Psychoeducational Group Therapy Changes The Face Of Managed Care
Robert M. Siegmann, MSW, MBA and Patty Bower, BSW, LSW
Originally published in Journal of Practical Psychiatry and Behavioral Health
In this article, the authors describe an innovative psychoeducational group therapy model first developed for use in an economically disadvantaged rural clinic. This new system enabled the clinic to serve many more clients, improve patient satisfaction, and dramatically increase revenues. The model is based on a combination of psychoeducation and group therapy delivered in the format of group classes. The authors discuss materials and skills needed to set up such a program and how to deal with confidentiality problems, referral sources, publicity, and community education. Most importantly, they explain how such a system can increase efficiency and improve the outcome of therapy in a managed care setting where costs must be contained.
KEY WORDS: psychoeducation, group therapy, managed care, rural health care
It takes people to make people sick and it takes people to make them well again.
Though their presenting problems vary, a considerable portion of hospitalized patients have decompensated as a result of some interpersonal crisis, often a real or threatened loss of a key interpersonal relationship. Furthermore, the great majority of patients are bedeviled by chronic interpersonal problems
Quinco's Board of Directors challenged its management team to introduce a service delivery system that would circumvent rationing of care, particularly to those citizens who had little or no money and thus no choices about where they sought services, i.e., our social mission clients. Our response to that charge was to develop a service philosophy that emphasizes consumer responsiveness (i.e., no waiting lists), consumer accessibility (i.e., multiple specialized offices out where the people are), and consumer acceptability (i.e., medical office and business office analogs).
We decided to introduce a new paradigm for clinical services, a brief therapy group model emphasizing psychoeducation. We focused our planning for this model in those offices that exist to serve all clients regardless of ability to pay (i.e., our social mission offices). Our plan was to prevent rationing of our psychoeducational group services, to increase client volume, and to improve cash flow in the process. We succeeded beyond our highest hopes.
We piloted our psychoeducational group model in our Jennings County office. (Jennings County was the setting for Jessamyn West's books The Friendly Persuasion and Except for Me and Thee.) This clinic was staffed with one full-time and several part-time clinicians and, because it was in one of our poorest counties, required more than $50,000 a year in subsidies to remain open.
In the years since we began the psychoeducational model in Jennings County, we have tripled the value of services billed, quadrupled our collected revenues, and have an overall customer satisfaction rating of almost 99%!
Community response to our changed format has been overwhelming. As a result of new contracts and requests for service, we have hired more full-time clinicians. We have destigmatized mental health services in this small, rural community and have expanded our psychoeducational format to other social mission offices. This new service model includes both process and psychoeducational groups and recognition of managed care philosophy.
Freuds patients lived in a structured and mechanistic world ... [and] did not lack social connectedness ... In therapy what was needed was a sacred and private place within which to explore the feelings and wishes that society prohibited. Typically, the situation is reversed today. Individualism is so dominant that social connections are not formed or, if formed, soon unravel ... The pathologies of the modern era are primarily difficulties in gaining and tolerating authentic intimacy (i.e., modern mankind's fragmented ability to relate) ... Group therapy seems to be a natural antidote to the predominant disorder of our age. 1
Group therapy has been a clinically accepted modality since World War II, with benefits documented by many authors. In fact, group treatments have been shown to be more effective than no treatment, placebo treatments, and, in some circumstances, other psychological treatments.2
Yalom was the first to present a comprehensive formulation of the beneficial factors of group therapy. He identified the important curative factors as the installation of hope, understanding that one is not alone (universality), developing social skills, learning to express feelings (catharsis), challenging maladaptive patterns (corrective reexperiencing of the primary family group), existential concerns, receiving feedback from others, imitating effective behaviors, learning to help others (altruism), reducing isolation and developing a sense of belonging (cohesion), interpersonal learning, and imparting information (education).3 Research on these curative factors has identified catharsis, insight, interpersonal learning, and cohesion as particularly useful in group therapy.1 However, additional research has supported Yaloms contention that the importance of specific curative factors shifts over the lifetime of the group and that particular factors are seen as most therapeutic depending on the type of group or client and the developmental stage of the group.2
Joseph Pratt, MD, an internist at Massachusetts General Hospital, is widely credited as the founder of group psychotherapy. Interestingly, his approach was primarily educational in nature. In 1905, he established a group of 15 tuberculosis patients. The format was to educate patients about their illness and to encourage discussion about their common problems in a small group setting. Pratt reported very positive results. 1
Since then, engaging clients in specific knowledge development and skill-building techniques has been accepted protocol in a variety of areas. For instance, a primary facet of treatment for many physical illnesses (e.g., diabetes) is teaching patients skills necessary to maintain compliance with their treatment regimen. This has been a longstanding strategy for patients in chemical dependency programs who are taught about the nature of their dependency and trained in skills needed to maintain sobriety. With the deinstitutionalization of mentally ill or mentally retarded patients, the emphasis of intervention has been to teach daily living skills in order to increase patients level of independence and allow them to live and work in their own communities instead of state hospitals.
