SelfhelpMagazine

by Marc G. Schramm, Psy.D., C.G.P.

Lately I've been asked about mandated referrals. These may come from the courts or from welfare departments (family services). Probation officers, guidance counselors, prosecutors, Judges, and case managers may be involved. When I first started practicing psychotherapy, I was skeptical of mandated treatment. How can psychotherapy succeed when the client has no real interest in treatment?

Since my first job was in community mental health, I nevertheless found myself with more than a few mandated referrals. These experiences significantly modified my opinion.

I soon discerned four initial levels of motivation among mandates. There are those who have no interest in treatment, and make no bones about this fact. They are of course very difficult to work with, but their honesty allows a starting place.

There are also the unmotivated who pretend to participate in therapy. Such patients tend to be sociopathic and are perhaps the most difficult mandatees to treat. I have also found mandatees who present with sincere motivation for therapy.

But the most interesting mandatees are those who profess disinterest in therapy, but are in fact motivated. They generally have shame issues around needing such help, and thus deny their desire for it. Nevertheless, it quickly becomes apparent that by using the mandate as a fig-leaf, they can participate in therapy without having to own it (at least at first).

It is often best to treat mandated patients in a specialized group. In a mixed group there is greater potential for scapegoating, and for intolerable feelings of shame on the part of the mandatee. If these problems are manageable, then there are advantages to treatment in a general psychotherapy group. Broader issues of self and identity are tapped, and the therapeutic factor of universality is available.

One key factor in making a placement decision is the reason for the mandate. The degree of odiousness is generally more important than the mandate itself: A person mandated to treatment for shoplifting is usually easier to place than a sex-offender (though the particular circumstances can make a difference).

A colleague of mine who leads an explosive men's group accepts both mandated and unmandated clients, but a program I once worked with only accepted mandated patients. We did not start this way, but quickly found that the leverage of a mandate almost always made a difference in attendance and participation. Many of the patients were of the hidden-motivation variety, with shame issues (even in a homogenous group) interfering with participation.

This brings us to the second key factor in placing mandated referrals in a group: motivation level. An unmotivated member often weighs down a group; if not mandated, his or her presence at least establishes ambivalence. When an unmotivated member is, unlike other members, compelled to be there, his or her presence can feel like a boundary violation, with resultant injury to group cohesiveness.

In a general group the unwilling mandatee does not have comparable levels of motivation or autonomy, and may have greater levels of shame or denial. The advantage of a specialized group for mandatees of a single broad presenting problem is that there is at least one clear dimension of comparability among all the members. New members experience more accurate empathy from older members, though often in the form of confrontation for the same rationalizations the older members used to employ themselves.

This sort of case is one of the few (excepting short-term therapy), where the advantages of a homogenous group may exceed those of a heterogeneous group. But the benefits of the latter are too great to abandon it all together. It need not be abandoned if the mandatees original offense does not place him or her beyond acceptance by others, and if he or she is not crippled by shame.

Absent these problems, I recommend to patients who have completed a mandated group that they join a general group. There they can broaden their sense of self, and experience the acceptance and universality not attainable in the homogenous group.

Whether the patient entering a mixed group is currently or formerly mandated, the question arises of how the group might be informed of this. I make it a practice to give little or no information to my groups about new members prior to their entry. If the patient is mandated, it may be best for the patient to agree to reveal this right away. But difficulty dealing with shame may make it wise for such revelation to be a marker of progress rather than an initial requirement. This is certainly the case if the mandate expired with the completion of an earlier phase of therapy.

In concluding, I'd like to suggest a mandate for any clinician working with this population. Ask yourself this question: How do *I* feel about this patient and what he/she has done that led to this mandate, and what impact do these feelings have on me clinically? This may be the most important question of all.

About the Author:

Marc G. Schramm, Psy.D., C.G.P., is a Founding Certificant of the National Registry of Certified Group Psychotherapists, a clinical member of the American Group Psychotherapy Association, and President of the Tri-State Group Psychotherapy Society.