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400 words of content (not including the references)
APA 7 ed. formatting for citations and references, including correct use of in-text citations, paragraph formation, and reference formatting.
at least two recent (published within the last three years) scholarly, peer-reviewed sources both must be from a peer-reviewed journal. Resources should be used to support the integration of Scripture, to include biblical commentaries.
The use of the textbook and the Bible is encouraged, but does not count toward the required two peer-reviewed resources.
EDCO 711
Discussion Assignment Instructions
Throughout this course, students will engage in four discussions with your classmates. These discussions are designed to foster a scholarly community of learning, where participants engage in meaningful dialogue, contribute original insights, and expand their understanding of the coursework through critical reflection and academic discourse.
Discussion Thread: Group Stages and Process
One basic task of a group therapist is to understand the group development stages and process. For this discussion,
choose one of the following group stages to discuss and then answer the questions provided.
1. Forming
2. Storming
3. Norming
4. Performing
5. Adjourning
Once you have chosen the group stage you would like to discuss, answer the following prompts
:
1. Define the group stage you chose.
2. Discuss what occurs during this stage.
3. Identify the group leader skill needed to navigate this stage.
4. Discuss the difference between group stages and group process.
Thread
Your thread must respond thoughtfully to the provided prompt or case situation for the specific Module: Week. It should reflect doctoral-level analysis, demonstrating a deep understanding of the relevant coursework and theoretical frameworks. Your thread must be well-supported with at least two recent (published within the last three years) scholarly, peer-reviewed sources both must be from a peer-reviewed journal. Resources should be used to support the integration of Scripture, to include biblical commentaries, Chaplain resources, Christian counseling resources, etc. The use of the textbook and the Bible is encouraged, but does not count toward the required two peer-reviewed resources. Each source should be integrated into your thread to support your arguments with evidence-based research, reflecting critical engagement with academic literature.
In addition to scholarly support, your thread should:
· Meet the required word count of
at least 400 words of content (not including the references).
· Exhibit a high standard of academic, professional writing, free from grammatical errors.
· Adhere to current
APA formatting for citations and references, including correct use of in-text citations, paragraph formation, and reference formatting.
Videos
https://canvas.liberty.edu/courses/753835/pages/watch-group-dynamics-and-process-group-stages?module_item_id=82809461
Watch: Group 3 Working Stage: EDCO711: Advanced Group Counseling (D04)
Read: Yalom: Chapters 10 – 12
Yalom, I. D., Leszcz, M. (2020-12-01). The Theory and Practice of Group Psychotherapy, 6th Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9781541617568
Chapter 10
In the Beginning
THE WORK OF THE GROUP THERAPIST BEGINS LONG BEFORE the first group meeting. As we have emphasized, successful group outcome is rooted largely in the therapist’s effective performance of the pretherapy tasks: proper group selection and composition, securing a proper setting, and client preparation. In this chapter we consider the birth and development of the therapy group: first, its stages of development, and then the important issues of attendance, punctuality, membership turnover, and the addition of new members.1 As we noted earlier, the added considerations for online group therapy will be addressed in Chapter 14.
FORMATIVE STAGES OF THE GROUP
Every therapy group, with its unique cast of characters and complex interaction, undergoes a singular development. All the members begin to manifest themselves interpersonally, each creating his or her own social microcosm. In time, if therapists do their job effectively, members will begin to identify their own interpersonal styles and will eventually begin to experiment with new behavior. Given the richness of human interaction, compounded by the grouping of several individuals with problematic interpersonal styles, it is obvious that the course of a group over many months or years will be complex and, to a great degree, unpredictable. Nevertheless, group dynamic forces operate in all groups and influence their development, and it is possible to describe an imperfect but nonetheless useful schema of developmental phases. Clinicians and researchers have proposed several models of group developmental stages. All these models share a move toward greater interactional depth and complexity, encompassing four or five main stages.2 We will address the first stages in this chapter and consider termination in the next chapter.
One well-known group developmental theory postulates five stages: forming, storming, norming, performing, and adjourning.3 This simple, rhythmic phrase captures well the range of group development models articulated by diverse researchers and applies to both time-limited and open-ended groups.4 Another leading model describes four stages: engagement, differentiation, interpersonal work, and termination.5 It is best not to think of stages rigidly; as we will discuss later, many group and member factors will impact and influence the group’s development. This developmental sequence requires a group duration of at least ten sessions to unfold. Group development is often accelerated in briefer groups.6 Ongoing groups may return to earlier developmental stages as current members graduate and new ones join.
In general, groups are first preoccupied with the tasks of member engagement and affiliation, followed by a focus on control, power, status, competition, and individual differentiation. Next comes a long, productive working phase marked by intimacy, engagement, and genuine cohesion. The final stage is termination of the group. There is debate in the field whether group development is linear or cyclical, but most models share the premise that each stage is shaped by and builds upon the success of preceding ones.7 Hence, early developmental failures will express themselves throughout the group’s life. Another premise of development is that threats to group integrity will cause groups to regress from higher levels of function to less mature stages.
As group development unfolds, we see shifts in member behavior and communication. As the group matures, increased empathic, positive communication will be evident. Members describe their experience in more personal and affective and less intellectual ways. Group members focus more on the here-and-now, are less avoidant of productive conflict, offer constructive feedback, are more self-disclosing, and are more collaborative. Advice giving, a telltale sign of group immaturity, is replaced by exploration, and the group grows to be more interactional, more self-directed, and less leader centered.8 This developmental shift to more meaningful work has also been demonstrated repeatedly in reliable studies of task and work groups and correlates significantly with enhanced productivity and achievement.9
There are compelling reasons for you as the therapist to familiarize yourself with the developmental sequence of groups. If you are to perform your task of assisting the group to establish therapeutic norms, and if you are to diagnose group blockage and intervene strategically to encourage healthy development, you must have a sense of both favorable and flawed development. Furthermore, knowledge of a broad developmental sequence will provide you with a sense of direction in the group; a confused and anxious leader engenders similar feelings in the group members. Familiarity with group development is essential to understanding group process and group dynamics. The group therapist must be reliably able to address the fundamental question of why this is happening in this way at this point.
The First Meeting
Despite the trepidation involved in preparing for the launch of the group, the first group therapy session is invariably a success. Clients (as well as neophyte therapists) generally anticipate it with such dread that they are always relieved by the actual event. Any actions therapists take to reduce clients’ anxiety and unease are generally useful. It is often helpful to call members a few days before the first meeting to reestablish contact and remind them of the group’s beginning. Greeting group members outside the room before the first meeting, or posting signs in the hallway directing clients to the meeting room, are easy and reassuring steps to take. Placing a sign on the door identifying it as the group therapy meeting room reduces the risk of a late arrival missing the session over uncertainty about where the group is meeting and whether it is acceptable to enter late.
Some therapists begin the first meeting with a brief introductory statement about the purpose and method of the group (especially if they have not thoroughly prepared the clients beforehand); others may simply mention one or two basic ground rules—for example, honesty and confidentiality. Knowing that most members will be apprehensive, we like to begin with a warm welcome and convey our excitement about starting the group. Some therapists suggest that the members introduce themselves; others remain silent, knowing that invariably some member will suggest that the members introduce themselves. In Western groups, the use of first names is usually established within minutes. Then a very loud silence ensues, which, like most psychotherapy silences, seems eternal but lasts only a few seconds.
Generally, the silence is broken by the individual destined to dominate the early stages of the group, who will say, “I guess I’ll get the ball rolling,” or words to that effect. Usually that person then recounts his or her reasons for seeking therapy, which often elicits similar descriptions from other members. An alternative course of events occurs when a member (perhaps spurred by the tension of the group during the initial silence) comments on his or her social discomfort or fear of groups. This remark may stimulate related comments from others who have similar feelings.
As we stressed in Chapter 5, the therapist, wittingly or unwittingly, begins to shape the norms of the group at its inception. This critical developmental task can be more efficiently performed while the group is still young. The first meeting is therefore no time for the therapist to be passive or inert.10 Group members’ anxiety will be high at the start, and it is helpful to acknowledge and normalize that. Even if the group is off to a very good start with self-disclosure and interaction, there is important work to do: the group leader’s observations about what is happening in the group demystifies group therapy and reinforces pro-group behavior. A member might ask the group leader for clarification.
“This kind of interaction is so welcome but so foreign to me. What is the group’s methodology? The more I can understand it, the more I can work with it,” one client said in the first session of one of my groups (ML). Other group members echoed her comments, and it led to a useful exploration of the work of group therapy. Although hers was an intellectual question, it easily led to exploration of group members’ feelings about group therapy and the back and forth we should expect between the thinking and feeling components of our work together.
The Initial Stage: Orientation, Hesitant Participation, Search for Meaning, Dependency
Two tasks confront members of any newly formed group. First, they must understand how to achieve their primary task—the purpose for which they joined the group. Second, they must attend to their social relationships in the group so as to create a niche for themselves. Ideally, they will forge roles that provide both the comfort and safety necessary to achieve their primary task and personal gratification from the sheer pleasure of group membership. In many groups, such as athletic teams, health-care teams, college classrooms, and work settings, the primary task and the social task are well differentiated.11 In therapy groups, the tasks are confluent—a fact vastly complicating the group experience of socially challenged individuals.
Several simultaneous concerns are present in the initial meetings. Members, especially if not well prepared by the therapist, search for the rationale of therapy; commonly, they may be confused about the relevance of the group’s activities to their personal goals in therapy. The initial meetings are often peppered with questions reflecting this confusion. Even many weeks later, members may wonder aloud, “How is this going to help? What does all this have to do with solving my problems?”
At the same time, the members are attending to their social relationships: they size up one another and the group. They search for viable roles for themselves and wonder whether they will be liked and respected or ignored and rejected. Although clients ostensibly come to a therapy group for treatment, social forces impel them to invest energy in a search for approval, acceptance, respect, or domination. To some, acceptance and approval appear so unlikely that they defensively depreciate the group by mentally derogating the other members and by reminding themselves that the group is unreal and artificial. Clients with a dismissive attachment style may reject group engagement and dismiss others who may be eager for engagement. Many members are particularly vulnerable at this time as the push and pull for engagement and belonging is strongly activated.12
In the beginning, the therapist is well advised to keep one eye on the group as a whole, and the other eye on each individual’s subjective experience in the group. Members wonder what membership entails. What are the admission requirements? How much must one reveal or give of oneself? At a conscious or near-conscious level, they seek the answers to questions such as these and maintain a vigilant search for the types of behavior that the group expects and approves. Most clients crave both a deep, intimate one-to-one connection and a connection to the whole group.13 Occasionally, however, a member with a very tenuous sense of self may fear losing his or her identity through submersion in the group. If this fear is particularly pronounced it may impede engagement. For such individuals, differentiation trumps belonging.14
Not only is the early group puzzled, testing, and hesitant, but it is also dependent. Overtly and covertly, members look to the leader for structure and answers as well as for approval and acceptance. Many comments and reward-seeking glances are cast at you as members seek to gain approval from authority. Your early comments are carefully scrutinized for directives about desirable and undesirable behavior. Clients appear to behave as if salvation emanated solely or primarily from you, if only they can discover what it is you want them to do. There is considerable realistic evidence for this belief: you have a professional identity as a healer, you host the group by providing a room or the online platform, you have prepared the members, and you charge a fee for your services. All of this reinforces their expectation that you will take care of them. Some therapists respond to the narcissistic stimulation of this idealization in ways that compound this belief.15
The existence of initial dependency thus stems from many sources: the therapeutic setting, the therapist’s behavior, a morbid dependency state on the part of the client, and, as we discussed in Chapter 7, the many irrational sources of the members’ powerful feelings toward the therapist. Among the strongest of these is the need for an omniscient, all-caring parent or rescuer.16
The content and communicational style of the initial phase tends to be relatively stereotyped, resembling the interaction occurring at a cocktail party or similar social encounters. Problems are approached rationally; clients suppress irrational aspects of their concerns in the service of support, etiquette, and group tranquility. Thus, at first, groups may endlessly discuss topics of apparently little substantive interest to any of the participants. These cocktail party issues, however, serve as a vehicle for the first interpersonal exploratory forays. The content of the discussion is less important than the unspoken process: members size each other up and attend to such matters as who responds favorably to them, who sees things the way they do, whom to fear, whom to respect.
In the beginning, therapy groups often spend time on symptom description, previous therapy experience, medications, and the like. The members often search for similarities. They are fascinated by the notion that they are not unique in their distress, and most groups invest considerable energy in demonstrating how the members are similar. This process often offers considerable relief to members (see the discussion of universality in Chapter 1) and provides part of the foundation for group cohesiveness. These first steps set the stage for the later deeper engagement that is a prerequisite for effective therapy.17 This early-stage comfort should not be confused with the more durable and difficult-to-attain group cohesion to follow.
Giving and seeking advice is another characteristic of the early group: clients seek advice for problems with spouses, children, employers, and so on, and the group attempts to provide some practical solutions. This guidance is rarely of functional value but serves as a vehicle through which members can express mutual interest and caring. It is also a familiar mode of communication that can be employed before members understand how to work fully in the here-and-now.
In the beginning the group needs direction and structure. The leader’s support and presence promote safety and create a secure base for group members. The leader can bolster the client’s therapeutic alliance by building safety and trust and offering a road map for what lies ahead. A silent, aloof leader will cause members high levels of avoidable, antitherapeutic anxiety. This phenomenon occurs even in groups of psychologically sophisticated members. In a training group of psychiatry residents led by a silent, nondirective leader, the members grew anxious during their first meeting and expressed fears of what could happen in the group and who might become a casualty of the experience. One member spoke of a recent news report of a group of seemingly “normal” high school students who beat a homeless man to death. Their anxiety lessened when the leader commented that they were all concerned about the harmful forces that could be unleashed as a result of joining this group of seemingly “normal” psychiatry residents. Wilfred Bion, a British analyst, long ago described the primitive unconscious group forces that operate beneath and alongside the more rational and conscious group forces.18
The Second Stage: Conflict, Dominance, Rebellion
If the first core concern of a group is with “in or out,” then the next is with “top or bottom.”19 In this second, “storming” stage, the group shifts from preoccupation with acceptance, approval, commitment to the group, definitions of accepted behavior, and the search for orientation, structure, and meaning to a preoccupation with dominance, control, and power. The conflict characteristic of this phase, among members or between members and leader, is what gives it its “stormy” character. Each member attempts to establish his or her preferred amount of initiative and power. Gradually, a hierarchy of control—a social pecking order—emerges.
Negative comments and intermember criticism are more frequent in this stage than in the first, and members often appear to feel entitled to a one-way analysis and judgment of others’ experiences. As in the first stage, members give advice, but in the context of a different social code; social conventions are abandoned, and members feel free to make personal critiques about other members’ behavior or attitudes. It is a time of “shoulds” and imperatives in the group, a time when the locker-room court is in session. Members make suggestions or give advice not as a manifestation of deep acceptance and understanding—sentiments yet to emerge in the group—but in the service of jockeying for status and position.
The struggle for control is part of the infrastructure of every group. It is always present: sometimes quiescent, sometimes smoldering, sometimes in full conflagration. If there are members with strong needs to dominate, control may be the major theme of the early meetings. A covert struggle for control often becomes more overt when new members are added to the group, especially new members who do not “know their place” and, instead of paying obeisance to the older members in accordance with their seniority, make strong early bids for dominance.
