MUSINGS ON SPECIALIZATION: DEVELOPING A GROUP PSYCHOTHERAPY PRACTICE
Dr. Scott Simon Fehr
Email: human8@attglobal.net
Licensed Psychologist
Faculty Nova Southeastern University
Author: Introduction to Group Therapy: A Practical Guide and
Group Therapy in Independent Practice
June, 2000

Due to the fact that my practice over the past 23 years has been predominantly group psychotherapy, it is not uncommon for both students and colleagues to question me on how does one develop and begin to implement group psychotherapy in their beginning or ongoing practices. I certainly cannot speak for all practitioners but rather from my own personal experience and what I have done in the hope that one or two ideas may help a colleague develop his/her practice in the modality that I consider to be one of the finest psychotherapy paradigms in helping people resolve interpersonal conflictual relationships. 

Upon reflection, that might be the underlying feeling that patients and prospective patients experience when speaking with me about group therapy. I appear to encourage my future group members to feel confident and encouraged in making the step into becoming a group therapy member because I truly believe in this modality and consider it to be far superior to individual psychotherapy for the resolution of interpersonal problems. I genuinely speak of its benefits in a most positive and reverential manner because I was once a group therapy member for 6 years and I saw the tremendous positive effect it had on me.

I also feel it is vitally important that a clinician go into group therapy as a patient before beginning to implement group therapy into his or her practice. The general training of group psychotherapists, no matter how effective or efficient a professor(s) may be, is not sufficient to teach group dynamics in an academic setting nor is internship or practicum sites sufficient in creating truly effective group therapists. Only experience on "both sides of the desk" and life experience in general, in my personal opinion, creates a truly effective group therapist. Personal experience in group therapy and working through ones own interpersonal issues as a member, is perhaps the best route to go if you wish to truly learn about yourself and experience the process of group psychotherapy. There is an old psychoanalytic statement, which I completely believe, stating, "We can only take a patient as far as we ourselves have gone." In order for you to sell the process and you must sell the process, you too must wholeheartedly believe in it and one of the the best ways to do that is to experience it firsthand as a patient. 

Granted and accepted is the belief by many clinicians that there exists both positive and negative group experiences for a group member but that does not discount the effectiveness of learning as one can just as easily learn what not to do as to what to do. Their argument should also include that individual psychotherapy can include both positive and negative experiences but that does not seem to be the case when they give their opinions. There is also another opinion that really must be done away with and that is group therapy is a second rate modality which it is not. It provides a very timely increase of affect and offers the wonderful opportunity of multiple transferences occurring thus permitting the patient to work on a number of interpersonal difficulties at the same time. In individual psychotherapy, the therapist must become the virtual surrogate of all those problematic people from the past in order for the patient to resolve these multiple historical interpersonal conflicts. 

Unfortunately, often through time or economic constraints and due to perhaps the nature and skill of the individual psychotherapist, this does not occur and the patient leaves therapy with an incomplete opportunity to work through as many interpersonal issues as possible within a shorter period of time. Besides being a finer therapeutic advantage, this obviously is economically more feasible for the patient to have a longer therapeutic experience as it is less costly than individual psychotherapy and offers more to be gained for the patient who may or may not have insurance. With these obviously opinionated beliefs in my specialty, let us move toward the more practical issues at hand.

Psychotherapy is a business. It is the business of helping people. Those individuals who have a greater acumen in business will do better in generating income into their practices than those who find the concept of helping others and making a living mutually exclusive concepts. It is my belief that specialization is the direction to follow and group therapy is a specialization, which can have within it many other specializations. Being a "jack of all trades and master of none," is probably the best route to go in one's developing practice in order to generate income in the beginning of a career but to remain as such creates restrictions on the capacity of the business to obtain economic growth and results. 

The specialization of group psychotherapy offers a therapist a route to proceed in which to generate more income in a shorter period of time besides providing an arena for a patient's timely growth. For example, if we run an hour and a half group of 8 members and charge for example, a fee of $60.00 per patient, we have generated $480.00 in an hour and half time. Very few therapists make $480.00 in a 90-minute session seeing a patient in individual psychotherapy. So group therapy cannot only be a tremendous psychological paradigm and experience for the patient but too a wonderful income producer for one's private practice. It is also seen that patients who belong to psychotherapy groups generally come on a more consistent basis than patients in individual psychotherapy thus providing a greater sense of economic security for the practitioner. 

Interestingly, our profession seems to elicit in many new clinicians a terrible conflict between money and care. If you charge for your services that in some way you have muddied the purity of the psychotherapeutic relationship. If you feel your service is worth nothing than it is worth nothing and will be seen by the patient as worth nothing. Granted wanting to help out a struggling individual seek psychotherapy is a most honorable deed. We occasionally do this but if you cannot afford to do this and continue setting the tone of your private practice as if it was a clinic, you are probably indicating a lower self-esteemed issue in your own personality as its correlates to your self-worth. The issue of money and charging for one's services is an amazing and very important issue in this profession. I have never seen this in any other profession. For example, the plumber has no problem charging me when he comes to do work as does the lawn man and the electrician. The guy who gives me a massage has no problem charging $60.00 for the hour even though he has only had a year of massage school but new therapists and some seasoned therapists, who have spend thousands of dollars and invested years of time for their education, seem to have difficulty when it comes to charging for their services. 