Patients with psychiatric disorders generally benefit from learning about the causes and nature of their illnesses and about behaviors and patterns that may help to alleviate their symptoms. Persons lacking certain skills (e.g., how to parent, how to control anger, how to cope with stress) benefit from skill-building activities. Virtually all clinicians, except for the most nondirective, teach through the therapy process. However, they tend to use private tutorials rather than a group format and their teaching is typically not done in a formalized or consistent fashion, posing problems for replication and research.
Research on group therapy has shown it to be an effective mode of treatment.4 Structured group therapy has been effective in treating depression5 and eating disorders.4 Structured groups have been shown to be superior to unstructured groups for divorce adjustment, agoraphobia, psychiatric inpatients, incarcerated felons, and problem solving. Regardless of group composition, it appears that structured groups typically produce greater change than unstructured groups, especially in a brief format.6 Although research has not yet definitively identified the particular agents of change in group psychotherapy (i.e., the ideal group composition for which clients suffering from what type of psychopathology), both structured and unstructured groups are becoming more prevalent and, increasingly, the preferred mode of treatment.
APPLICATION OF PSYCHOEDUCATIONAL GROUP THERAPY TO MANAGED CARE
We believe that this model is a more than credible response to managed care, a primary goal (if not the primary goal) of which is to better conserve scarce resources. Managed care companies have tended to focus only on reducing the length of the individual therapy process. While this is clearly a useful strategy in reducing costs, it is by no means the only or the most effective approach. Group therapy can be offered for well below half the cost of individual therapy. A single therapist can see four to eight people during a given time period instead of one person. For the same expenditure, a client can be seen for 20 group sessions instead of five to eight individual sessions. For most patients, group therapy is at least as effective as, if not more effective than, individual therapy.
Research in the chemical dependency field shows that treatment over a longer period of time is more effective in promoting sobriety than highly intensive treatment for a brief period.7 This may also hold true in general outpatient populations. By purchasing a longer course of group therapy for the same price as a brief series of individual sessions, the effectiveness of treatment may well be improved.
Why hasnt the managed care industry encouraged more use of group therapy? Perhaps the industry is merely reflecting back what they see in our field, telling clinicians to practice as we conventionally practice (individual therapy), only to do it more briefly and cheaply. As clinicians, it behooves us to encourage the managed care entities to understand the benefits of a model that uses psychoeducational group therapy in addition to individual brief therapy.
A bachelors level social worker and a psychologist took considerable initiative in designing this new delivery model. Both had group therapy experience and understood the marketing and financial dilemmas facing their office. They were given certain financial parameters and the subsequent freedom to create a clinic predominantly based on a psychoeducational group therapy model. As part of this project, they developed a small library of psychoeducational literature, including useful audiovisual materials. Our clinicians experimented with the menu of offerings, comparative ratios of structured psychoeducation to process therapy groups, and comparative use of time-limited versus open-ended groups. The result was an amalgamation of those factors. Approximately 15 to 18 groups per week are offered in both time-limited and open-ended formats (see the Appendix for a sample menu of the groups offered). Three distinct varieties of group styles evolved (the percentage of groups offered in that style is shown in parentheses):
This highly structured format consists of providing problem-focused or skill-building education in one- or two-hour time-limited groups. There is opportunity for discussion of the presented material but there is very little true processing of personal issues. There are several occasions when psychoeducation is sufficient to meet consumer needs. For example, at the courts request, four of our offices provide a 90-minute divorce education program called Children First! in which parents are taught the potential effects of divorce on their children. This is a one-time requirement for parents who are divorcing and have children under the age of 18. A second reason for pure psychoeducation groups is that there are clients for whom group therapy does not work. For instance, there are people who are unable to maintain confidentiality for a variety of reasons; there are clients who are clearly in need of treatment but continue to engage in antisocial behaviors; and there are clients who are unmotivated to participate in treatment, such as forced referrals by courts or other government entities. Our approach with noncompliant clients is to limit the number of available sessions, have shorter meeting times (e.g., one hour), expand educational and skillbuilding content, and eliminate the process component. For example, our One-to-Grow-On psychoeducation series consists of education and exercises aimed at enhancing clients basic coping skills in order to improve their personal effectiveness and instill a positive sense of self-efficacy.