The emergence of hostility toward the therapist is inevitable in the development of a group. Many observers have emphasized an early stage of ambivalence toward the therapist coupled with resistance to self-examination and self-disclosure. Hostility toward the leader has its source in the unrealistic, indeed magical, attributes with which clients secretly imbue the therapist. Their expectations are so limitless that they are bound to be disappointed by any therapist, however competent. Gradually, as group members recognize the therapist’s humanity and concern for them, reality sets in and their hostility dissipates. The group therapist must attend to managing and containing conflict without responding defensively or, worse, hostilely, to group members’ challenges. It is easier for the group leader to stay grounded if he or she understands that such conflict generally emerges from natural group developmental forces.20
This is by no means a clearly conscious group process. The members may intellectually advocate a democratic group that draws on its own resources, but nevertheless, on a deeper level, crave dependency and attempt first to create and then destroy an authority figure. Group therapists refuse to fill the traditional authority role: they do not provide answers and solutions; they urge the group to explore and to employ its own resources. The members’ dependency cravings linger, however, and it is usually only after several sessions that the group members come to realize that the therapist will frustrate their yearning for the ideal leader.
Yet another source of resentment toward the leader lies in the gradual recognition by each member that he or she will not become the leader’s favorite child. During the pretherapy session, each client comes to harbor the fantasy that the therapist is his or her very own therapist, intensely interested in the minute details of that client’s past, present, and fantasy world. In the early meetings of the group, however, each member begins to realize that the therapist is no more interested in him or her than in the others. Seeds are thus sown for the emergence of rivalrous, hostile feelings toward the other group members. Echoes of prior issues with siblings may emerge, and members begin to appreciate the importance of peer interactions in the work of the group.21
These unrealistic expectations of the leader and consequent disenchantment are by no means a function of a childlike mentality or psychological naïveté. The same phenomena occur, for example, in groups of professional psychotherapists. In fact, there is no better way for the trainee to appreciate the group’s proclivity both to elevate and to attack the leader than to be a member of a training or therapy group and to experience these powerful feelings firsthand. (We will discuss the training role of experiential learning in Chapter 16.)
The members are never unanimous in their attack on the therapist. Invariably, some champions of the therapist will emerge from the group. The lineup of attackers and defenders may serve as a valuable guide for the understanding of characterological trends useful for future work in the group. Generally, the leaders of this phase, those members who are earliest and most vociferous in their attack, are heavily conflicted in the area of dependency and have dealt with intolerable dependency yearnings by reaction formation. These individuals, initially considered counterdependents, may also have an avoidant and dismissive attachment style and are inclined to reject prima facie all statements by the therapist.22 Some may even entertain the fantasy of unseating and replacing the leader.
For example, approximately three-fourths of the way through the first meeting of a group for clients with bulimia, I (IY) asked for the members’ reflections on the meeting: How had it gone for them? Disappointments? Surprises? This is generally an effective process intervention that causes the group members to reflect on their experience. One member, who was to control the direction of the group for the next several weeks, commented that it had gone precisely as she had expected; in fact, it had been almost disappointingly predictable. The strongest feeling that she had had thus far, she added, was anger toward me, because I had asked one of the members a question that evoked a brief period of weeping. She had felt, at that moment, “You’ll never break me down like that!” Her first reactions were very predictive of her behavior for some time to come. She remained on guard and strove to be self-possessed and in control at all times. She regarded me not as an ally but as an adversary, and was sufficiently forceful to lead the group into a major emphasis on control issues for the first several sessions.
If therapy is to be successful, counterdependent, dismissive members must at some point experience their flip side. This entails recognizing and working through deep dependency needs buried beneath the assertiveness and fear of rejection and unresponsiveness. They need to experience some comfort with belonging and asking for help. The challenge in their therapy is first to understand that their counterdependent behavior often evokes rebuke and rejection from others; only then can their wish to be nourished and protected be experienced or expressed.
Some members invariably side with the leader and they must be helped to investigate their need to defend the therapist at all costs, regardless of the issue involved. Occasionally, clients defend you because they have encountered in their past a series of unreliable care providers, and they misperceive you as extraordinarily frail; others need to preserve you because they fantasize an eventual alliance with you against other powerful members of the group. Beware that you do not inadvertently transmit covert signals of personal distress to which the rescuers appropriately respond.
Many of these conflicted feelings crystallize around the leader’s title. Are you to be referred to by professional title (“Dr. Jones”) or, even more impersonally, as “the group instructor” or “the counselor,” or by first name? We always address this issue in the preparation process and invite clients to use our first names. We link the use of first names to our wish for a flattened hierarchy in the group and to remind clients that each member of the group carries therapeutic impact and responsibility. Some members will immediately use the therapist’s first name or even a diminutive of the name before inquiring about the therapist’s preference. Others, even after the therapist has wholeheartedly agreed to proceeding on a first-name basis, still cannot bring themselves to mouth such irreverence and continue to bundle the therapist up in a professional title. One client, a successful businessman who had been consistently shamed and humiliated in childhood by a domineering father, insisted on addressing me (ML) as “the Doctor,” because he claimed this was a way to ensure that he was getting his money’s worth. Another member also addressed me as “the Doctor” as a way to distance herself from me because, in her experience, closeness and familiarity with older men were a setup for exploitation and sexual abuse. Establishing a formal distance helped her to manage her negative transference. Later, when she began to call me by my first name, as all the other group members did, it was a big step for her, representing both greater trust and liberation from the past.
Although we have posited disenchantment and anger with the leader as a ubiquitous feature of small groups, the process is by no means constant across groups in form or degree. The therapist’s behavior may potentiate or mitigate both the experience and the expression of rebellion. What kind of leader evokes the most negative responses? Generally, it is those who are ambiguous or deliberately enigmatic; those who are authoritative yet offer no structure or guidelines; or those who covertly make unrealistic promises to the group early in therapy.23
This developmental stage is often difficult and personally unpleasant for group therapists. For your own comfort, you must learn to discriminate between an attack on your person and an attack on your role in the group. The group’s response to you is similar to transference distortions in individual therapy in that it is not directly related to your behavior. Its source in the group must be understood from both an individual psychodynamic and a group dynamic viewpoint. The power of multiple critical voices can be daunting even to a seasoned therapist, but it is essential that the leader explore and understand the criticism without being defensive, hostile, or blaming. If you feel you have missed the mark in your approach, own the error and repair it.24 In so doing you model that everyone in the group can be the focus of feedback: no one and nothing is off limits.25 Keep in mind that group conflict may be a way for members to differentiate themselves after achieving an initial sense of belonging. Conflict can be a developmental response to members’ dependent feelings. It is also an excellent time to highlight the fact that differences in perspective are welcome and will make the group an even richer experience for all. We seek to foster acceptance of difference, assertiveness, and freedom to challenge, but not destructive hostility, which may hinder the group’s development into the next stage of intimacy and interpersonal work.26
Therapists who are particularly threatened by a group attack protect themselves in a variety of ways.27 Once I (IY) served as a consultant for two therapy groups, each approximately twenty-five sessions old, that had developed similar problems. Both groups seemed to have plateaued, and the members seemed to have withdrawn their interest in the therapy. A study of current and recent meetings revealed that neither group had yet dealt directly with any negative feelings toward the therapists. However, the reasons for this inhibition were quite different in the two groups. In the first group, the two co-therapists (first-time leaders) had clearly exposed their throats, as it were, to the group, and, through their obvious anxiety, uncertainty, and avoidance of hostility-laden issues, pleaded frailty. In addition, they both desired to be loved by all the members and had been at all times so benevolent and so solicitous that an attack by the group members would have appeared unseemly and ungrateful.
The therapists of the second group had forestalled an attack in a different fashion: they remained aloof, Olympian figures whose infrequent, ostensibly profound interventions were delivered in an authoritarian manner. At the end of each meeting they summarized, often in unnecessarily complex language, the predominant themes and each member’s contributions. To attack these therapists would have been both blasphemous and perilous.
Therapist countertransference in these two instances obstructed the group’s work. Placing one’s own emotional needs ahead of the group’s needs is a recipe for failure.28 Either of these two leadership styles tends to inhibit a group: suppression of important ambivalent feelings about the therapist results in a counterproductive taboo that opposes the desired group norm of interpersonal honesty and emotional expression. Furthermore, an important model-setting opportunity is lost. The therapist who withstands an attack without being either destroyed or vindictive, but instead attempts to understand and work through the sources and effects of the attack, demonstrates to the group that aggression need not be lethal but can be expressed and understood in the group.
One of the consequences of suppression of therapist-directed anger for the two groups in question, and for most groups where this occurs, is the emergence of displaced, off-target aggression. For example, one group persisted for several weeks in attacking doctors in general. Previous unfortunate experiences with doctors, hospitals, and individual therapists were described in detail, often with considerable group consensus on the injustices and inhumanity of the medical profession. In one group, a member attacked the field of psychotherapy by bringing in a newspaper article purporting that psychotherapy is ineffective.
Scapegoating of other group members is another off-target manifestation. The roots of the concept are biblical, going back to the Book of Leviticus, where a goat is selected to carry all the sins of the people and then banished into the desert.29 Like many group phenomena, scapegoating is often the result of the intersection of individual and group dynamics. Nonetheless, it is the group members who do not conform to the group who are most likely to become scapegoats.30 The factors that set the scapegoated individual apart may be related to socioeconomic, political, or ethnocultural factors or to disability, gender, sexual orientation, age, or any of a host of factors that make one different from others.31 However, scapegoating rarely persists in a therapy group without the therapist deflecting aggression away from him or herself and onto a group member (or members). Peer attack is a safer way of expressing aggression and rivalry or of elevating one’s status in the group than an attack on the therapist. Added to this dynamic is the group members’ unconscious need to export and project unacceptable aspects of self, such as envy, neediness, or shame, onto a susceptible group member.
At worst, this scapegoated member can be sacrificed by the group under the covert and misguided belief that if only it were not for this one member, the group would become a utopia.32 Be very cautious regarding that violent fantasy. The deviant voice often carries a message, wish, or fear that is covertly shared by others. The group leader should work to reduce the isolation of the scapegoat by humanizing that person and linking him or her to others in the group. Create a functional subgroup that joins the potential scapegoat with others by asking, “Is there anyone else in the group who feels what others are criticizing in this member (for example, mistrust of others’ intentions, hunger for more attention, fear of vulnerability)?”33 Do not be seduced by the idea that cohesion will arise from the extrusion of the scapegoat: that idea is illusory. Group members will feel guilt for their attack and apprehension that they could be next. Encourage group members to reflect on any attack that takes place and to reclaim their projected affects and wishes. This is not easy work, but it is therapeutically and ethically necessary.
Yet another source of group conflict originates in the intrinsic process of change. Rigidly entrenched attitudes and behavioral patterns are challenged by other members, and each individual is faced with the discomfort of discarding old patterns. This is the inevitable tear-and-repair process of psychotherapy—coming together, coming apart, and coming together again.34
The Third Stage: Development of Cohesiveness
A third commonly recognized formative phase of a group is the development of mature group cohesiveness. Many phrases with similar connotations have been used throughout the literature to describe this phase: in-groupconsciousness;35 common goal and group spirit;36 consensual group action, cooperation, and mutual support;37 group integration and mutuality;38 we-consciousness unity;39 and support and freedom of communication.40 In this phase, the interpersonal world of the group is one of balance, resonance, safety, increased morale, trust, and self-disclosure.41 Some members reveal more fully the real reason they have come for treatment: sexual secrets, past trauma, and long-buried transgressions are shared. Desires for extragroup contact begin to bubble up. Attendance improves, and clients evince considerable concern about missing members.
The chief concern of the group is with greater intimacy. If we characterize clients’ concerns in the first phase as “in or out” and the second as “top or bottom,” then we can think of the third phase as dealing with “near or far.” The members’ primary anxieties have to do with not being liked, not being close enough to others, or being too close to others.42
Although there may be greater freedom of self-disclosure in this phase, there may also be communication restrictions of another sort: often the group suppresses all expression of negative affect in the service of cohesion. Compared with the previous stage of group conflict, all is sweetness and light, and the group basks in the glow of its newly discovered unity.43 Eventually, however, unless differentiation and conflict in the group are permitted to emerge, the glow will pale and the group embrace will seem ritualistic. Only when all affects can be expressed and constructively worked through in a cohesive group does the group become a mature work group—a state lasting for the remainder of the group’s life, with periodic short-lived regressive recrudescence of each of the earlier phases. Thus, one may think of the maturation of cohesiveness as consisting of two phases: an early stage of great mutual support (the group against the external world), and a more advanced stage of group work, or true teamwork, in which tension emerges, not out of the struggle for dominance, but out of each member’s struggle with his or her own resistances.
Group Development in Practice
Now that we have outlined the stages of group development, let us qualify our statements, lest the novice take the proposed developmental sequence too literally. The developmental phases are essentially constructs—entities that exist for the semantic and conceptual convenience of group leaders. Although the research shows persuasively, using different measures and client populations, that group development occurs, the evidence is less clear on whether there is a precise, inviolate sequence of development.
The use of measures such as the Group Climate Questionnaire (GCQ) can provide more objective monitoring of the development and function of the group by tracking the members’ engagement, conflict, and avoidance.44 The GCQ is a twelve-item self-report widely used in clinical research in both brief and longer-term group therapies (twenty sessions and eighty sessions, respectively). High engagement and lower avoidance scores are more consistently associated with better clinical outcomes. A conflict phase is by no means necessary for group development or improved therapeutic outcome, but its emergence can be usefully understood developmentally. Unsurprisingly, groups marked by low engagement and high conflict and avoidance are doomed to fail. Do not focus only on measurement at the group-wide level alone. The individual client’s GCQ results are a better predictor of individual outcome than the group-wide scores are.45 Throughout, the group leader’s task is to foster engagement, reduce avoidance, and harness conflict.46 A concluding, termination phase marked by high client engagement and low avoidance is also essential to consolidate client gains.47
Another approach to group development research is to track the course of particular variables such as cohesion,48 emotionality,49 or intimacy50 through the course of the group. No linear course exists. In considering group development, think of replacing an automobile wheel: one tightens the bolts one after another just enough so that the wheel is in place; then the process is repeated, each bolt being tightened in turn, until the wheel is entirely secure. In the same way, phases of a group emerge, become dominant, and then recede only to have the group return to the same issues with greater thoroughness later. Thus, it is more accurate to speak of developmental tasks than to speak of developmental phases or a predictable developmental sequence. We may, for example, see a sequence of high engagement and low conflict followed by lower engagement and higher conflict, followed, in turn, by a return to higher engagement.51 David Hamburg suggested the term cyclotherapy to refer to this process of returning to the same issues but from a different perspective and each time in greater depth.52 Often a therapy group will spend considerable time dealing with dominance, trust, intimacy, or the relationship between the co-therapists and then, months later, return to the same topics from an entirely different perspective.
The group leader is well advised to consider not only the forces that promote the group’s development but also those that oppose development and have been identified as antigroup forces.53 These common forces encompass individual and societal resistance to joining: the fear of merging; the fear of loss of one’s sense of independence; the loss of one’s fantasy of specialness, or the fear of being turned away.
THE IMPACT OF CLIENTS AND OTHER FACTORS ON GROUP DEVELOPMENT
The developmental sequence we have described portrays the unfolding of events in a theoretical, unpeopled therapy group. In the course of the group, we must anticipate the richness and unpredictability of human interaction, which complicates treatment and yet contributes to its excitement and challenge. Many factors will modify the group’s development and alter its trajectory. Some can be anticipated; some emerge unexpectedly; but all require therapist attention.
