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Book Reviews |
Key Words: Book Reviews
Roy MacKenzie's new book Time-Managed Group Psychotherapy will be most useful to those who are developing a group program as an integral part of the service delivery of mental health care. MacKenzie makes a strong argument for the necessity for all psychotherapy delivery systems to respond to the realities of limited resources. A group therapy program modeled after MacKenzie responds to those realities.
In Section I, MacKenzie reviews the current status of the behavioral health delivery system and the effectiveness of the group modality. As in his earlier book, An Introduction to Time-Limited Group Psychotherapy,1 he reviews the literature and research on small-group process and therapeutic factors. This review is one of the most comprehensive and well discussed in the group therapy literature. MacKenzie develops and describes what he calls generic group psychotherapy; that is, the therapeutic contract, operations, bond, self-relatedness, and in-session impact that are present in all group therapies, regardless of theoretical orientation.
MacKenzie moves to assessment of the patient, including multimodal diagnosis, in Section II. Interpersonal diagnosis, often neglected in the standard diagnostic evaluation, is emphasized. An extremely useful interpersonal worksheet is included in the appendix. Implementation of the generic group is the subject of Section III. Here MacKenzie thoroughly describes the developmental stages of the group, what can be expected from the group, and the role of the group therapist in each stage.
Section IV, Group Models for Clinical Service Systems, is a wholly developed group therapy delivery system, beginning with a plan for a group program. MacKenzie delineates 10 types of groups, all in time-limited format, addressing focal problems (depression, panic disorder, eating disorders, substance abuse), problems in living (interpersonal problems, crisis intervention, personality problems), and inpatient groups. This section is invaluable not only in setting up groups, but also in managing specific group members' work through a problem-solving approach.
The importance of time, its meaning, and its use as a therapeutic factor have not always been recognized in the literature on time-limited therapy. MacKenzie devotes a full chapter to the meaning of time and its relationship to termination. MacKenzie recognizes the tremendous contribution of James Mann to our understanding of time limits to therapy.2,3 Two aspects of time as a therapeutic factor are that 1) the termination process is an opportunity to revisit and work through unresolved separation and individuation issues and 2) the reality of a time limit from the beginning of therapy brings into sharp relief existential awareness of limits of time, imperfections, and the fact that dependency needs can never be completely fulfilled. When the question of time is kept continually before the group members, as MacKenzie emphasizes, responsibility for progress and change rests more largely on the group. When time-limited groups do not work with time as a therapeutic factor, group members can feel cheated and deprived when the end draws near. Acting out of feelings of disappointment is more likely when such feelings are not acknowledged or expressed.4
The theoretical position of this book is primarily cognitive-behavioral and interpersonal. What of the psychodynamic and group dynamic perspectives? Institutional pressures and continuing change in the health care environment affect the development of group therapy programs. It is essential to recognize the unconscious or covert processes in individuals, groups, and institutions. Success of a group program depends on the acknowledgment and exploration of the complexities of group life.
MacKenzie identifies an important area for further research and study when he notes, "All three mainstream approaches to psychotherapeutic treatment of resistant depressed states . . . have been reported to have significant recurrence rates." MacKenzie offers the option of a monthly meeting for patients who have completed a time-limited group and who are highly likely to have a recurrence of symptoms. These meetings would be called "Maintaining your Interpersonal Health."
There may be a subgroup of patients who are not candidates for time-limited groups but are candidates for ongoing, open-ended group therapy as a highly effective and economic treatment of choice.5 Individual therapy, more costly in time and money, is less necessary when such patients are well established in a highly supportive and consistent group environment. Loosely structured monthly meetings, which MacKenzie suggests, require further research to establish their possible efficacy.
Time-Managed Group Psychotherapy is a worthwhile addition to the literature on group therapy in general and on time-limited group therapy in particular. It is comprehensive, theoretically consistent, and creative in its approach to financial limitations in health care delivery. It will be especially useful to those practitioners who wish to implement a group program. MacKenzie's blueprint offers a solid foundation.
Footnotes
Dr. Cohen is Clinical Instructor in Psychology, Department of Psychiatry, Harvard Medical School, and Group Therapy Supervisor and Consultant, Massachusetts Mental Health Center, Boston, MA. She is in private practice in Wellesley, MA.
References
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