Process Group Therapy
At the other end of the spectrum is process group therapy. Since group therapy has been written about and practiced extensively, there is no need to describe it here any further. In one of our clinics where we serve a predominantly sophisticated clientele, we use process groups extensively because we believe that this form of treatment has clear benefits over a traditional individual model. Even if the psychoeducation aspect of the model we are describing is not adopted, most clinics and their patients would benefit by substantially increasing the number of process groups.
Composite Psychoeducation and Process Groups
The majority of clients are treated in composite groups where the first portion of the session is devoted to education and the second half is more traditional process therapy. The therapist provides information about a topic and then facilitates interactive discussion about how this pertains to the clients problems. Composite groups are moderately structured with a predetermined theme for each session, yet the therapist individualizes material for the group members during the subsequent discussion.
These groups are usually ongoing with open entry and exit, a concept Yalom describes in his book Inpatient Group Psychotherapy. Inpatient units by necessity operate groups with open entry and exit. We have adopted this concept in the outpatient arena. For example, in a 10-session curriculum for depression, we allow new clients to enter at any session. We try to shape the curriculum so that a given session is understandable and valuable whether or not the client attended previous sessions. Clients may also continue to rotate through the full curriculum of the group more than once. We have found that clients benefit from going through the same curriculum for a second or even third rotation, since they are sometimes so distressed that their comprehension level is minimal the first time. During a second rotation, they not only understand the material better, but also find that they can successfully implement some of the knowledge and skills they learn.
Changing the Whole Service Delivery System
In starting our clinic model, we followed a practice used by Irvin Yalom. In 1966, he started nine new groups at his clinic within a period of 8 weeks by administratively closing off the option of individualized treatment and routing all patients to group therapy. These patients reported satisfaction levels equal to those carefully selected and referred to group therapy.9 We similarly made group therapy the principal treatment option, with patients not given the choice of receiving individual therapy unless it was a clinical necessity. Much as occurred with Yaloms clinic, our groups filled rapidly. Our experience with instituting this model in other clinics in our own facility, as well as in other centers, is that, when clinicians and administrators adopt the model wholeheartedly, patients and referral agents find it attractive.
ROLES AND GUIDELINES
Developing Psychoeducational Materials
In this model, we focused on high-incidence, treatable diagnoses and on high-risk issues (e.g., depression, family conflict, attention-deficit/hyperactivity disorder). For each group, we decided on the essential information that clients should know about the cause and nature of the given illness or problem area. Based on available research, we selected the skills and behaviors that would be beneficial for clients to learn. Materials were organized by group topic in stand-alone modules. We tried to keep the language and concepts simple and remove jargon, because most clients in a rural area simply dont understand the language that therapists use. In delivering information, we use a multimedia approach (entertainment), blending lecture, overheads, video, and written and oral exercises.
Preparing for the Teacher/Group Therapist Roles
Our most common kind of group involves teaching during the first half and process therapy during the second half. Discussion tends to follow the topic that has just been taught to the clients but focuses on their personal issues and how the new information can help their situation.
In the first half of the class, the facilitator takes the role of teacher, instructing the participants about the topic and about skills that are useful in coping with and alleviating the illness or problems. To create accurate expectations, the facilitator states at the beginning of each session that participants will not be dealing in depth with any of their personal problems during the first half of the session. However, there will be times when they will be asked to reveal examples from their own lives that relate to the course material, the purpose being to further elucidate a concept rather than to encourage discussion and personal revelation. The participants role during the first half of the session is to be students. Their task is both to absorb the information and to apply that material to their day-to-day life.