Our experience is that group development is heavily and invariably influenced by chance—by the unique composition of each group. Often the course of the group is set by a single member, generally the one with the loudest interpersonal pathology. By loudest we refer not to severity of pathology but to pathology that is most immediately manifest in the group. For example, in the first meeting of a group of victims of childhood sexual abuse, a member made a number of comments to the effect that she was disappointed that so many members were present whose healing was at such an earlier state than hers. Naturally, this evoked considerable anger from the others, who attacked her for her condescending remarks. Before long, this group developed into the angriest and least caring group we had ever encountered. We cannot claim that this one member put anger into the group. It would be more accurate to say that she acted as a lightning rod to release anger that was already present in each of the participants. But had she not been in the group, it is likely that the anger may have unfolded more slowly, perhaps in a context of greater safety, trust, and cohesiveness. Groups that do not start well face a far more difficult challenge than ones that follow the kind of developmental sequence described in this chapter.
Many individuals who seek group therapy struggle with relating and engaging; indeed, that is often why they seek therapy. Many say of themselves, “I am not a group person.” Clients with a dismissive or fearful attachment style exemplify this.54 A group composed of several such individuals will doubtless struggle with the group tasks more than a group containing several members who have had constructive and effective experience with groups.55 That is why, in the preceding chapter, we advised therapists to seed new groups with a veteran or two with prior constructive group experience.
Other individuals who may alter typical group developmental trends include those with monopolistic proclivities, exhibitionism, promiscuous self-disclosure, or an unbridled inclination to exert control. Not infrequently, such individuals receive covert encouragement from the therapist and other group members. Therapists value these clients because they provide a focus of irritation in the group, stimulate the expression of affect, and enhance the interest and excitement of a meeting. The other members often initially welcome the opportunity to hide behind the protagonist as they themselves hesitantly examine the terrain.
Recall the study of the dropouts of nine therapy groups, which we reviewed in Chapter 8. In five of the groups, a client with a characteristic pattern of attention-seeking behavior fled the therapy group within the first dozen meetings.56 These clients (“early provocateurs”) differed from one another dynamically but assumed similar roles in their groups: they stormed in, furiously activated the group, and then vanished. Some of these early provocateurs were active counterdependents and challenged the therapist early in the group. One, for example, challenged the leader in the third meeting in several ways: he suggested that the members hold longer meetings and regular leaderless meetings, and, only half-jokingly, tried to launch an investigation into the leader’s personal problems. Other provocateurs prided themselves on their honesty and bluntness, mincing no words in giving the other members candid feedback. Still others, heavily conflicted in intimacy, both seeking it and fearing it, engaged in considerable self-disclosure and exhorted the group to reciprocate, often at a reckless pace. Although the early provocateurs usually claimed that they were impervious to the opinions and evaluations of others, in fact they cared very much; in each instance, they deeply regretted the nonviable role they had created for themselves in the group.57
Therapists must recognize this phenomenon early in the group and, through clarification and interpretation, help prevent these individuals from committing social suicide. Perhaps even more important, therapists must recognize and discontinue their own covert encouragement of an early provocateur’s behavior. They may so welcome the behavior of these clients that they fail to appreciate the client’s distress as well as their own dependence on these individuals for keeping the group energized.
It is useful for therapists to take note of their reactions to the absence of the various members of the group. If some members are never absent, you may fantasize their absences and your reaction to it. Consider what thoughts, feelings, fantasies, and actions these individuals generate in you, and what they do to generate that impact.58 If you dread the absence of certain members, feeling that there would be no life in the group that day, then it is likely that there is too much burden on those individuals, and so much secondary gratification that they will not be able to deal with their primary task in therapy. Their restricted role will inevitably undermine their therapy.
We believe much of the confusion about group development is that each group is, at the same time, like all groups, like some groups, and like no other group! Of course, all therapy groups go through some change as they proceed. Of course, there is some early awkwardness as the group deals with its raison d’être and its boundaries. Of course, this is followed by some tension and by repeated attempts to develop intimacy. And of course, all groups must face termination—the final phase. And from time to time, but only from time to time, one encounters a group that runs “on schedule.”
Large group experiences can provide dramatic insight into the powerful dynamics of group participation and group development. I (IY) took part in a week-long Tavistock Clinic intergroup exercise in which the sixty participants were asked to form four groups in any manner they wished and then to study their in-group relationships. The sixty participants, in near panic, stampeded from the large room toward the four rooms designated for the four small groups. Lest we forget, all sixty were mental health professionals, underlining the power of regression in unstructured groups. The panic, an inevitable part of this exercise, probably stemmed from primitive fears of exclusion from a group.59 In the group in which I participated, the first words spoken after approximately sixteen members had entered the room were, “Close the door. Don’t let anyone else in!” Once the group’s boundaries were defined and its identity vis-à-vis the outside world established, the group turned its attention to regulating the distribution of power by speedily electing a chairman, before multiple bids for leadership could immobilize the group. Only later did the group experience and discuss feelings of trust and intimacy, and then, much later, feelings of sadness as the group approached termination.
Research also notes that in addition to leader and individual client variables, there are other factors that will influence a group’s developmental trajectory. In cultures in which collectivism and authority are held in great respect and deference, groups show less conflict and less storming and may stay in a more dependent mode.60 I (ML) have experienced that in my cross-cultural group work in China. Group members were initially reluctant to talk to one another for fear that it would impede the authoritative leader from speaking.
Therapy groups for women influenced by women’s relational models may not experience conflict until there is a solid platform of safety and intimacy.61 A study of brief group cognitive-behavioral therapy (CBT-G) and group interpersonal therapy for social phobia reported very little conflict and much less storming in both groups, but particularly in CBT-G. This is likely a manifestation of the avoidant nature of the primary condition that brought the members into treatment.62 Briefer groups of fewer than ten sessions, and groups that are highly structured and may be homogeneous in composition, will not likely proceed through these developmental stages but instead stay in a position of early engagement.63 Structured groups that follow an agenda should include information and education about group development as part of the curriculum.64
In summary, there are some advantages to group therapists’ possessing some broad schema of a group developmental sequence: it enables them to maintain objectivity and to chart the voyage of a group despite considerable yawing, and to recognize if a group is either not progressing past a certain stage or omitting some stage entirely. At times, therapists may demand something for which the group is not yet ready: mutual caring and concern, for example, develop late in the group; in the beginning, caring may be more pro forma, as members view one another as interlopers or rivals for the healing touch of the therapist. The therapist who is aware of normative group development is able to remain more finely attuned to the group and shape interventions accordingly.
But there is a downside to the boilerplate clinical application of group developmental ideas. The inexperienced therapist may take them too seriously and use them as a template for clinical practice. We have seen beginning therapists exert energy on forcing a group, in procrustean fashion, to progress in lockstep through set phases. Such formulaic therapy—and it grows more common with standardized therapy via treatment manual—lessens the possibility of real therapist-client engagement. The sacrifice of realness, of authenticity, in the therapeutic relationship is no minor loss: It is the loss of the very heart of psychotherapy.
Certainly, the first generations of psychotherapy manuals diminished therapists’ authenticity in therapy by their slavish attention to adherence to the model. There is strong evidence that this is frankly counterproductive. More contemporary therapy manuals do less micromanaging of treatment and provide more scope for therapist flexibility and naturalness.65
Psychotherapy, whether with a group or with an individual client, should be a shared journey of discovery. There is danger in every system of “stages”—in the therapist having fixed, preconceived ideas and procedural protocols—in any kind of growth-oriented therapy.
In the mid-1970s, I (IY) began the first group for cancer patients with Katy Weers, a remarkable woman with advanced breast cancer. She often railed about the harm brought to the field by Elisabeth Kübler-Ross’s “stages” of dying, and dreamed of writing a book to refute this concept. To experience the client against a template of stages interferes with the very thing so deeply desired by clients: “therapeutic presence.”66 Katy and I both suspected that therapists cloaked themselves in the mythology of “stages” to muffle their own death anxiety.
MEMBERSHIP PROBLEMS
The early developmental sequence of a therapy group is powerfully influenced by membership problems. Turnover in membership, tardiness, and absences are facts of life in the developing group and often threaten its stability and integrity. Considerable absenteeism may redirect the group’s attention and energy away from its developmental tasks toward the problem of maintaining membership. It is the therapist’s task to discourage irregular attendance and, when necessary, to replace dropouts appropriately by adding new members.
Turnover
In the normal course of events, a substantial number of members drop out of interactionally based groups in the first twelve meetings. If two or more members drop out, new members are usually added—but often a similar percentage of these additions drop out in their first dozen or so meetings. Only after membership has stabilized does the group solidify and begin to engage in matters other than those concerning group stability. Generally, by the time clients have remained in the group for approximately twenty meetings, they have made the necessary long-term commitment. In a very well conducted study, briefer groups (twenty sessions) had a much lower dropout rate (8.6 percent) than longer-term (eighty sessions) groups (33 percent). This result may reflect in part the more manageable commitment clients are asked to make to the briefer group. Some of the dropout variance reflects the heightened activity of the brief therapy group leaders, who were very mindful of the pressure of time and the need to create a cohesive group quickly.67
In another study of five groups, there was considerable turnover in membership within the first twelve meetings, a settling in between the twelfth and twentieth, and near-perfect attendance, with excellent punctuality and no dropouts, between the twentieth and forty-fifth meetings (the end of the study).68 Most studies demonstrate similar findings.69 It is unusual for the number of later dropouts to exceed that of earlier phases.70 In one study in which attrition in later phases was higher, the authors attributed the large numbers of later dropouts to mounting discomfort arising from the greater intimacy of the group. Some groups had a wave of dropouts, where one dropout seemed to seed others.71 Prior or concurrent individual therapy substantially reduces the risk of premature termination.72
As noted, short-term groups generally report lower dropout rates.73 In closed, time-limited groups, it is useful to start with a large enough number of clients that the group can withstand some attrition and yet be sufficiently robust for the duration of the group’s course. Too large a starting size invites dropout from those individuals who will feel marginalized and peripheral to the group. Starting with nine or ten members is probably ideal in this situation.
Attendance and Punctuality
Despite the therapist’s initial encouragement of regular attendance and punctuality, these difficulties usually arise in the early stages of a group. At times the therapist, buffeted by excuses from clients—childcare problems, work demands, vacations, commute difficulties, bad weather and bad traffic, work emergencies, out-of-town guests—becomes resigned to the impossibility of synchronizing the schedules of eight busy people. Resist that! Tardiness and irregular attendance usually signify resistance to therapy. When several members are often late or absent, search for the source of the group resistance; for some reason, cohesiveness is limited, and the group is foundering. If a group solidifies into a hardworking cohesive group, then—mirabile dictu—the scheduling problems vanish and there may be perfect attendance and punctuality for many months.
At other times, the resistance is individual rather than group based. We are continually amazed by the transformation in some individuals, who for long periods have been tardy because of “absolutely unavoidable” contingencies—for example, periodic business conferences or family demands—and then, after recognizing and working through the resistance, become the most punctual members for months on end. One habitually late member hesitated to involve himself in the group because of shame about his bisexuality and his infidelity to his wife. After he disclosed these concerns and worked through his feelings of shame, he found that the crucial business commitments responsible for his lateness—commitments that, he later revealed, consisted of perusing his email and checking social media—suddenly evaporated.
Whatever the basis for resistance, it is behavior that must, for several reasons, be modified before it can be understood and worked through. For one thing, irregular attendance is destructive to the group. It is contagious and leads to group demoralization. This statement is supported both by clinical experience and research. A study of member attendance demonstrates that a culture of absence foredooms the group. Each absence encourages further absences. Missing one meeting increases the likelihood of that member missing a subsequent one. These absences, in turn, will undermine the more committed members, who then also begin to miss sessions.74 Obviously, it is impossible to work on this issue when the relevant members are not present. Few exercises are more futile than addressing the wrong audience, and deploring irregular attendance with the group members who are present—the regular, punctual participants.
Occasionally, a therapeutic dilemma may emerge regarding attendance. These are situations in which the personal growth of the member may conflict temporarily with the contract of attending the group. One group member needed to miss two months of meetings because of her hard-earned return to university after twenty years of doing unvalued and poorly paid work. Returning to school was a key step in her growth, and the group members readily supported her choice.
In another situation, a young, single woman, Sara, entered group therapy to deal with chronic depression, much of which was rooted in her submission to the demands of her elderly parents and her self-abnegation. She described spending each weekend driving up to her parents’ home to shop, cook, and clean for them. Her older brothers provided virtually no meaningful support, and she initially defended them by noting that in her culture, it was the duty of unmarried daughters to care for their parents. But it grew harder for her to tolerate her anger toward her brothers, and she began to appreciate that her self-denial and self-sacrifice were feeding her depression. One group member commented that she could hardly form a significant relationship with a man if she spent every weekend with her parents. Nothing would change if she did not change it. In the here-and-now of the group, Sara began to find her voice, and she regularly began to ask for time and attention. Several months into her therapy, she asked the group if it was okay that she leave midway through the meeting to go to a concert that a friend invited her to attend. It was her favorite performer, in town for only this performance. The group’s response was unanimously supportive. They recognized this as the burgeoning of Sara’s ability to carve out time for herself despite feelings of obligations to others.
We stress the importance of attendance and tell clients in the preparation for group therapy that they need to treat the group time as sacrosanct. If they are in the city and not ill, then they are expected to attend the group. Group therapy is a team sport and every member must show up.
Clients who appear likely to have scheduling or transportation problems are best referred for individual therapy, as are those who must be out of town once a month or who, a few weeks after the group begins, plan an extended out-of-town vacation. Group therapy carries many unique advantages, but has no flexibility in terms of scheduling. Each session missed produces the effect of reading a novel with a chapter missing. The occasional missed chapter can be managed, but too many missed chapters will distort the understanding of the novel. Charging full fees for missed sessions is standard practice. Many private practitioners set a fixed monthly rate that is not reduced for any reason of absence.
Men who have physically abused their partners are typically resistant group members, but at the same time, there is robust evidence that if they remain in treatment group interventions are effective. However, dropout rates of 40 to 60 percent within three months are not uncommon. Clinicians working with this population have tackled the problem of poor motivation directly with intensive pregroup training, including psychoeducational videos to increase empathy for the victims and inform abusers about the physiology and psychology of violence.75 An even simpler intervention has also proven to be powerfully effective. In a study of 189 men, group leaders who reached out actively via phone calls, expressions of concern, and personalized alliance-building measures produced dramatic results. These simple, low-tech interventions significantly increased both attendance and tenure in both interpersonal and cognitive-behavioral group therapies and significantly reduced the incidence of domestic violence.76 The simple act of a telephone, email, or text prompt has repeatedly been shown to increase attendance, and although it may feel like coddling or fostering dependence, it at least provides the opportunity to address the issues in person.77
It is critical that the therapist be utterly convinced of the importance of the therapy group and of regular attendance. The therapist who acts on this conviction will transmit it to the group members. Thus, therapists should arrive punctually, award the group high priority in their own schedule, and, if they must miss a meeting, inform the group of their absence weeks in advance. It is not uncommon to find that therapist absence or group cancellation may be followed by poor members’ attendance. If you miss meetings with regularity, aside from planned vacations, you encourage group members to prioritize other competing activities as well. When launching a new group, it is wise to start after a planned therapist vacation rather than start and then miss the second or third meeting.
