This article provides an interesting perspective on how clinicians and researchers can assess the process of change in group psychotherapy and take initial steps to explore the question: Is there value in incorporating the views of close friends or family when assessing client or group member improvement?
Hewitt, P., Qiu, T., Flynn, C., Flett, G., Wiebe, S., Tasca, G., & Mikail, S. (2019). Dynamic-relational group treatment for perfectionism: Informant ratings of patient change. Psychotherapy, Advance online publication. http://dx.doi.org/10.1037/pst0000229.
The authors developed a 10-session group psychotherapy model for perfectionism, defined as a personality vulnerability factor associated with a concern and drive to be perfect, i.e., a predisposition to evaluate one’s own life, and sometimes others’ lives, by expectations that are never satisfied no matter what the accomplishment; feelings of failure inevitably ensue as these impossible standards are not met. The treatment approach combines components of interpersonal and psychodynamic theory and aims to address perfectionism-related relational patterns that arise within and between group members. In prior articles, the authors demonstrated a clinically significant decrease in self-reported perfectionistic tendencies, depression, social anxiety, and interpersonal problems for a significant proportion of participants both at the end of the intervention and four months later. There were some participants (11 of 61), however, who experienced a worsening of symptoms on at least one perfection subscale (e.g., the self-oriented perfectionism subscale of the Multidimensional Perfectionism Scale, which measures the demands a person places on oneself to be perfect). The authors argue that using self-report measures alone to assess treatment outcomes may be insufficient given perfectionism is considered a personality vulnerability factor with a relational component.
In this study, the authors present the results of perfectionism questionnaires administered to close family members or friends (informants) about participants who completed the group treatment. Consistent with the earlier self-report findings, informants observed that the participants made significant improvements by the end of the intervention that were maintained four months post-treatment.
These findings hold several implications for practice. First, the results offer additional support for a time-limited dynamic-relational group therapy for perfectionism although the fact that some participants experienced symptom worsening underscores the need for monitoring each individual patient’s response to treatment to ensure therapeutic progress. Second and most interestingly, this study offers an additional perspective on how clinicians might gauge change in psychotherapy by assessing the views of a close other in the patient’s life. Though not an uncommon practice in child and adolescent psychotherapy (i.e., parent report measures), it is relatively rare in adult psychotherapy. The views of informants may offer additional credibility to treatment progress (or lack thereof), may help build social support around treatment, and may provide critical information the patient may omit (e.g., safety concerns).
White fragility refers to the psychological and emotional manifestations of White racial socialization, which typically entails such defensive expressions as anger or denial in conversations about race and racism (DiAngelo, 2011; 2018). While this construct has received increasing attention in the popular literature, it has only rarely been formally studied within psychotherapeutic contexts.
Kivlighan, D. M. III, Drinane, J. M., Tao, K. W., Owen, J., & Liu, W. M. (2019). The detrimental effect of fragile groups: Examining the role of cultural comfort for group therapy members of color. Journal of Counseling Psychology, 66(6), 763-770. http://dx.doi.org/10.1037/cou0000352
Given the prevalence of racially heterogenous therapy groups and guided by White fragility theory, Kivlighan and colleagues (2019) explored the differential impact of members’ perceptions of their group’s cultural comfort for members of color and White members. Results were consistent with their hypotheses. When members of color perceived the White members of their group as responding with fragility (i.e., low cultural comfort), they experienced less group cohesion and less therapeutic improvement than their White counterparts. Simply put, the group’s comfort in discussing issues of culture and diversity significantly impacted perceived group cohesion and improvement for the members of color in the group, but White participants were relatively unaffected.
This is not the first study to highlight the importance of culture in group therapy, but it does provide important insights into cultural processes that may be relevant to the experiences of diverse group members. Clinically, these findings highlight the importance for group leaders to be cognizant of ways members engage in conversations of culture and diversity and aim to enhance the ease and comfort of this discourse.
One useful framework for this work is the Multicultural Orientation (MCO) framework with its three core constructs of cultural opportunities, cultural humility, and cultural comfort (Owen, Tao, Leach, & Rodolfa, 2011; Kivlighan & Chapman, 2018). Group facilitators’ ability to seize opportunities to discuss cultural issues and support members in engaging in authentic and nondefensive discussions are central to members’ growth. Ideally, members will begin to broach these cultural conversations on their own without prompting, but it may be helpful for facilitators to model these processes in early stages of group development. It is also important to acknowledge how the group might be recapitulating broader social dynamics and that discussions around certain topics (e.g., racism) take a strong commitment.
References
DiAngelo, R. (2011). White fragility. The International Journal of Critical Pedagogy, 3(3). 54-70.
DiAngelo, R. (2018). White Fragility: Why It's So Hard for White People to Talk About Racism. Beacon Press.
Owen, J. J., Tao, K., Leach, M. M., & Rodolfa, E. (2011). Clients' perceptions of their psychotherapists' multicultural orientation. Psychotherapy, 48(3), 274-282.
Kivlighan III, D. M., & Chapman, N. A. (2018). Extending the multicultural orientation (MCO) framework to group psychotherapy: A clinical illustration. Psychotherapy, 55(1), 39-44.