The second half of the class is a structured group therapy session and should be led by a person with adequate clinical training. At the beginning of this portion, the therapist should orient patients, especially new ones, on what to expect. The facilitators role shifts from teacher to active therapist who facilitates participants personal change by helping members request, receive, and provide feedback and focus on dealing with their problems and developing further strengths. Because the therapist has only 45 minutes to an hour to run a group therapy session with 6 to 12 patients, she or he should develop an impression of the patients problems and concerns and how the didactic information relates to their personal issues during the hour spent educating the clients. The participants role is more that of clients in group therapy who are expected to share problems and concerns and to discuss how they want to make corrective changes in their lives. Interaction between the members is very desirable, as is providing mutual support and empathy. It is therefore important that the therapist help clients develop good relationship skills (e.g., teach clients how to listen and support each other, how to receive and provide feedback, how to self-disclose, how to show good eye contact and speak in a fashion that is neither meek nor overpowering). Such interactions help people realize that they are valued human beings, that they are not flawed, and that they have the ability for mutual caring and respect.
It is important for the therapist to create a warm, accepting, supportive atmosphere for the patients, both by modeling this and by encouraging such behavior among group members. The therapist needs to help group members learn to feel comfortable giving feedback in a supportive and caring manner and to think in a more realistic and less negative fashion. Thus, the therapist needs to redirect the clients focus to areas that are more amenable to change while also emphasizing the positive aspects of their lives and their personal strengths, with the goals that the patients will ultimately be able to do this for one another and for themselves.
Even in the most carefully matched groups, clients may feel like they are not benefiting from or not suited to a particular group. Sometimes animosities or awkward relationships of which group leaders are unaware exist among members. For this reason, it is advisable to encourage clients to share with group leaders in private their discomforts concerning being in group therapy. Whenever such a problem occurs, it is recommended that the client be transferred to another group focusing on similar issues.
Many clinicians believe that groups are particularly hard to run in rural communities because of privacy and confidentiality issues. It may be harder for people to maintain secrecy because many of them know each other outside the treatment setting. Individuals who are unfamiliar with psychotherapy may have trouble distinguishing between therapy and socializing. Our clinicians therefore paid special attention to confidentiality in developing this model. They deal with confidentiality within the group by prescreening members to assess their ability to fully comprehend the concept of confidentiality, using a group rule list, continually reiterating the importance of confidentiality, and confronting and discussing breaches when they occur. At the outset of every new group, a packet of group rules is distributed to members and discussed. These rules not only stress confidentiality but also serve to educate group members concerning the purpose and operation of groups. Whenever a new member is added to a group, the groups rules are verbally reiterated and the importance of confidentiality is stressed again.
If the therapist becomes aware of a willful breach of confidentiality by a group member, it is necessary to confront the infraction in the group immediately. Typically, the importance of confidentiality is reiterated and the guilty party is warned that he or she will be removed from the group if there is a recurrence of such an event.
Confidentiality in the community is dealt with by creating multiple group alternatives, developing knowledge of the community and its residents, and not hesitating, to transfer someone when mistakes in placement are made. Within any community, there are individuals who should not be in groups together. In a small community, it is especially important to offer numerous alternatives so that individuals can be separated from persons they may feel uncomfortable relating to in a group. Examples of such relationships include enemies, ex-spouses, mistresses and ex-lovers, relatives, employers and employees, and sexual perpetrators and victims. To avoid problematic combinations of group members, it is ideal to have at least one therapist who is well acquainted with the community and its members. While this will not eliminate all potential problems, it significantly decreases the probability of group members having an outside relationship with each other.
Some individuals are unwilling to protect the confidentiality of themselves and others and are consequently inappropriate for inclusion in the usual psychotherapy group. Adolescents are particularly at risk of breaches in confidentiality because of the importance of social contact and communication in their daily lives.
CONSUMERISM AND PUBLICITY
Our offices sponsor a free community education seminar each month. It is advertised in the newspaper so that residents are aware of the activity whether they attend that particular seminar or not. In addition to conveying useful information, the seminars give community residents an opportunity to meet our therapists, see our facilities, and learn about our psychoeducational group offerings.