> Upon arriving at a psychotherapy group for elderly men, I (ML) discovered that half the group of eight was absent. Illness, family visits, and conflicting appointments had all conspired to diminish turnout. As I surveyed the room strewn with empty chairs, one man spoke up and suggested with some resignation that we cancel the group, since so many members were away. My first reaction was one of quiet relief at the prospect of unexpected free time in my day. My next thought was that canceling the meeting was a terrible message to those present. In fact, the message would echo the diminishment, isolation, and unwantedness that the men felt in their lives. I suggested that it might be even more important than ever to meet today. The men actively embraced my comment as well as my suggestion that we remove the unnecessary chairs and tighten the circle so that we could hear one another better. << A member who has a poor attendance record (whatever the reason) is unlikely to benefit from the group. In a study of ninety-eight group participants, one study found that poor attendance early in the group was linearly related to later dropout (at six to twelve months).78 Thus, inconsistent attendance demands decisive intervention. > In a new group, one member, Dan, was consistently late or absent. Whenever the co-therapists discussed his attendance, it was clear that Dan had valid excuses: his life and his business were in such crisis that unexpected circumstances repeatedly arose to make attendance impossible. The group as a whole had not jelled; despite the therapists’ efforts, other members were often late or absent, and there was considerable flight during the sessions. At the twelfth meeting, the therapists decided that decisive action was necessary. They advised Dan to leave the group, explaining that his schedule was such that the group could be of little value to him. They offered to help Dan arrange individual therapy, which would provide greater scheduling flexibility. Although the therapists’ motives were not punitive, and they were thorough in their explanation, Dan was deeply offended and walked out in anger midway through the meeting. The other members, feeling extremely threatened, supported Dan to the point of questioning the therapists’ authority to ask a member to leave.
Despite the initial, emotionally laden reaction of the group, it was soon clear that the therapists had made the proper intervention. One of the co-therapists phoned Dan and saw him individually for two sessions, then referred him to an appropriate therapist for individual therapy. Dan soon appreciated that the therapists were acting not punitively but in his best interests: irregularly attending a therapy group would not have been effective therapy for him. In the group, meanwhile, attendance immediately improved, and it remained near perfect over the next several months. Once the members recovered from their fear of similar banishment, they gradually disclosed their approval of the therapists’ decision and their resentment toward Dan for having treated the group in such a cavalier fashion. << Some therapists attempt to improve attendance by harnessing group pressure—for example, by refusing to hold a meeting until a predetermined number of members (usually three or four) are present. Even without formalization of this sort, the pressure exerted by the rest of the group is an effective lever to bring to bear on errant members. The group is often frustrated and angered by the repetitions and false starts necessitated by irregular attendance. The therapist should encourage the members to express their reactions to late or absent members. Be mindful, though, that the therapist’s concern about attendance is not always shared by the members: a young or immature group often welcomes the small meeting, regarding it as an opportunity for more individual attention from the leader. Similarly, be careful not to punish the regular participants by withholding treatment in the process of applying group pressure on the absent members. Like any event in the group, absenteeism or tardiness is a form of behavior that reflects an individual’s characteristic patterns of relating to others. Be sure to examine the personal meaning of the client’s action. If Maria arrives late, does she apologize? Does Joe enter in a thoughtless, noisy, exhibitionistic manner? Does Sally arrive late because she experiences herself as a nonentity who makes no contribution to the group’s life in any event? Does Antoine come as he chooses because he believes nothing of substance happens without him anyway? Does Jess ask for a recap of the events of the meeting? Is her relationship with the group such that the members provide her with a recap? If Ronin is absent, does he call or text in advance to let the group leader know? Does he offer complex, overelaborate excuses, as though convinced he will not be believed? Not infrequently, a client’s psychopathology is responsible for poor attendance. For example, one man who sought therapy because of a crippling fear of authority figures and a pervasive inability to assert himself in interpersonal situations was frequently late because he was unable to muster the courage to interrupt a conference call with a business associate. An obsessive-compulsive client was late because he felt compelled to clean his desk over and over before leaving his office. Don’t settle easily for explanations such as bad traffic on the way or subway delays if you have concerns about client resistance. Absenteeism and lateness are part of the individual’s social microcosm and, if handled properly, may be harnessed in the service of self-understanding. For both the group’s and the individual’s sake, however, they must be corrected before being analyzed. No feedback can be heard by an absent group member. In fact, the therapist must attend to the timing of his comments to the returning member. Clients who have been absent or are late often enter the meeting with some defensive guilt or shame and are not in an optimal state of receptiveness for immediate observations about their behavior. The therapist does well to attend first to group maintenance and norm-setting tasks, and then, later, when the timing seems right and defensiveness has diminished, to attempt to help the individual explore the meaning of his or her behavior. The timing of feedback is particularly important for members who have greater psychological vulnerability and mistrust of relationships.79 Group members who must miss a meeting or arrive late should, as they were advised in pregroup preparation, alert the therapist in advance, in order to spare the group the tendency to waste time expressing curiosity or concern about their absence. Often, in advanced groups, the fantasies of group members about why someone is absent can provide valuable material for the therapeutic process; in early groups, however, such speculations tend to be superficial and unfruitful, and may be needlessly anxiety provoking. An important adage of interactional group therapy, which we emphasize throughout this book, is that any event in the group can serve as grist for the interpersonal mill. Seize the opportunity that each new constellation of members creates through a change in the group dynamics. As this vignette demonstrates, the absence of a member can generate important, previously unexplored material: > A group composed of four women and three men held its eighth meeting in the absence of two of the men. Albert, the only male present, had previously been withdrawn and submissive in the group, but in this meeting a dramatic transformation occurred. He erupted into activity, talked about himself, questioned the other members, spoke loudly and forcefully, and, on a couple of occasions, challenged the therapist. His nonverbal behavior was saturated with quasi-courtship bids directed at the women members: for example, frequent adjustment of his shirt collar and stroking his beard. Later in the meeting, the therapist engaged the group in processing Albert’s change, and Albert realized and expressed his fear and envy of the two missing males, both of whom were aggressive and assertive. He had long experienced a pervasive sense of social avoidance and failure, which was reinforced by his feeling that he never made a significant impact on groups of people, especially groups of women. In subsequent weeks, Albert did valuable work on these issues, now in the presence of his rivals—issues that might not have become accessible for many months without the chance absence of the two other male group members on the same day. << Our clinical preference is to encourage attendance but never, regardless of how small the group is, to cancel a session. There is considerable therapeutic value for the client in knowing that the group is always there, that it is stable and reliable; indeed, its constancy will in time beget constancy of attendance. We have held meetings with very small numbers when a confluence of legitimate factors, such as planned summer vacations, conspires to reduce attendance over a period of one or two weeks—even with as few as two members. These meetings proved to be critical for those attending. The technical problem with such meetings is that without the presence of interaction, the therapist may often revert to focusing on intrapsychic processes in a manner characteristic of individual therapy and forgo group and interpersonal issues. It is far more therapeutically consistent to focus in-depth on group and interpersonal processes, even in the smallest of sessions. Consider the following clinical example from a ten-month-old group: > For various reasons—vacations, illnesses, resistance—several members of one of my (IY) groups were absent for one session, and only two members and I attended. The two members were Wendy, a depressed thirty-eight-year-old woman with borderline personality disorder, and Martin, a twenty-three-year-old man who was socially avoidant and highly immature.
Wendy spent much of the early part of the meeting describing the depth of her despair, which during the past week had reached such proportions that, preoccupied with suicide, she had gone to the hospital emergency room. While there, she had surreptitiously read her medical chart, which contained a consultation note I had written a year earlier. I had diagnosed her with borderline personality disorder in the note, and Wendy said she had been anticipating this diagnosis, and now she wanted to be hospitalized.
Martin then recalled a fragment of a dream he’d had several weeks before but had not yet discussed. In the dream, I was sitting at a large desk interviewing him, and Martin stood up and looked at the paper on which I was writing. There he saw in huge letters one word covering the entire page: IMPOTENT. I helped both Wendy and Martin discuss their feelings of awe, helpless dependence, and resentment toward me as well as their inclination to shift responsibility and project their bad feelings about themselves onto me.
Wendy proceeded to underscore her sense of helplessness by describing her inability to cook for herself and her delinquency in paying her bills, which was so extreme that she now feared legal action against her. Martin and I commented on her persistent reluctance to talk about her positive accomplishments—for example, her continued excellence as a teacher. I wondered aloud whether her presentation of herself as helpless was not designed to elicit responses of caring and concern from the other members and me—responses that she felt would be forthcoming in no other way.
Martin then mentioned that he had gone to the medical library the previous day to read some of my professional articles. In response to my question about what he really wanted to find out, Martin answered that he guessed what he really wanted to know was how I felt about him. He proceeded to describe, for the first time, his longing for my sole attention and love.
Later, I expressed my concern about Wendy reading my note in her medical record. I candidly discussed both my own discomfort at having to use diagnostic labels for hospital records and the confusion surrounding psychiatric diagnostic terminology. I explained as best I could my reasons for using that particular label and its implications.
Wendy then commented on the absent members and wondered whether she had driven them from the group (a common reaction). She dwelled on her unworthiness and, at my suggestion, made an inventory of her destructive characteristics, citing her slovenliness, selfishness, greed, envy, and hostile feelings toward all those in her social environment. Martin both supported Wendy and identified with her, since he recognized many of these feelings in himself. He discussed how difficult it was for him to reveal himself in the group with others present.
Later, he discussed his fear of getting drunk or losing control in other ways: for one thing, he might become indiscreet sexually. He then discussed, for the first time, his fear of sex, his inability to maintain an erection, and his last-minute refusals to take advantage of sexual opportunities. Wendy empathized deeply with Martin; although she had for some time regarded sex as abhorrent, she expressed a strong wish (a wish, not an intention) to help him by offering herself to him sexually. Martin then described his strong sexual attraction to her, and later both he and Wendy discussed their sexual feelings toward the other members of the group.
I commented that Wendy’s interest in Martin and her desire to offer herself to him sexually belied many of the items in her inventory: her selfishness, greed, and ubiquitous hostility to others. This observation subsequently proved to be of great therapeutic importance to Wendy. << Although only two members were present at this meeting, they met as a group and not as two individual clients. The other members were discussed in absentia, and previously undisclosed interpersonal feelings between the two clients and toward the therapists were expressed and analyzed. It was a valuable session, deeply meaningful to both participants. It is worth noting again here that talking about group members in their absence is not “talking behind people’s backs.” A member’s absence cannot dictate what gets addressed by those in attendance, although it is essential that absent members be brought back into the loop upon their return. As with extragroup contact, that discussion is less of a problem than secretiveness about it would be. Dropouts There is no problem more threatening for the neophyte group therapist (and for many experienced therapists for that matter) than the dropout from group therapy. Dropouts concerned me (IY) greatly when I first started to lead groups, and my first group therapy research was a study of all the group participants who had dropped out of the therapy groups in a large psychiatric clinic.80 It is a significant issue. As we discussed earlier, the group therapy demographic research demonstrates that a substantial number of clients will leave a group prematurely regardless of what the therapist does. In fact, some clinicians suggest that dropouts are not only inevitable but necessary in the sifting process involved in achieving a cohesive group.81 But we believe that we should always aim to reduce dropout rates even as we acknowledge their inevitability. Aim to reduce but not eliminate dropouts. If you have no dropouts, you may be setting the bar for admission into your groups too high and sidelining some clients who could be helped in your groups. Consider, too, that the existence of an escape hatch may be essential to allow some members to make their first tentative commitments to the group. The group must have some decompression mechanism; mistakes in the selection process are inevitable, unexpected events occur in the lives of new members, and group incompatibilities develop. There are various reasons for premature termination, as we will briefly review here. Consider the dropout phenomenon from the perspective of the interaction of three factors: the client, the group, and the therapist.82 In general, client factors stem from problems caused by client deviancy, severe interpersonal deficits and conflicts in intimacy and disclosure, the role of the early provocateur, external life stress, inability to share the leader, and fear of emotional contagion. Misaligned client expectations also may play a large role through a negative impact on the therapeutic alliance. All these factors will be amplified by the potential stress of early group development. Potential dropouts are exposed to unaccustomed demands for candor and intimacy; they are often confused about the group procedures; they believe that the group activities bear little relevance to their problems; and, finally, they feel too little support in the early meetings. Group factors include the consequences of subgrouping, poor compositional matches among clients, scapegoating, member-member impasses, or unresolved conflict. The therapists also play an essential role. What errors do therapists make that increase the risk of dropouts? They may select members too hurriedly; they may not prepare members adequately; they may not attend to building group cohesion and addressing group developmental tasks; they may neglect cultural and diversity issues; and they may be influenced by unresolved countertransference reactions.83 Research shows that there can be a fourfold difference between therapists in the rate of clients dropping out of individual therapy, and we suspect the same is true for group therapists.84 Even the organizational setting contributes if it creates an unstable environment that compromises therapist morale and undermines the value of the clinical work.85 As we discussed earlier, the two most important methods of decreasing the dropout rate are proper selection and comprehensive pretherapy preparation. Both actions foster a stronger therapeutic alliance, a powerful predictor of good outcomes.86 It is especially important that in the preparation procedure, the therapist make it clear that periods of discouragement are to be expected in the therapy process. Clients are less likely to lose confidence in a therapist who appears to have the foreknowledge that stems from experience. In fact, the more specific the prediction, the greater its power. For example, it may be reassuring to socially anxious and phobic individuals to anticipate that there will be times in the group when they will wish to flee, or will dread coming to the next meeting. The therapist can emphasize that the group is a social laboratory and suggest that the client has the choice of making the group yet another instance of failure and avoidance or, for the first time, staying in the group and experimenting, in a low-risk situation, with new behaviors. We have often told clients in pregroup meetings that there will be times when the last place they want to be is in the group. “Try to welcome that discomfort,” we tell them. “Alert us to it, as it may be a sign of you hitting on a key point in your therapy.” Often groups contain experienced group members who assume some of this predictive function, as demonstrated in the following case: > One group graduated several members and was reconstituted by adding five new members to the remaining three veteran members. In the first two meetings, the old members briefed the new ones and told them, among other things, that by the sixth or seventh meeting some member would decide to drop out, and then the group would have to drop everything for a couple of meetings to persuade him to stay. The old members went on to predict which of the new members would be the first to decide to terminate. Rendered with compassion and the wish to retain the new members, this form of prediction is a most effective manner of ensuring that it is not fulfilled. << Despite painstaking preparation, many clients will still consider dropping out. When a member informs a therapist that he or she wishes to leave the group, a common approach is to urge the client to attend the next meeting to discuss it with the other group members. Underlying this practice is the assumption that the group will help the client work through resistance and thereby dissuade him or her from terminating. This approach, however, is rarely successful. In one study of thirty-five dropouts from nine therapy groups (with a total original membership of ninety-seven clients), we found that every SINGLE one of the dropouts had been urged to return for another meeting, but not once did this final session avert premature termination.87 In short, asking the client who has decided to drop out to return for a final meeting is usually an ineffective use of group time. The exception to this rule is the client who believes himself to be undesirable and worthless and hopes the group will disconfirm his beliefs. Many clients approach therapy with juxtaposed dread and hope: dread of repetition of their poor relationship experiences and hope that this time it might be different.88 Even when the dropout is very critical of the group, there may be deeply hidden wishes to be embraced by the group. After dropping out of a group and rejecting the offer of a follow-up individual session with me (ML), one woman asked for a consultation several months later regarding a question about a change in her antidepressants. We addressed the matter quickly and then moved on to discuss her departure from the group. Much to my surprise, she spent most of the rest of our session expressing disappointment that there had been no goodbye card for her at her last meeting, which she had seen at a prior departure by another member. I was surprised by the depth of her emotion, which she had previously concealed from the group, and I acknowledged that we had been unaware of her well-concealed hope for acceptance by the group despite her evident rejection of the group. Generally, the therapist is well advised to see a potential dropout for a short series of individual interviews to discuss the sources of group stress. A therapeutic impasse may present a unique therapeutic opportunity: impasses arise at critical points when core wishes and fears are activated and the client feels it is unsafe or useless to proceed.89 Occasionally an accurate, penetrating interpretation will keep a client in therapy. > Joseph, a socially avoidant man with a profound sense of alienation, announced in the eighth meeting that he felt he was getting nowhere in the group and was contemplating termination. In an individual session set up before the next group, he told me (IY) something he had been unable to say in the group—namely, that he had many positive feelings toward a couple of the group members. Nevertheless, he insisted that the therapy was ineffective and that he desired a more accelerated and precise form of therapy.