The reality is we only have two things upon which we can charge and make a living: 
1) OUR KNOWLEDGE and 2) OUR TIME. The care we give is free as there cannot be placed a price on that commodity. We do not give a tangible product like a grocery store and if you feel your knowledge and your time is not worth anything of value then you will be having some salient problems in this profession unless you seek some sort of paid position. It truly doesn't matter how many lives you have saved that month. The utility companies that service your office aren't interested and if you can't pay your bills you will not have a roof over your head, electric, phone, etc. in which to practice your profession. Also, if you can't help yourself, how can you truly expect to help others help themselves?

In returning to psychology as a business, it must be remembered that your office itself does not generate any income but only debt, i.e., rent, electric, malpractice, phone etc. All revenues from one's office come from outside of the office in the form of patients, corporations, writing, etc. This indicates that the private practitioner must go outside of his or her office to generate income. What is meant by going outside of one's office is basically; you need to make yourself known in the community in which you practice. Foremost you must be cognizant of your community. Is psychotherapy a viable profession in the location of your choice? For example, it would be foolish to place a gourmet market in a lower socioeconomic environment, as it would be foolish to set up a practice in an area where there is a paucity of potential patients.

In my case, I chose to settle in an environment where the professions, i.e., doctors, lawyers, psychologists etc. are respected and used and I wanted people in my community to think Dr. Scott Simon Fehr when looking for a psychotherapist. But how does one make himself or herself known? Obviously, this comes about through interaction with the community in which the therapist lives. By interaction, I mean generously volunteering your time to give talks on all kinds of psychological issues to any organization that will listen, offer help on committees, write columns in the local newspaper, teach at an academic site, join community organizations, etc. It really is not any different if you live in Hollywood, Florida or New York City, New York as there is a community of individuals out there who will accept your offer to give of yourself for their benefit. No matter how proficient you may be as a clinician, if you are unknown the chances of your practice filling up is really quite unlikely unless you have a wonderful referral source and someone who is consistently looking out for your economic well being. 

It is very important to continuously remember that you are selling a product and that product is defined as group therapy. You are also selling yourself. As uncomfortable as that last sentence may seem and perhaps aversive, it is a reality. It is important that you give those community activities a positive experience not only of your profession but also of yourself. It is in your interest that when the people walk away from their experience of "you" that they are able to say, "I liked that man or woman and I could see coming to him or her to talk or my child, friend, lover, uncle, aunt etc. might feel comfortable talking with that person." Sadly, many well-intentioned and often very bright clinicians are just not approachable. They seem to have taken the "distance therapist stance" from the office out into the real world. If you have difficulty giving talks and making yourself known then either work on getting over that or seek employment in a clinic setting in which you will only be required to do therapy and not required to seek out patients. For many people this is a more comfortable route to go but has its obvious economic limitations. I am by nature a relatively shy man but have encouraged and at times forced myself out into the community as I refused to allow this shyness feature of my personality to limit my success as a professional and what I wish to establish in my career.

After having established my presence in the community and receiving referrals from these talks, I began to build my individual psychotherapy practice. From my individual psychotherapy practice, I chose those patients that I felt were ready for group therapy. I personally do not place a patient in group therapy immediately although other therapists do with apparent success. The majority of patients in my groups have seen me for at least three months in individual therapy. These people have initially come to my office through referrals of other patients, making myself known in the community and referrals from colleagues who do not run groups in their practices for whatever reason(s) they have chosen.

I believe a relationship must be developed between the patient and therapist before he/she can make a positive transition into group therapy. It is important that the patient has an initial positive experience in his/her first group session. Group can be a highly anxiety creating stimulus for most people and if the first meeting has been aversive, the chances are he or she will not be coming back. In fact, that might definitely be a healthy response on the part of the patient, as I would not go back to a group that was initially an aversive experience. By your patients having at least one person, the therapist, whom he or she feels relatively comfortable and safe knowing, it makes the adjustment easier and increases the probability of the patient continuing in this modality plus you have at your disposal a wealth of previous material because you have had a relationship with the patient over the past 3 months.

In summary, if you don't believe in what you are doing and its validity, you will have a very difficult time selling your product. Yes, it is unfortunate after all your hard work, time and finances for your education that doors have not been flung wide open for you but that is one of the harsh realities of life. The old model of scientist/practitioner has now been expanded to read practitioner/businessperson/scientist. If you wish to succeed you must make that which you want by implementing all kinds of feasible routes to that goal. If you wish a group therapy practice, you must make it happen and part of that is being flexible and creative but never sacrificing ethics. In this short essay, I hope I have provided some ways that have been of benefit to me. 

The interested reader may also wish to research the American Psychological Association Group Psychotherapy forum on the Internet. This most worthwhile Listserv discussed this very same issue. Here you will find many fine seasoned clinicians who have given their own personal accounts of establishing a group therapy practice. The archival dates of this discussion group were during the months of April and May, 2000.