Our staff developed an informal survey to screen current and potential referral sources, to educate them about the value of psychoeducational groups, and to obtain feedback on desired and potential group offerings. The survey begins with a statement such as the following: We are improving our services by providing more skill-building and educational groups for our clients. People appear to profit a great deal from learning specific skills to help alleviate their problems when going through the therapy process. The benefits of psychoeducation are ... Some of the groups which we are developing include ..." We then ask why they refer people to counseling and if they believe skill-building groups and classes would be beneficial to the people they serve. We also ask what kind of groups they would they like us to offer in an effort to target their clientele and to be more consumer-responsive. The clinicians in our Jennings County office also developed a newsletter to facilitate regular communication with referral agents. Schedule changes, new group offerings, and public education seminars are noted in this newsletter.
Finally, we continually survey clients anonymously on their level of satisfaction with our services in order to help us improve our model.
At the Jennings County Clinic of Quinco Behavioral Health Systems, we successfully modified the service delivery system to offer 15 to 18 psychoeducational groups per week with only two therapists. This new model has been very well received by the clients we serve and beneficial to referral agents and the community. The following ten points exemplify our success.
CHOOSE PSYCHOEDUCATIONAL GROUPS? THE PATIENT, REFERRAL SOURCE, AND PROVIDER PERSPECTIVE
From the patient or consumer perspective, this model reduces the stigma of mental health service, helps to concretize and demystify the abstract, and offers the customer an opportunity to be "educated instead of "being in therapy."
For many potential patients, particularly in rural communities, the benefits of psychotherapy are quite difficult to comprehend. When we make the concept less obscure and demystify it by identifying skills or knowledge to be gained, potential patients and families more easily understand how mental health professionals can be of benefit to them. While persons in some suburban communities might openly discuss being in therapy and even wear it as a badge of honor, we find that most people in rural communities are embarrassed about needing to obtain mental health treatment. When our therapists began to refer to treatment groups as classes, they found that clients who had previously shied away from therapy were more comfortable with, and were even attracted to, classes. People in this rural community who would never admit to neighbors or bosses that they were in therapy seemed very comfortable saying that they were taking a class to develop a skill. To help with acceptance by clients, groups are often given appealing names, e.g., Healing the Wounded Heart, to assist women recovering from child abuse, or Escaping the Fool's Circle, for teens learning better methods for dealing with their anger.
Referral sources appreciate this model because of the specific skill and competence development and because the service is delivered in a consistent, replicable form.
Many referral sources are frustrated because it is difficult for them to explain to potential clients what the therapy process is or what they will gain from it. This model makes the referral procedure easier. Referral agents were pleased to know that a specific knowledge base and set of skills would be taught during treatment. We have found that referral sources want service delivered in a consistent, replicable format that is not clinician-dependent. Because clinician styles differ dramatically and we perform behind closed doors, it is beneficial to referral agents (as well as clients and service providers) if there is more consistency with particular types of diagnoses or problems, which is the whole emphasis behind practice protocols.
This model benefits the clinicians and providers by reducing waiting lists and scheduling difficulties, allowing for increased billings (productivity), making it easier to deal with multiproblem families, and offering meaningful service for low-pay or social mission clients.
Waiting lists are the bane of our profession. (If someone breaks a leg, our health care system does not schedule an appointment in three weeks.) We try to see every patient for evaluation within two to five days. We can offer rapid accessibility because, in the group therapy model, clinician time is not tied up with vast numbers of individual appointments. There are also fewer scheduling difficulties, since secretaries can simply reschedule a missed appointment for the next week. The flip side of accessibility for patients is saving clinician time and energy wasted by cancellations and no-shows.
Therapists today work with families who have increasingly severe problems. A group model takes some of the pressure off the individual therapist and can instill hope in therapists who are working with multiproblem families.
In many states, government funds have targeted chronically mentally ill adults and severely emotionally disturbed children. Large numbers of people with no means to pay full fees are also in need of and can benefit from treatment. This model allows a low-cost method to treat these adults and children.
We believe that psychoeducational group therapy is an excellent model for providing mental health services in rural areas. Obviously, starting a new model is never easy. It takes time, training, and effort for clinicians and managers to become comfortable with this new model and the new roles involved.