I correctly interpreted Joseph’s intellectual criticism of the group therapy format as a rationalization: he was, in fact, fleeing from the closeness he had felt in the group. I again explained the social microcosm phenomenon and informed Joseph that he was repeating his lifelong style of relating to others in the group. Joseph had always avoided or fled intimacy, and he no doubt would always do so in the future unless he stopped running and allowed himself the opportunity to explore his interpersonal problems in vivo. The intervention was successful. Joseph continued in the group and eventually made considerable gains in therapy. << In general, the therapist can decrease premature terminations by attending assiduously to early-phase problems. We will have much to say later in this text about self-disclosure, but for now keep in mind that outliers—excessively active members and excessively quiet members—are both dropout risks. Try to keep client self-disclosure balanced and well-paced. It may be necessary to slow down the client who too quickly reveals deeply personal details in the very first sessions. Try to help the client shift from vertical disclosure of the details of their life to horizontal disclosure that examines how it feels to open these issues up with the members of the group. The client will not feel silenced and yet will not overexpose herself. It converts self-disclosure into an interpersonal engagement. On the other hand, members who remain silent session after session may become demoralized: each session of silence makes it exponentially harder for these group members to return and talk at the next session. Negative feelings, misgivings, and apprehensions about the group or the therapeutic alliance must be openly addressed and not pushed underground. Moreover, the expression of positive affects should also be encouraged and, whenever possible, modeled by the therapist.90 This is part of your norm-setting role. In one session of supervision, the co-therapists reported that the meeting (the sixth of twenty-eight sessions) went so well that they remained quiet and felt they had little to add. I (ML) challenged them, noting that though the group indeed was working well, there was more they could do to reinforce the group’s work and norms. Could they share their reactions and ask the group to reflect on this session to foster the continuation of that good work? They could help the group discuss the experience of clients’ risk-taking; the quality of the feedback they provided to each other; their high level of care for one another; their taking responsibility for the work; and other related pro-group themes. Inexperienced therapists are particularly threatened by the client who expresses a wish to drop out. They begin to fear that, one by one, their group members will leave, and that they will one day come to the group and find themselves alone in the room. (And what, then, do they tell their group supervisor?) Therapists for whom this fantasy truly takes hold cease to be therapeutic to the group. The balance of power shifts. They feel blackmailed. They begin to be seductive, cajoling—anything to entice the clients back to future meetings. Once this happens, of course, any therapeutic leverage is lost entirely. After struggling in our own clinical work with the problem of group dropouts over many years, we have finally achieved some resolution on the issue. By shifting our personal attitude, we have fewer group therapy dropouts. But we do have more group therapy throw-outs! We do not mean that we frequently ask members to leave a therapy group, but we are perfectly prepared to do so if it is clear that the member is not working in the group. We are persuaded (from our clinical experience and from empirical research findings) that group therapy is a highly effective mode of psychotherapy. If an individual is not going to be able to profit from it, then we want to get that person out of the group and into a more appropriate mode of therapy, and bring someone else into the group who will be able to use what the group has to offer. This method of reducing dropouts reflects a posture on the part of the therapist that increases the commitment to work. Once you have achieved this particular mental set, you communicate it to your clients in direct and indirect ways. You convey your confidence in the therapeutic modality and your expectation that each client will use the group for effective work. Removing a Client from a Group Taking a client out of a therapy group is an act of tremendous significance for both that individual and the group and as such it must be approached thoughtfully. Once a therapist determines that a client is not working effectively, the next step is to identify and remove all possible obstacles to the client’s productive engagement in the group. If the therapist has done everything possible yet is still unable to alter the situation, there is every reason to expect one of the following outcomes: (1) the client will ultimately drop out of the group without benefit (or without further benefit); (2) the client may be harmed by further group participation (because of negative interaction or the adverse consequences of the deviant role); or (3) the client will substantially obstruct the group work for the remaining group members. Hence, it is folly to adopt a laissez-faire posture: The time has come to remove the client from the group. How? There is no adroit, subtle way to remove a member from a group. Often the task is better handled in an individual meeting with the client than in the group. The situation is so anxiety-provoking for the other members that generally the therapist can expect little constructive group discussion; moreover, an individual meeting reduces the member’s public humiliation. Is it helpful to invite the client back for a final meeting to work things through with the group? That is generally not a useful option: if the individual were able to work things through in an open, nondefensive manner, there would have been no need to ask him or her to leave the group in the first place. Whenever you remove a client from a group, you should expect a powerful reaction from the rest of the group. The ejection of a group member stirs up deep levels of anxiety in the others associated with primal fears of rejection or abandonment. You may get little support from the group, even if there is unanimous agreement among the members that the client should have been asked to leave. Even if, for example, the client consistently disrupted the entire group, the members will still feel threatened by your decision. There are two possible interpretations the members may give to your act of removing the member. One interpretation is rejection and abandonment: that is, that you did not like the client; you resented him, you were angry, you’re an authoritarian and a bully, and you wanted him out of the group and out of your sight. Who might be next? The other interpretation (the correct one, let us hope) is that you are a responsible mental health professional who acted in the best interests of that client and of the remaining group members. Every individual’s treatment regimen is different, and you made a responsible decision about the fact that this form of therapy was not suited to a particular client at this particular moment. Furthermore, you acted in a professionally responsible manner by ensuring that the client would receive another form of therapy more likely to be helpful. No single effective treatment works universally well for all. It is as true for psychotherapies as for biological therapies. The remaining group members often lean toward the first—the “rejection”—interpretation. Your task is to help them arrive at the second interpretation. You may facilitate the process by making the reasons for your actions clear and sharing your decisions about future therapy for the extruded client, such as individual therapy with you or a referral to a colleague. Be mindful of privacy limitations in this situation. You can certainly be transparent about your own thinking, but do safeguard the client’s personal information unless you have clear consent to disclose it. Occasionally, the group may receive the decision to remove a member with relief and appreciation. A sexually abused woman described the removal of a sadistic, destructive male group member as the first time in her life that the “people in charge” were not helpless or blind to her suffering. The Departing Member: Therapeutic Considerations When a client is asked to leave or chooses to leave a group, the therapist must endeavor to make the experience as constructive as possible. Such clients ordinarily are considerably demoralized, and they tend to view the group experience as one more failure. Even if the client denies this feeling, the therapist should still assume that it is present and, in a private discussion, provide alternative methods of viewing the experience. For example, the therapist may present the notion of readiness or group fit. Some clients are able to profit from group therapy only after a period of individual therapy; others, for reasons unclear to us, are never able to work effectively in a therapy group. It is also entirely possible that the client may achieve a better fit and a successful course of therapy in another group, and this possibility should be explored. We have seen this happen many times. In any case, you should help the removed member understand that this outcome is not a failure on his or her part but that, for several possible reasons, a form of therapy has proved unsuccessful. It is usually more than just the client’s failing when therapy falters, and by sharing that responsibility with the client, you may both help the client and further your own self-exploration about your work as a therapist.91 It may be useful in the final interview to review the client’s experience in the group in some detail. Occasionally, a therapist is uncertain about the advisability of confronting someone who is terminating therapy. Should you, for example, confront the denial of an individual who attributes his dropping out of the group to his hearing difficulties, when in fact he had not been a good fit and had been rejected by the group? As a general principle, it is useful to consider the client’s entire career in therapy. If the client is very likely to reenter therapy, a constructive, gentle confrontation will, in the long run, make any subsequent therapy more effective. If, on the other hand, it is unlikely that the client will pursue a dynamically oriented therapy, there is little point in presenting a final interpretation, because the client will never be able to use or extend these insights in the future. Test the denial. If it is deep, leave it be. There is no point in undermining defenses, even self-deceptive ones, if you cannot provide a satisfactory substitute. Avoid adding insight to injury.92 The Addition of New Members Whenever the group census falls too low (generally five or fewer members), the the therapist should introduce new members. This may occur at any time during the course of the group, but in the long-term group there are major junctures when new members are usually added: during the first twelve meetings (to replace early dropouts) and after twelve to eighteen months (to replace improved, graduating members). With closed, time-limited groups, there is a narrow window of the first three to four weeks in which it is possible to add new members and yet provide them with an adequate duration of therapy. The success of introducing new members depends in part on proper timing. There are favorable and unfavorable times to add members. Generally, a group that is in crisis, that is actively engaged in an internecine struggle, or that has suddenly entered into a new phase of development does not favor the addition of new members; it will often reject the newcomers or else evade confrontation with the pressing group issue and instead redirect its energy toward the newcomers. Examples include a group that is dealing for the first time with hostile feelings toward a controlling, monopolistic member, or a group that has recently developed such cohesiveness and trust that a member has, for the first time, shared an extremely important secret. Your attention to the group’s developmental stage is helpful here. Better to add members in the forming or norming/performing stages than in the midst of conflict and high tension.93 Some therapists postpone the addition of new members if the group is working well, even when the census is down to four or five. We prefer not to delay, and promptly begin to screen candidates. Small groups, even highly cohesive ones, will eventually grow even smaller through absence or termination and soon will lack the interaction necessary for effective work. The most auspicious period for adding new members is during a phase of stagnation in the group. Many groups, especially older ones, sensing the need for new stimulation, actively encourage the therapist to add members. Some groups are very clear about the timing of new members joining. This was the case for a group where the members are all women with metastatic breast cancer, for example. In a group dealing with a very ill, dying, or recently deceased member, the members may prefer not to have new additions, because they need all of their energy and time to address their loss and grief.94 Response of the Group to New Members A cartoon cited by a British group therapist portrays a harassed woman and her child trying to push their way into a crowded train compartment. The child looks up at his mother and says, “Don’t worry, Mother, at the next stop it will be our turn to hate!”95 The parallel to new members entering the group is trenchant. Hostility to the newcomer is evident even in a group that has beseeched the therapist to add new members, and it may reach potent levels. The attention to group process and group dynamics is always essential but even more so at these important developmental points. The addition of new members is also an opportunity for the existing members to reevaluate their progress and reset goals. One member who had long refused to disclose his occupation to his group announced that he wanted to share that information now before new members entered. He was embarrassed at his obstinacy and secretiveness. His early refusal to share that information was initially a control issue for him. Then he felt stuck in the secret, but now he saw how absurd it would be to hold that position as a “group veteran” with new members arriving. His trust had grown, as had his desire for openness, and he wanted to start there with the new members. At other times the entry of new members may prompt regressive behavior by the older group members. We have observed many times that when new members are slated to enter a meeting, existing members begin to arrive late; they may even remain for a few minutes talking together animatedly in the waiting room while the therapists and the new clients wait in the therapy room. A content analysis of sessions in which a new member or members are introduced reveals several themes that are hardly consonant with benevolent hospitality. The group suddenly spends far more time than in previous meetings discussing the good old days. Long-departed group members and events of bygone meetings are avidly recalled, reminding new members, as if they could possibly have forgotten, of their novitiate status. Old battles are reengaged to make the group as unwelcoming as possible. Similarly, members may remark on resemblances they perceive between a new member and some departed, failed member. The newcomer may get grilled. A group may also express its ambivalence by discussing, in a newcomer’s first meeting, threatening and confidence-shaking issues. For example, one group “welcomed” two new members by noting that the therapists were listed on the psychiatry website as second-year residents and suggesting that they might be leading their first group. This issue—an important one that should be discussed—was nonetheless highly threatening to new members. It is of interest that this information was widely known to several group members but had never been mentioned until that meeting. On the other hand, there can be strong feelings of welcome and support if the group has been eager to add new members. The members may exercise great gentleness and patience in dealing with new members’ initial fear or defensiveness. The group may attempt, in a variety of ways, to increase its attractiveness to the newcomer. Often members gratuitously offer testimonials and describe the various ways in which they have improved. In one group, a newcomer asked a disgruntled, resistant member about her progress, and before she could reply, two other members, sensing that she would devalue the group, interrupted and described their own progress. Although groups may unconsciously wish to discourage newcomers, members are generally not willing to do so by devaluing their own group. Groups may have ambivalent responses to new members for several reasons. Some members, who highly prize the solidarity and cohesiveness of the group, may feel threatened by any proposed change to the status quo. Will the new members undermine the group? In one group, I (ML) was grilled by the existing members about the proposed entry of new members after a hostile dropout had shaken the group. How could I have brought such a disruptive person into their midst? Could I be trusted to make a good selection this time? Powerful sibling rivalry issues may be evoked at the prospect of a new drain on the group’s supplies: members may envision newcomers as potential rivals for the therapist’s and the group’s attention and perceive their own fantasized role as favored child to be in jeopardy.96 A common concern of a group is that new members will slow the group down: the group fears that familiar material will have to be repeated for the newcomers and that the group must recycle and relive the tedious stages of gradual social introduction and ritualistic etiquette. Fortunately, this expectation generally proves to be unfounded. New clients introduced into an ongoing group generally move quickly into the prevailing level of group communication and bypass the early testing phases characteristic of members in a newly formed group. Commonly, the new members of the group have a unique and constructive perspective on the group members. They see the older members as they currently are, rather than how they used to be, often admiring their perceptiveness, social comfort, and interpersonal skills, and thus reinforcing the changes veteran members have achieved. This feedback can serve as a powerful reminder of the value of the therapeutic work done to date. The morale of the new and the old members can be enhanced simultaneously, and cohesion strengthened. Therapeutic Guidelines for Adding New Members Clients entering an ongoing group require not only the comprehensive preparation to group therapy we discussed in Chapter 9 but also additional preparation to help them deal with the unique stresses of joining an established group. Entry into any established culture—a new living situation, job, school, and so on—produces anxiety and, as extensive research indicates, demands orientation and support.97 We tell new members to expect feelings of exclusion and bewilderment on entering a new and unusual culture and we reassure them that they will be allowed to enter and participate at their own pace. New clients entering established groups may be daunted by the sophistication, openness, interpersonal facility, and daring of more experienced members. They may also be frightened or fear contagion, since they are immediately confronted with members revealing more of their pathology than is revealed in the first meetings of a new group. These contingencies should be discussed with the client. It is generally helpful to describe the major events of the past few meetings to the incoming participant. If the group has been going through some particularly intense, tumultuous events, it is wise to provide an even more thorough briefing. If the therapist uses a written summary technique (described in Chapter 13), then the new member, with the group’s permission, may be asked to read the summaries of the past few meetings. We make an effort to engage the new client in the first meeting or two. Often it is sufficient merely to inquire about his or her experience of the meeting—something to the effect of: “Sally, this has been your first session. So far, what has the meeting felt like for you? Does it seem like it will be difficult to get into the group? What concerns about your participation are you aware of so far?” It’s often useful to help new clients assume some control over their participation. For example, the therapist might say, “I note that several questions were asked of you earlier. How did that feel? Too much pressure? Or did you welcome them?” Or, “Sally, I’m aware that you were silent today. The group was deeply engaged in business left over from meetings when you were not present. How did that make you feel? Relieved? Or would you have welcomed questions directed at you?” Note that all of these questions are here-and-now centered. Many therapists prefer to introduce two new members at a time, a practice that may have advantages for both the group and the new members. Occasionally, if one client is integrated into the group much more easily than the other, it may backfire and create even greater discomfort for the other newcomer, who may feel that he is already lagging behind his cohort. Nevertheless, introduction in pairs has much to recommend it: the group conserves energy and time by assimilating two members at once, and the new members may ally with each other and thereby feel less alien. Many months later, we have heard clients who joined an ongoing group at the same time refer to the support and comfort of joining with someone else. The number of new members introduced into the group distinctly influences the pace of absorption. A group of six or seven can generally absorb a new member with scarcely a ripple; the group continues work with only the briefest of pauses and rapidly pulls the new member along. On the other hand, a group of four confronted with three new members often comes to a screeching halt: ongoing work ceases and the group devotes all its energy to the task of incorporating the new members. The old members will wonder how much they can trust the new ones. Dare they continue with the same degree of self-disclosure and risk-taking? To what extent will their familiar, comfortable group be changed forever? The new members will be searching for guidelines to behavior. What is acceptable in this group? What is forbidden? If their reception by the established members is not gracious, they may seek comfort in an alliance of newcomers. The therapist who notes frequent use of “we” and “they,” or “old members” and “new members,” should heed these signs of schism. Until incorporation is complete, little further therapeutic work can be done. Research into groups that have old members regularly departing and new ones entering shows that the alliance and approach to the work of the group is reliably transmitted.98 A similar situation often arises when the therapist attempts to amalgamate two groups that have been reduced in number. This procedure is not easy. A clash of cultures and cliques formed along the lines of the previous groups can persist for a remarkably long time, and the therapist must actively prepare clients for the merger. It is best in this situation to end both groups and then resume as a totally new entity. An important principle of group therapy, which we have discussed, is that every major stimulus presented to the group elicits a variety of responses by the group members. It is like a projective test. The investigation of the reasons behind these different responses is generally rewarding and clarifies aspects of character structure. Thus, the introduction of new members may shed light on the inner world of the old members, who may respond to a newcomer in highly idiosyncratic styles. Members who observe others responding to a situation in ways remarkably different from their own may obtain considerable insight into their own behavior. Such an opportunity is unavailable in individual therapy but constitutes one of the chief strengths of the group therapeutic format. The group’s capacity to reflect on itself is essential. Much learning emerges from examining the process of what is unfolding without becoming enmeshed in the content. An illustrative clinical example may clarify this point: > A new member, Alexia—forty years old, attractive, divorced—was introduced at a group’s eighteenth meeting. The three men in the group greeted her in strikingly different fashions.
