of every successful group. The great challenge for the leader of a group that is Storming is to balance members’ needs to express their fears (in the complicated ways they need to express them) with their needs for cohesion and safety. This brings us to my Question #2, about what you can do to help a group that is Storming. I think there are a number of actions worth considering that may help the group find a workable balance. Here is a short list:
--Whenever possible, direct your interpretations and reflections to the group as a whole. This implicitly reassures people that no matter how hard they are struggling, you still think of the group as an intact entity. Leaders’ comments like, “This group is really working hard,” tend to help.
--Consider teaching them, if they don’t know it already, that what is happening is a healthy, crucial stage of group development.
--Invite the silent member in--she may be holding feelings of fear for other group members. If this fear can be verbalized, it could activate everyone’s nurturing feelings towards each other.
--Place the group’s current struggle in the larger context of members’ individual challenges. Each of them joined the group out of a wish to connect. You can congratulate them (without sarcasm) on connecting with each other so powerfully, and observe that they are all learning the profound lesson that human connection poses challenges of its own. Once members have gotten better at coping with the challenges of connecting, they will be much less likely to feel alone.
Finally, I’d like to return to your original question about micro groups. I encourage you to keep looking for new members, since three is very small. And at this stage of group development, I’d be judicious about whom I’d invite to join the group. I’d avoid taking someone into the group right now who is deeply unstable, as it could further rock the boat.
All the best,
Adam Silk, M.D., CGP
Dear Easy as 1-2-3,
First of all, good for you for starting a group! And the sparks are already flying!
The number of people with which to start a new group has long been discussed and debated. In normal times, which these are obviously not, I typically encourage leaders to start with four or more members and have a decent referral stream for potential new members. There is no guarantee that each new referral will be appropriate for the group. Furthermore, despite our best screening practices, there is no way to accurately predict who will stay in a group. Sometimes the ones you think are solid, leave, and the ones you think are a risk surprise you.
As you astutely reveal, as soon as you decide to start a new group, the leader feels pressure to actually deliver a “group.” If you start with a small group and it shrinks, are you holding up your end of the agreement in providing group therapy? This risk may be more real if the dyad (or even single member) continues for an undefined amount of time due to a lack of appropriate referrals. I had this happen once and it seemed to generate anxiety about whether the group would last (in both the members and myself).
In thinking about your question, I cannot ignore that these are not normal times. Covid-19 has changed everything about the way we practice. It has changed how we might market a new group to colleagues and other agencies. We are no longer able to hold our groups in person so that members can have a felt sense of connection. In today’s reality of quarantine and social isolation, is three members a group? I would say, a resounding YES!
In starting a group, you don’t want to make them wait too long. The risk of losing potential new members this way is real. It sounds like you listened to your inner group leader and knew if you did not start this new group now, you might not have a group to start. A small online group might be a more comfortable way to enter a group for members who struggle with social anxiety and isolation. Also, a small group can have a special kind of intimacy. I have had group members mourn the loss of a particular period of time when the group was small. Of course, there is much to explore there, but I believe there can be value in the small group.
The information they are giving you so far seems like a “green light.” Of course they have doubts and fears about your leadership and the safety of the group, but they feel safe enough to express them. Some are revealing their guilt, shame and anxiety, peeking from around the borders of their Zoom squares to test if this is a “place” they will be seen and accepted if they reveal these aspects of themselves. The pandemic has made it more urgent than ever before to connect people who are isolated and struggle with social anxiety. Covid-19 has stagnated social and emotional development, especially for young people. This group, be it small, may help reduce their shame and isolation and give them a place to continue to grow and change, despite the limitations the pandemic has imposed on them.
For leaders, starting a new group means taking the risk that it won’t “hold.” I have found freedom in accepting the possibility that it could all fall apart. Once I let go of my own anxiety about whether a group would last, I was able to be more present with the group that was showing up. Even if all three decide to leave, they may be more likely to join another group in the future or make more connections with people in their lives. Sometimes being able to freely leave a group is the healing a member needs.
I would advise you to continue advertising amongst your colleagues and other connections for suitable new members, but keep in mind licensure laws that prevent us from seeing people in states we are not licensed. Describe the type of member that would be a good fit for this group. Prepare the group to welcome new members. I have come to trust that even our greatest blunders are experiences from which we can learn. Running groups in a pandemic is new for all of us and you started a new group in the middle of these desperate times. I say, good work!