To successfully implement this model, the clinicians and the organization must make some changes. Regardless of orientation, most clinicians practice in an individual mode because it is their area of expertise and what they are most comfortable with. In this model of service delivery, clinicians need the training and ability to teach and to provide group therapy. Many clinicians have at least minimal experience teaching classes, and some have training in group psychotherapy. With additional training and supervision on, most clinicians can develop the skills needed for this format. Supervision and discussion groups can also help clinicians become more comfortable with this mode of treatment.
The organization must be willing to train and support its clinicians in this new model. Typically, systems inside or outside the organization reward individual therapy more than group therapy. This is a major obstacle. If reimbursement rates are extremely low for group compared to individual therapy, then individual therapy will be the preferred mode of treatment. If organizations dont give therapists ample credit for running groups, it is more challenging to change the delivery model. To effectively implement this service model, the organization needs to examine its values, its communication with third-party payers, and its style of support to clinicians.
1. Rutan, JS, Stone WN Psychodynamic Group Psychotherapy. 2nd Ed. New York: The Guilford Press
2. Bednar R, Kaul T. Experiential group research: Can the canon fire? In: Bergin A, Garfield S, eds. Handbook of psychotherapy and behavior change, 3rd Ed. New York; John Wiley; 631-63.
3. Yalom ID. The theory and practice of group psychotherapy. 3rd Ed. New York: Basic Books.
4. Bergin AE, Garfield SL, eds. Handbook of psychotherapy and behavior change. 3rd Ed. New York: John Wiley.
5. Lewinsohn PM, Antonuccio DO, Breckenridge JS, Teri L. The coping with depression course. Eugene, OR: Castlia Publishing.
6. Flowers JV, Booraem CD. A psychoeducational group for clients with heterogeneous problems: Process and outcome. Small Group Res 1991;22:258-73.
7. Ojehagen A, Skjaerris A, Berglund M. Prediction of posttreatment drinking outcome in a 2-year outpatient alcoholic treatment program. A follow-up study. Alcohol Clin Exp Res 1988;12:46-51.
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Specific Group Offerings
Certain groups (e.g., depression, anxiety reduction, child and teen groups) are run on a regular basis, whereas others (e.g., pain management, anger control groups) are run intermittently. Other offerings are made on an experimental basis, such as a group to help pregnant women learn pain and stress management techniques. The following is an example of our curriculum:
Focuses on depression and loss issues, including loss of health, employment, loved one, etc.
Up with Kids
For children, grades 1 through 6, with behavior difficulties at home or school. Focuses on peers, self-esteem, and socialization.
Opening the Door to Recovery
For women who have been in abusive relationships or have children who were abused. Issues addressed include rape, incest, molestation, victimization, healing, and recovery.
Attention Deficit Parenting
Psychoeducational group for parents of children with attention-deficit/hyperactivity disorder (ADHD). Issues include understanding ADHD, rules and limits for children with ADHD, and supportive parenting.
A women's educational and therapeutic support group focusing on assertiveness, depression, and self-esteem.
For adolescents, ages 13 to 18. Focuses on peer problems, family difficulties, school problems, relationships/social skills, improving behavior, and self-esteem.
For preschool children. Focuses on self-esteem, relationships, and stress.
Ongoing group for parents and adolescents. Addresses adolescent development, blended family issues, effective limit setting, and family relationships.
Offered periodically on an as-needed basis. Focuses on improving assertive parenting skills through effective limit setting, supporting, and coaching.
Supportive group for those with more chronic care issues. Focuses on issues of support, socialization, and maintenance. Some focus on skill building, such as meal planning and preparation.
Stress for Success
Teaches clients relaxation skills, such as breathing exercises, progressive relaxation, and other techniques.
Fit and Trim
Addresses the needs of overweight adolescents and their adult counterparts. Clients explore weight loss problems, learn about healthy eating styles, and develop healthy lifestyle changes including exercise.
Addresses the needs of new immigrants who are in transition to a new culture and new language.
Responding without Fury
Focuses on teaching social skills and specific exercises which allow the client to respond to family members, employers, etc. without rage or violence. Persons with active substance abuse are referred for addictions treatment first and persons with severe histories of violence are excluded.
Education for Families of the Mentally Ill
A six week program designed to help families understand and cope with chronic mental illness.
A group for adults over 65, providing specialized attention to the unique and psychological concerns of aging.
Additional Potential Groups