Peter arrived fifteen minutes late and missed the introduction. For the next hour, he was active in the group, discussing issues left over from the previous meeting as well as events occurring in his life during the past week. He totally ignored Alexia, avoiding even glancing at her—a formidable feat in a group of seven people in close physical proximity. Later in the meeting, as others attempted to help Alexia participate, Peter, still without introducing himself, fired questions at her like a harsh prosecuting attorney. He had sought therapy because he “loved women too much,” as he phrased it, and had had a series of extramarital affairs. In subsequent meetings, the group used the events of Alexia’s first meeting to help Peter investigate the nature of his “love” for women. Gradually, he came to recognize how he used women, including his wife, as sex objects, valuing them for their bodies alone and remaining insensitive to their feelings and experiential world.
The two other men in the group, Arturo and Brian, on the other hand, were preoccupied with Alexia during her first meeting. Arturo, a twenty-nine-year-old who had sought therapy because of his massive sexual inhibition, reacted strongly to Alexia and found that he could not look at her without experiencing an acute sense of embarrassment. His discomfort and blushing were apparent to the other members, who had previously helped him explore his relationship with the other women in the group. Arturo had desexualized the other two women in the group by establishing in his fantasy a brother-sister relationship with them. Alexia, who was attractive and available and at the same time old enough to evoke in him affect-laden feelings about his mother, presented a special problem for Arturo, who had previously been settling into too comfortable a niche in the group.
Brian transfixed Alexia with his gaze and delivered a broad, unwavering smile to her throughout the meeting. An extraordinarily dependent thirty-three-year-old, Brian had sought therapy for depression after the breakup of a love affair. Having lost his mother in infancy, he was a poor little rich boy, raised by a succession of nannies and housekeepers; he had had only occasional contact with his aloof, powerful father, of whom he was terrified. His romantic affairs, always with considerably older women, had invariably collapsed because of the insatiable demands he made on the relationship. The other women in the group in the past few meetings had similarly withdrawn from him. With progressive candor, they had confronted him about, as they termed it, his puppy-dog presentation of himself. Brian thus welcomed Alexia, hoping to find in her a new source of succor. In subsequent meetings, Alexia proved helpful to Brian. During her first meeting, she revealed her extreme discomfort at his beseeching smile and her persistent sense that he was asking for something important from her. She said that although she was unsure of what he wanted, she knew it was more than she had to give. << Freud once compared psychotherapy to chess in that far more is known and written about the opening and the end games than about the middle game. Accordingly, the opening stages of therapy and termination may be discussed with some degree of precision, but the vast bulk of therapy cannot be systematically described. Thus, the subsequent chapters follow no systematic group chronology but deal in a general way with the major issues and problems of later stages of therapy as well as with some specialized therapist techniques. Chapter 11 The Advanced Group ONCE A GROUP ACHIEVES A DEGREE OF MATURITY AND STABILITY, it no longer exhibits discrete, easily described stages of development. The rich and complex working-through process begins, and the major therapeutic factors we described earlier operate with increasing force and effectiveness. Members engage more deeply in the group and use the group interaction to address the concerns that first brought them to therapy. The advanced group is characterized by members’ growing capacity for self-disclosure, feedback, and reflection.1 Hence, it is difficult to formulate specific procedural guidelines for all contingencies. In general, the therapist must strive to encourage development and operation of the therapeutic factors. The application of the basic principles of the therapist’s role and technique to specific group events and to each client’s therapy, as discussed in Chapters 5, 6, and 7, constitutes the art of psychotherapy, and for this there is no substitute for clinical experience, reading, supervision, and intuition. HOW INTERPERSONAL LEARNING WORKS In our discussion of the therapeutic factors, we emphasized that helping clients understand and improve their interpersonal relationships is at the very core of the group therapy endeavor. The following vignette illustrates some of the complexities and subtleties of helping group members understand and alter their modes of relating to others: > Four men and four women were members of an open-ended group. Andie, a forty-two-year-old single woman working as a health-care aide, began the session. She had sought group therapy to deal with chronic issues of depression, poor self-esteem, and a pattern of making poor choices concerning partners. She had also struggled with substance abuse and significant feelings of shame and self-devaluation. Noah, a forty-five-year-old married businessman, was another key member in the meeting. He had sought group therapy to deal with issues of interpersonal isolation and chronic relational dissatisfaction. He consistently felt neglected and unrecognized for his talents and abilities, and his marriage was marked by chronic tension and distress.
Andie, who had been in the group for approximately four months, began the group meeting in obvious emotional distress. Crying as she spoke, she told us that she was very grateful to be in the group, but felt badly about herself for not having made as much use of the group as she had hoped. She said she’d come to the group that day determined not to leave without opening up about her core concerns. She had often seen others in the group do so to good effect, and she had lamented going home session after session feeling that she had barely scratched the surface. She was apprehensive about how the group would respond but decided that she would take that risk.
In compelling detail, Andie described how she had struggled all of her life with poor self-esteem. She had grown up with a single mom and never knew her father. Her relationships with men were exploitative and abusive—if not physically, then certainly emotionally and financially. To deal with her strong negative emotions, she had used marijuana and cocaine to such an extent that she had accumulated significant financial debt. This, in turn, meant that she had to work long hours to stay afloat financially. She had considered declaring bankruptcy but refused to do so, feeling that it would be yet another capitulation to her inability to manage her life with integrity. This was a powerful revelation on Andie’s part and the group was attentive to her every word.
Some members shared similar experiences about substance abuse, bankruptcy, and poor relationship choices. One member commented how she could palpably feel the kind of shame that Andie harbored, and reassured Andie that she, and others, as well, could relate to her and identify with her situation. The best way to deal with shame, she added, was to bring it into the light of day just as she was doing now. Another member commented on his increased respect for Andie.
This was an eye-opening experience for Andie: not only did group members identify with her, but she was admired and respected for her courage. The impact on her shame was profound. Tears of relief flowed as she acknowledged her gratitude for the group’s support.
Everyone in the group was deeply involved with Andie except for Noah, who sat absolutely silent with his chair a half inch out of the circle. I (ML) felt irritated by this. We had worked hard on Noah’s narcissistic self-absorption and his tendency to seek attention from the group without giving back to it. He seemed disinterested in Andie’s declaration to the group, and the hard work we had done with him was not evident in his reaction.
During a momentary pause—the kind of pause that groups often use to shift focus—Noah jumped in and said that he also had important things to talk about. He described another round of difficulties with his wife and his anger at her lack of responsiveness toward him. In contrast to the earlier segment of the meeting, in which people were literally leaning forward in their chairs, drawing as close as they could to Andie, people listened politely but with little engagement. I made a process inquiry, asking the group to compare how they felt in the first part of the meeting with how they were feeling now. Despite a couple of inquiries, there was little response to my question, and I decided to express my feelings more openly.
“Noah,” I began, “I want to share something with you that I hope I can convey clearly. I am going to take a bit of a risk here, and I hope you don’t experience this as harsh. I’m finding it hard to generate interest in what you are saying to the group, and it’s not because what you feel isn’t important, but because I feel disappointed and irritated that you were silent throughout the meeting until you began to talk about your own issues. I want to ask you a question: How did you feel about what Andie shared with us?”
Noah acknowledged that he felt supportive of Andie but had chosen not to say anything to her. He was eager to talk about his own concerns, however, and he wanted to make sure there would be time for him in the group. I commented that his lack of response to Andie made it harder for me to respond to him, and wondered whether the group’s subdued response to his disclosure reflected similar feelings that others had. Several heads nodded. I then told Noah that his waiting for an opening to turn the group’s attention onto him, rather than providing support and feedback for Andie’s important self-disclosure, was very problematic for him. I asked him to consider the idea that the more he gave to others, the more others would reciprocate. I added that I knew this was a foreign concept to him, based upon what he had shared with us earlier about his very competitive and narcissistic family, a family in which the loudest and most demanding individual got whatever little bit of attention was available.
Noah acknowledged that he felt hurt by my feedback and wondered how long I had harbored that feeling before speaking to him. I told him I had been thinking about it throughout the meeting and spoke about it as soon as it was clear in my mind. I hoped he heard it in the spirit in which I had intended it. He commented that he valued our relationship and he would have to think about this. He then asked others in the group what they thought about my feedback to him. Jack, an older group member, commented that he felt it was incredibly important feedback, and he hoped Noah would be able to hear it. He had wanted to give similar feedback but had not been able to think of a way to do it without possibly hurting Noah.
Noah seemed to take this in, and as we explored these ideas more fully in the group as a whole, Sharon—a woman who had grown up in an environment of great emotional deprivation and neglect, asked me, “How did you decide to say what you did? Was that just technique or was it coming from a real place in you?”
I responded to Sharon, “Choosing to share it and how to share it involved technique but, without doubt, it came from a real place inside me.” Sharon responded that she tended to mistrust care providers—she expected us to be disinterested in her. That was why she had wondered if I was truly present or just going through the motions. << This illustration underscores some of the key elements that make group therapy and the group therapist effective: • The group functioned as a social microcosm, with members genuinely bringing themselves into the here-and-now. Noah’s behavior in the group closely paralleled his behavior in his life outside the group. • Group cohesion provided the safety that encouraged Andie’s risk-taking and self-disclosure. • Andie’s self-disclosure was followed by feedback that disconfirmed her expectation of being judged and shamed. • Noah displayed his interpersonal pathology in the group, which, in his social world, alienated people and left him isolated. • Group members responded in a perfunctory manner to Noah, depriving him of meaningful engagement. • I paid close attention to my feelings about Noah. • I recognized that I had been hooked by Noah interpersonally and I knew that if I didn’t get unhooked, I would stay either disinterested or angry with him. • Instead, I used my awareness of my irritation as a way to understand Noah’s contributions to his being neglected and invalidated. • When I metabolized my reactions sufficiently, I described what I saw him doing and what its impact was on me and on others. • I tried to embed my feedback with care for him, and I bolstered the feedback by linking it to his primary goals in therapy. • I modeled risk-taking and judicious self-disclosure in my comments to Noah. I commented about something that was alive and palpable in the group that others at that moment felt unable to express. • When Sharon asked about my comments, I was careful to answer in an open and authentic way, responding to what I believed were questions about my genuineness and my respect for and involvement with the group members. • At every step along the way, we examined what the group experience felt like and what it meant to the group members. For example, I asked Andie, “What was it like coming home after each group for the last several sessions having not spoken to us?” Toward the end of the meeting, I asked her, “What will it be like going home tonight knowing that you have opened this up?” • Lastly, I tried to draw a parallel for Noah between his way of relating to us and how he may have been relating to his wife and to others in his life. We begin this chapter with this detailed example to illustrate many of the key concepts and principles that we have addressed earlier in the book. We now turn our attention to some key challenges of the advanced group. While it is not possible to anticipate all contingencies, certain issues and problems occur with sufficient regularity to warrant discussion. In this chapter, we consider subgrouping, conflict, self-disclosure, and termination of therapy. In the next chapter, we’ll discuss certain recurrent behavioral configurations in individuals that present a challenge to the therapist and to the group. SUBGROUPING Subgrouping—the splitting off of smaller units—occurs in every social organization. Who among us has not sought the comfort of connection with others in a smaller section of a larger group? The process may be transient or enduring, helpful or harmful, for the parent organization. The subgroup may express itself subtly in emotional terms alone, or the subgroup may be transparent and visible to the entire group. Therapy groups are no exception. Subgroup formation is an inevitable and often disruptive event in the life of the group, yet there, too, the process, if understood and harnessed properly, may advance the therapeutic work.2 How do we account for the phenomenon of subgrouping? We need to consider both individual and group factors in the creation of the subgroup. At times the subgroup is concealed and blocks group functioning and understanding in ways that are disruptive, even destructive, to the group. At other times, the subgroup exists in plain sight and coalesces around difficult emotions, such as wishes and fears present in the larger group related to strong feelings of dependence, vulnerability, envy, or mistrust. When we examine a subgroup in depth we can deepen our understanding of what the subgroup is holding for the members of the group at large.3 Individual factors, such as members’ concerns about personal connection and status, often motivate the creation of the subgroup within in the therapy group. A subgroup arises from the belief of two or more members that they can derive more gratification from a relationship with one another than from the entire group. Members who violate group norms by forming secret liaisons are opting to gratify needs rather than to pursue personal change—their primary reason for being in therapy (see the discussion of primary task and secondary gratification in Chapter 6). Need frustration occurs early in therapy: for example, members with strong needs for intimacy, dependency, or dominance may soon sense the challenge of gratifying these needs in the group, and thus attempt to gratify them outside the formal group. In one sense, these members are “acting out”: they are engaging in behavior outside the group therapy setting that relieves inner tensions and avoids direct expression or exploration of feeling or emotion. Sometimes it is only possible in retrospect to discriminate “acting out” from participating in the therapy group. Let us clarify. The course of the therapy group is a continual cycle of action and then analysis of this action. The social microcosm of the group depends on members engaging in their habitual patterns of behavior, which are then examined by the individual and the group. Acting out turns into resistance only when one refuses to examine one’s behavior. Extragroup behavior that is not examined in the group becomes a particularly potent form of resistance, whereas extragroup behavior that is subsequently brought back into the group and worked through may prove to be of considerable therapeutic import. It is the secretiveness and silence that is most destructive to the group.4 Subgrouping may also come about as a consequence of “group factors”: for example, it may be a manifestation of a considerable degree of unaddressed emotion or undischarged hostility in the group, especially toward the leader. Research on styles of leadership demonstrates that a group is more likely to develop disruptive in-group and out-group factions under an authoritarian, restrictive style of leadership.5 This kind of leadership impedes cohesion and a sense of safety in the group. Group members, unable to express their anger and frustration directly to the leader, release these feelings obliquely by binding together or by scapegoating one or more of the other members. At other times, subgrouping is a sign of problems in group development. A lack of group cohesion will encourage members to retreat from large and complex group relationships into simpler, smaller, more workable subgroups. Hence, any sustained threat to group integrity and group stability can foster subgrouping. Clinical Appearance of Subgrouping Extragroup socializing is often the first stage of subgrouping. A clique of three or four members may begin to have telephone conversations, text, email, or Facebook exchanges, or they may meet over coffee, ride the subway home together, look after one another’s pets, or visit each other’s homes. Occasionally, two members will become sexually involved. A subgroup may also occur completely within the confines of the group therapy room, as members who perceive themselves to be similar form coalitions. In settings such as day hospitals and residential treatment programs, subgrouping becomes even more likely owing to the large amounts of time members spend with one another between sessions and outside of the actual therapy group meetings. In forming into subgroups, members seek to reduce the anxiety that stems from being part of the larger group and find comfort by joining with others with whom they share some common bond: a comparable educational level, similar values, or the same ethnocultural background, age group, sexual orientation, marital status, or group status (for example, the old-timer original members). As one clique forms, the members who are left out may feel diminished and excluded. The stage is set for polarization, marginalization, and scapegoating. The members of a subgroup may be identified by a general code of behavior. For example, they may agree with one another regardless of the issue and avoid confrontations among their own membership; they may exchange knowing glances when a member not in the clique speaks; they may arrive at and depart from the meeting together; or their wish for friendship may override their commitment to examination of their behavior.6 Their perspective is shaped by the pressure to maintain the subgroup rather than the commitment to doing the work of therapy (a process all too painfully familiar in the world of tribal politics). The Effects of Subgrouping Subgrouping can have an extraordinarily disruptive effect on the course of the therapy group. In a study of thirty-five clients who prematurely dropped out from group therapy, I (IY) found that eleven of them (31 percent) did so largely because of problems arising from subgrouping. Complications arise whether the client is included in or excluded from a subgroup.7 Inclusion. Those included in a twosome or a larger subgroup often find that group life becomes vastly more complicated, and ultimately, less rewarding. As a group member transfers allegiance from the group goals to the subgroup goals, loyalty becomes a major and problematic issue. For example, should one abide by the group procedural rules of free and honest discussion of feelings if that means breaking a confidence established secretly with another member? > Christine and Jerry often met after the therapy session to have long, intense conversations. Jerry had remained withdrawn in the group and had sought out Christine because, as he informed her, he felt that she alone could understand him. After obtaining her promise of confidentiality, he soon was able to reveal his gender identity confusion to her and his deep distrust of the group leader and the group leader’s judgment. In the group, Christine felt restrained by her promise and avoided interaction with Jerry, who eventually dropped out unimproved. Ironically, Christine was an exceptionally sensitive member of the group and might have been particularly useful to Jerry by encouraging him to participate in the group, had she not felt restrained by the antitherapeutic subgroup norm (that is, her promise of confidentiality). << Sharing with the rest of the members what one has learned in extragroup contacts is tricky, and it is for that reason that leaders must explain clearly, as early as the preparation stage, that subgrouping undermines therapy. Members who conceal secret information about one another arising from extragroup meetings are placed in a difficult antitherapeutic situation. > An older, avuncular man often gave two other group members a ride home after group meetings. On one occasion he invited them to watch a ball game on television at his house. The visitors witnessed an argument between the man and his wife and at a subsequent group session said that they felt he was mistreating his wife. The older member felt betrayed by the two members, whom he had considered his friends, and began concealing issues from the group. Ultimately, he dropped out of treatment. << Severe clinical problems can occur when two group members engage in an intimate relationship. Therapy group members who become involved intimately will almost inevitably come to award their dyadic relationship higher priority than their relationship to the group. In forming this partnership, they sacrifice their value for each other as helpmates in the group. They will refuse to betray confidences, and rather than being honest in the group, they will attempt to be charming to each other. They perform for each other, blotting out the therapists and other members of the group, and, most important, they lose sight of their primary goals in therapy. Often the other group members are dimly aware that something important is being actively avoided in the group discussion, a state of affairs that usually results in global group inhibition. An unusual chance incident provided empirical evidence substantiating these comments:8 > A research team happened to be closely studying a therapy group in which two members developed a clandestine sexual relationship. Since the study had begun months before the liaison occurred, good baseline data was available. Several observers (as well as the clients themselves, in postgroup questionnaires) had for months rated each meeting along a seven-point scale for the amount of affect expressed, the amount of self-disclosure, and the general value of the session. In addition, the communication-flow system was recorded, with the number and direction of each member’s statements charted on a who-to-whom matrix.
During the observation period, Bruce and Hailey developed a sexual relationship. They kept it secret from the therapist and the rest of the group for three weeks. During that time, the data (when studied in retrospect) showed a steep downward gradient in the scoring of the quality of the meetings, with reduced verbal activity, expression of affect, and self-disclosure. Moreover, very few verbal exchanges were recorded between Hailey and Bruce. << This last finding is the quintessential reason that subgrouping impedes therapy. The primary goal of group therapy is to facilitate each member’s exploration of his or her interpersonal relationships. Here were two people who knew each other well, had the potential of being deeply helpful to each other, and yet barely spoke to each other in the group. The couple resolved the problem by deciding that one of them would drop out of the group (not an uncommon resolution). Hailey dropped out, and in the following meeting, Bruce discussed the entire incident with relief and great candor. (The ratings by both the group members and the observers indicated this meeting to be exceptionally valuable, with active interaction, strong affect expression, and much disclosure from others as well as Bruce.) The positive, affiliative effects of subgrouping within the therapy group may be turned to therapeutic advantage.9 The therapy group is generally a large and dynamic group made up of several smaller subgroups. Subgrouping occurs (and may even be judiciously encouraged by the therapist) as a component of addressing areas of conflict or distress within the group. Clients who have difficulty acknowledging their feelings or disclosing themselves may do better if they sense they are not alone. Hence, the therapist may actively point out clusters of members who share some basic intrapersonal or interpersonal concern. Other members may be invited to explore their own relationships to the emotions, fears, wishes, or aspirations carried by others. The question of “Anyone else?”10 following a personal disclosure underscores that many in the group may resonate with what has been shared. Encouraging such interaction across the subgroup boundaries promotes a safer, more inclusive therapy environment. It fosters universality and integration rather than isolation.11 Exclusion. Exclusion from the subgroup complicates group life. Anxious memories associated with earlier peer exclusion experiences are evoked and may become disabling if they are not discharged by working through the issue in the group. Often it is difficult for members to comment on their feelings of exclusion: they may not want to reveal their envy of the special relationship, or they may fear angering the involved members by “outing” the subgroup in the session. Nor are therapists immune to this problem. I (IY) recall a group therapist, one of my supervisees, who told me he had observed two of his group members walking arm in arm along the street. The therapist found himself unable to bring his observation back into the group. Why? He offered several reasons: • He knew these members were married to other people and he did not want to assume the position of spy or disapproving parent in the eyes of the group. • He works in the here-and-now and is not free to bring up nongroup material. • He hoped the involved members would, when psychologically ready, discuss their relationship. These are rationalizations, however. There is no more important issue than the interrelationship of the group members. Anything that happens between group members is part of the here-and-now of the group. The therapist who is unwilling to bring in all material bearing on member relationships can hardly expect members to do so. If you feel yourself trapped in a dilemma—on the one hand, knowing that you must bring in such observations, and, on the other, not wanting to seem to be playing detective—then generally the best approach is to share your dilemma with the group—both your observations and your personal uneasiness and reluctance to discuss them.12 Therapeutic Considerations By no means is subgrouping, with or without extragroup socializing, invariably disruptive. If the goals of the subgroup are consonant with those of the parent group, subgrouping may ultimately enhance group cohesiveness. The key is to improve communication across the boundaries of the subgroup and to reduce the isolation of its members. Some of the most significant therapeutic opportunities arise as a result of some extragroup contacts that are then fully worked through in therapy. > Two women members who had gone to a dance together after a meeting discussed, in the following meeting, their observations of each other in that purely social setting. One of them had been far more flirtatious, even openly seductive, than she had been in the group; furthermore, much of this was “blind spot” behavior—out of her awareness. << > In another group, a dramatic example of effective subgrouping occurred when the members became concerned about one member who was in such despair that she considered suicide. Several group members maintained a week-long telephone vigil, which proved to be beneficial both to that client and to the cohesiveness of the entire group. << > In another example of subgrouping that enhanced therapeutic work, a client attempted to form an extragroup alliance with every member of the group. Ultimately, as a result of his extragroup activity and the exploration of it in the group, he arrived at important insights about his manipulative modes of relating to peers and about his adversarial stance toward authority figures. << The principle is clear: any extragroup contact may prove to be of value, provided that the goals of the parent group are not relinquished. If such meetings are viewed as part of the group’s rhythm of action and subsequent analysis, much valuable information can be made available to the group. To achieve this end, the involved members must inform the group of every important extragroup event. If they do not, the disruptive effects on cohesiveness we have described will occur. The cardinal principle is this: It is not the subgrouping per se that is destructive to the group, but the conspiracy of silence that surrounds it. The therapist should encourage open discussion and analysis of all extragroup contacts and all in-group coalitions while continuing to emphasize the members’ responsibility to bring extragroup contacts into the group. We must utilize all the interpersonal data accessible to us. The therapist who surmises from glances between two members in the group, or from their appearance together outside the group, that a special relationship exists between them should not hesitate to present this thought to the group. No criticism or accusation is implied, since the investigation and understanding of an affectionate relationship between two members may be as therapeutically rewarding as the exploration of a hostile impasse. Furthermore, other members must be encouraged to discuss their reaction to the relationship, whether it be envy, jealousy, or vicarious satisfaction.13 Clients engaged in some extragroup relationship that they are not prepared to discuss in the therapy group may ask the therapist for an individual session and request that the material discussed not be divulged to the rest of the group. If you make such a promise, you may soon find yourself in an untenable collusion from which extrication is difficult. We suggest that you refrain from offering a promise of confidentiality; instead, assure the clients that you will be guided by your professional judgment and will try to act with sensitivity on their therapeutic behalf. Though this promise may not offer sufficient reassurance to all members, it will protect you from entering into awkward, antitherapeutic pacts. It is impossible to function as a group leader with pertinent information about members you are unable to address within the group as a whole. Therapy group members sometimes develop sexual relationships with one another, but not with great frequency. The therapy group is not prurient; clients often have sexual conflicts resulting in such problems as impotence, nonarousal, and sexual guilt. Our experience suggests that far less sexual involvement occurs in a therapy group than in any equally long-lasting social or professional group. The therapist cannot, by edict, prevent the formation of sexual relations or any other form of subgrouping. Sexual acting out is often symptomatic of the relationship difficulties that led to therapy in the first place. As in all situations, we want our clients to bring themselves as they genuinely are to the group. The emergence of sexual acting out in the group may well present a unique therapeutic opportunity to examine the behavior. Though extragroup subgrouping cannot be forbidden, it should never be encouraged. We have found it most helpful to make our position on this problem explicit to members in the preparatory or initial sessions. We tell them that extragroup activity often impedes therapy, and we clearly describe the complications caused by subgrouping. We emphasize that if extragroup meetings occur, fortuitously or by design, then it is the subgroupers’ responsibility to the other members and to the group to keep the others fully informed. As we noted earlier, the therapist must help the members understand that the group therapy experience is a dress rehearsal for life; it is the bridge, not the destination. It will teach the skills necessary to establish durable relationships but will not provide the relationships. If group members do not transfer their learning to their lives outside the group, and instead derive their social gratification exclusively from the therapy group, therapy becomes unproductive and interminable. For these reasons, it is unwise to include two members in a group who already have a long-term special relationship: husband and wife, roommates, professional colleagues, business associates, and so on. Occasionally, the situation may arise in which two members naïvely arrive for a first meeting and discover that they know one another from a prior or preexisting personal or employment relationship. It is not the most auspicious start to a group, but the therapist must not avoid examining the situation openly and thoroughly. Is the relationship ongoing? Will the two members be less likely to be fully open in the group? Are there concerns about confidentiality? How will it affect other group members? Is there a better or more workable option? The therapist must reach a quick and a shared decision, including potentially finding other groups for the affected members. It is possible for group therapy to focus on current long-term relationships between members, but that entails a different kind of therapy group than that described in this book—for example, a marital couples’ group, conjoint family therapy, and multiple-family therapy.14 As we noted earlier, the problem of extragroup relationships in inpatient psychotherapy groups and day hospital programs is even more complex, since the group members spend their entire day in close association with one another. The following case is illustrative: > In a group in a state psychiatric hospital for criminal offenders, a subgrouping problem had created great divisiveness. Two male members—by far the most intelligent, articulate, and educated of the group—had formed a close friendship and spent much of every day together. The group sessions were characterized by an inordinate amount of tension and hostile bickering, much of it directed at these two men, who by this time had lost their separate identities and were primarily regarded, and regarded themselves, as a dyad. Much of the attacking was off target, and the therapeutic work of the group had become overshadowed by the attempt to destroy the dyad.
As the situation progressed, the therapist, with good effect, helped the group explore several themes. First, the group had to consider that the two members could scarcely be punished for their subgrouping, since everyone had had an equal opportunity to form such a relationship. The issue of envy was thus introduced, and gradually the members discussed their own longing for friendships and their inability to establish them. Furthermore, they discussed their feelings of intellectual inferiority to the dyad as well as their sense of exclusion and rejection by them.
The two members had, however, exacerbated these responses by their actions. Both had maintained their self-esteem by demonstrating their intellectual superiority whenever possible. When addressing other members, they deliberately used polysyllabic words, and they maintained a conspiratorial attitude that accentuated the others’ feelings of inferiority and rejection. Both members profited from the group’s description of the subtle rebuffs and taunts they had meted out and came to realize that others had suffered painful effects from their behavior. << Nota bene, our comments on the potential dangers of subgrouping apply to groups that rely heavily on the therapeutic factor of interpersonal learning and self-understanding. In other types of groups, such as cognitive-behavioral groups for eating disorders, extragroup socializing has been shown to be beneficial—for example, in altering eating patterns.15 Twelve-step groups, self-help groups, and support groups also make good use of extragroup contact. In groups of cancer patients, extragroup contact becomes an essential part of the process, and participants may be actively encouraged to contact one another between sessions as an aid in coping with the illness and its medical treatment.16 On many occasions, we have seen the group rally around members in deep despair and provide extraordinary support. In our groups for women with advanced breast cancer, group members may attend medical appointments together, prepare meals for ill members, and even deliver eulogies at the funerals of group members. CONFLICT IN THE THERAPY GROUP Conflict cannot be eliminated from human groups, whether they are dyads, small groups, macrogroups, or megagroups, such as nations and blocs of nations. If overt conflict is denied or suppressed, it will invariably manifest itself in oblique, corrosive, and often ugly ways. Although our immediate association with conflict is negative—destruction, bitterness, war, violence—a moment of reflection brings to mind positive associations: drama, excitement, change, and development. Therapy groups are no exception. Some groups become “too nice” and diligently avoid conflict and confrontation, often mirroring the therapist’s avoidance of aggression. In the supervision of hundreds of group leaders, we have seen a spectrum of behavior by therapists when it comes to conflict, ranging from avoidance to comfort to a frank attraction to aggression. Therapists should cultivate self-awareness of their personal attitudes toward conflict, as these attitudes will shape group norms. Conflict is so inevitable in the course of a group’s development that its absence suggests some impairment of the developmental sequence. Furthermore, conflict can be exceedingly valuable to the course of therapy, provided that its intensity does not exceed the members’ tolerance and the group understands how to work with it. Learning how to deal effectively with conflict is an important therapeutic step that contributes to individual maturation and emotional resilience.17 Culture and gender may influence group members’ comfort with the expression of anger and conflict. It is particularly important that female clients who have been abused or exploited learn to be more assertive in dealing with conflict and aggression during the course of therapy.18 In this section, we consider conflict in the therapy group—its sources, its meaning, its contribution to therapy, and its therapeutic management. Sources of Hostility There are many sources of hostility in the therapy group and an equal number of relevant explanatory models and perspectives, ranging from ego psychology to object relations to trauma theory to gender psychology to self-psychology.19 The group leader’s capacity to identify the individual, interpersonal, group dynamic, and societal contributions to the hostility in the group is essential.20 Some antagonisms are projections of the client’s self-contempt. Some clients project their own feelings of shame onto other members and then attack the recipient of their projection. Devaluation begets devaluation, and a destructive interpersonal loop of attack and counterattack may easily ensue. Transference often generates hostility in the therapy group. One may respond to others not on the basis of reality but on the basis of an image of the other that is distorted by one’s own past relationships and current interpersonal needs and fears. Should the distortion be negatively charged, then a mutual antagonism may be initiated. The group may function as a “hall of mirrors” that aggravates hostile and rejecting feelings and behaviors.21 Individuals may have long suppressed some traits or desires of which they are much ashamed; when they encounter another person who embodies these very traits, they generally shun the other or experience a strong but inexplicable antagonism toward the person. Think of the contempt a former smoker may show a current smoker. The process may be close to consciousness and recognized easily with guidance by others, or it may be deeply buried and understood only after many months of investigation. > One client, Vincent, a second-generation Italian American who had grown up in the Boston slums and obtained a good education with great difficulty, had long since dissociated himself from his roots. Having invested in his intellect with considerable pride, he spoke with great care in order to avoid betraying any part of his accent or background. In fact, he abhorred the thought of his lowly past and feared that he would be found out, that others would see through his front to his core, which he regarded as ugly, dirty, and repugnant. In the group, Vincent experienced extreme antagonism for another member, also of Italian descent, who had, in his values and in his facial and hand gestures, retained his identification with his ethnic group. Through his investigation of his antagonism toward this member, Vincent arrived at many important insights about himself and gained the group acceptance he longed for but had undermined by his attacking stance. << > In a group of psychiatric residents, Bob agonized over whether to transfer to a more academically oriented residency. The group, with one member, Rick, as spokesman, resented the group time Bob took up for this problem, rebuking him for his weakness and indecisiveness and insisting that he “crap or get off the pot.” When the therapist guided the group members into an exploration of the sources of their anger toward Bob, many dynamics became evident. One of the strongest sources was uncovered by Rick, who discussed his own paralyzing indecisiveness. He had, a year earlier, faced the same decision as Bob; unable to act decisively, he had resolved the dilemma passively by suppressing it. Bob’s behavior reawakened that painful scenario for Rick, who resented Bob not only for disturbing his uneasy slumber but also for struggling with the issue more honestly and more courageously than he had. << The psychiatrist Jerome Frank described a reverberating double-mirror reaction: In one group, a prolonged feud developed between two Jewish members, one of whom flaunted his Jewishness while the other tried to conceal it. Each finally realized that he was combating in the other an attitude he repressed in himself. The militant Jew finally understood that he was disturbed by the many disadvantages of being Jewish, and the man who hid his background confessed that he secretly nurtured a certain pride in it.22 Another source of conflict in groups arises from projective identification, an unconscious process which consists of projecting some of one’s own (but disavowed) internal attributes onto another. The projector (or exporter) generally feels an uncanny attraction-repulsion toward the recipient. A stark literary example of projective identification occurs in Dostoevsky’s nightmarish tale “The Double,” in which the protagonist encounters a man who is his physical double and yet a personification of all the dimly perceived, hated aspects of himself. The tale depicts with astonishing vividness both the powerful attraction and the horror and hatred that develop between the protagonist and his double.23 Projective identification has intrapsychic and interpersonal components. It is both a defense—primitive in nature because it polarizes, distorts, and fragments reality—and a form of interpersonal relationship.24 Elements of one’s disowned self are put not only onto another and shunned, as in simple projection, but into another. The behavior of the recipient actually changes within the ongoing relationship, because the projector’s overt and covert interpersonal communication influences the recipient’s psychological experience and behavior.25 An abused and traumatized client, for example, may export the vulnerable and abused part of herself into others in the group, including the leader, and become abusive toward them. These projections may overwhelm other group members and deskill the group leader. This bodes poorly for all unless the group leader is able to understand the impact of the client’s projection and ensure that group safety is maintained.26 There may be many other sources of anger in a therapy group. Individuals with a fragile sense of self can respond with rage to experiences of shame, dismissal, or rejection and seek to bolster their personal stature by retaliation. At times anger can be a desperate reaction to one’s sense of fragmentation and may represent the client’s best effort at avoiding total emotional collapse.27 Rivalry and envy may also fuel conflict. Group members may compete with one another in the group for the largest share of the group’s or therapist’s attention or for some particular role: for example, the most powerful, respected, sensitive, disturbed, or needy person in the group. Members search for signs that the therapist may favor one or another of the members. In one group, for example, a member asked the therapist where he was going on vacation. When the therapist answered with uncharacteristic candor, another member became bitter and upset: she soon recalled how her sister had always received things from her parents that she had been denied.28 The addition of a new member can ignite rivalrous feelings, as the following example illustrates: > In the fiftieth meeting of one group, a new member, Ginny,i was added. In many ways she was similar to Douglas, one of the original members: they were both artists, mystical in their approach to life, often steeped in fantasy, and seemingly all too familiar with their unconscious. It was not affinity, however, but antagonism that soon developed between the two. Ginny immediately established her characteristic role by behaving in a spirit-like, irrational, and disorganized fashion in the group. Douglas, who saw his role as the sickest and most disorganized member being usurped, reacted to her with intolerance and irritation. Only after active interpretation and Douglas’s assumption of a new role (“most improved member”) was an entente between the two members achieved. << Certain clients, because of their character structure, will invariably be involved in conflict and will engender conflict in any group they attend. Consider a man with paranoid tendencies whose assumptive world is that there is danger in the environment. He is eternally suspicious and vigilant. He examines all experience with an extraordinary bias as he searches for clues and signs of danger. He is tight, never playful, and looks suspiciously upon such behavior in others, anticipating their efforts to exploit him. Obviously, such traits will not endear that individual to the other group members: sooner or later, anger will erupt all around him. The more severe and rigid his character structure, the more extreme the conflict will be. Eventually, if therapy is to succeed, the client must access and explore the feelings of vulnerability that reside beneath the hostile mistrust. > In supervision, two female co-leaders addressed the difficulty they had in empathizing with Mark, an aggressive, narcissistic man who had been very critical of Sandi, a vulnerable woman in the group. He resented her for avoiding group interaction and silently watching him. It was much easier for the group leaders to understand and side with Sandi than to consider Mark’s concerns.
Mark was a big man, a body builder with an imposing presence who intimidated the group and the leaders. As group supervisor, I (ML) encouraged the group leaders to examine Mark’s sense of vulnerability rather than focusing on his manifest aggressive behavior. Once the leaders approached him in this more compassionate spirit, Mark softened and was able to speak to his fear of silence.
To him, silence suggested impending harsh judgment by others. He lamented that everyone was concerned about Sandi’s feelings and her tears, but no one paid attention to his feelings of distress. He shared for the first time his early experience of abuse, and realized that his bigness and bluster were a defense to ward off attack. The group responded by honoring his courage and need for care. << The group setting invites a greater degree of interpersonal interaction than is typical of individual therapy and therefore may provide a safer exposure to interpersonal conflict. A playful, jousting tone can emerge that promotes a developmentally healthy “give-and-take” repartee. When done in the spirit of healthy assertion it can strengthen cohesion and broaden the opportunity to address and examine competition, rivalry, and healthy aggression.29 Disappointment with the therapist for falling short of expectations can be another source of group hostility. If the group is unable to confront the therapist directly, it may create a scapegoat—a highly unsatisfactory solution for both victim and group.30 Recognizing that hostility emerges from multiple sources is essential in avoiding reductionistic explanations.31 The group may give voice to every potential perspective on aggression—the victim, the perpetrator, protective intervenors, or disinterested witnesses.32 Hostility in the group can also be understood from the perspective of stages of group development. In the early phase, the group fosters regression and the emergence of irrational, uncivilized parts of individuals. The young group is also beset with anxiety (from fear of exposure, shame, feelings of powerlessness) that may be expressed as hostility. A range of aggressions may emerge from cultural and racial misunderstandings and assumptions among the members. These microaggressions may seem small to the perpetrator but may cut the targeted individual deeply, through the invalidation or diminishment of the targeted member’s personhood and ethnocultural identity.33 These are essential to recognize, address, and repair. The first step is making the aggression visible so that it can be worked with in the group. Throughout the course of the group, narcissistic injury (wounds to self-esteem from feedback or from being overlooked, unappreciated, excluded, or misunderstood) is often suffered and responded to through angry retaliation. Later in the course of the group, anger may stem from other sources: projective tendencies, sibling rivalries, transference, or the premature termination of some members. And, of course, let us not forget the group leader’s defensiveness and self-protectiveness in the face of critics as a source of fuel for conflict in the group. Therapist countertransference can be an important contributor to destructive hostility in the therapeutic process.34 Management of Hostility Regardless of its source, discord, once begun, often follows a predictable sequence. The antagonists develop the belief that they are right and the others are wrong, that they are good and the others bad. Moreover, these beliefs are characteristically held with equal conviction and certitude by each of the two opposing parties. Where such a situation of opposing beliefs exists, we have all the ingredients for a deep and continuing tension, even to the point of impasse. Not uncommonly, a breakdown in communication ensues. The two parties cease to listen to each other with any understanding. If they were in a social situation, the two opponents would most likely completely rupture their relationship at this point and never be able to correct their misunderstandings. Not only do the opponents stop listening, but they may also unwittingly distort their perceptions of one another. The opponent’s words and behavior are distorted to fit a preconceived view. Contrary evidence is ignored; conciliatory gestures may be perceived as deceitful tricks. (The parallel to international relations is all too obvious.) In short, there is a greater investment in verification of one’s beliefs than in understanding the other.35 Opponents view their own actions as honorable and reasonable, and the behavior of others as scheming and evil. If this sequence, so common in human events, were permitted to unfold in therapy groups, the group members would have little opportunity for change or learning. A group climate and group norms that preclude such a sequence must be established early in the life of the group. Therapy groups must be places that enable “difficult dialogues” to take place that look at the conflict from the perspective of all those involved, whether they are about race or gender relations or interpersonal tensions.36 Cohesiveness is the primary prerequisite for the successful management of conflict. Members must develop a feeling of mutual trust and respect and come to value the group as an important means of meeting their personal needs. They must understand the importance of maintaining communication if the group is to survive; all parties must continue to deal directly with one another, no matter how angry they become. Furthermore, everyone is to be taken seriously. When a group treats one member as a “mascot,” someone whose opinions and anger are lightly regarded, the hope of effective treatment for that individual has all but officially been abandoned. Covert exchanges between members, sometimes bordering on the “rolling of one’s eyes” in reaction to the mascotted member’s participation, are an ominous sign. Mascotting jeopardizes group cohesiveness; no one is safe, particularly the next most peripheral member, who will have reason to fear similar treatment. The cohesive group in which everyone is taken seriously soon elaborates norms that obligate members to go beyond name calling and superficial judgments. Members must pursue and explore derogatory labels and be willing to search more deeply within themselves to understand their antagonism and to make explicit those aspects of others that anger them. Norms must be established that make it clear that group members are there to understand themselves, not to defeat or ridicule others. In one group I (ML) led, a member became involved in a vitriolic exchange with another member who had earlier mocked her for her guardedness. She yelled in the group, “Either Joe leaves or I leave. This group is not big enough for the two of us.” I responded, “We are a therapy group, not an old TV Western; the group is indeed big enough for you both and we need to understand what’s driving this heat.” Effective therapy groups work with words, not actions; treat all members with respect; and understand that there is rarely a single objective truth—more typically, there are multiple subjective truths that group members need to understand together.37 It is particularly useful if members try to reach within themselves to identify feelings and impulses they have in common. Terence, a Roman dramatist of the second century BC, gave us a valuable perspective when he said, “I am human and nothing human is alien to me.”38 We all contain every element of the human experience. Empathy is an important element in conflict resolution and facilitates humanization of the struggle. But empathy is harder to muster when one’s feelings are too strong. At such times the therapist needs to lower the temperature in the group by encouraging empathy, leaning forward in the chair, making eye contact with the antagonists, and validating their distress.39 Often, understanding the past plays an important role in the development of empathy: once an individual appreciates how aspects of an opponent’s earlier life have contributed to his or her current stance, then the opponent’s position not only makes sense but may even appear right. Empathy emerges more readily when there is greater familiarity and knowledge of the other.40 This is one of the reasons why it is wise to reduce hostile exchanges in the early stages of the group’s life: mutual knowledge of one another has not yet been sufficiently achieved. Conflict resolution is often impossible in the presence of off-target or oblique hostility. > Maria began a group session by requesting and obtaining the therapist’s permission to read a letter she was writing in conjunction with a court hearing on her impending divorce, which involved complex issues of property settlement and child custody. The letter reading consumed a considerable amount of time and was often interrupted by the other members, who disputed the contents of the letter. The sniping by the group and defensive counterattacks by the protagonist continued until the group atmosphere crackled with irritability.
The group made no constructive headway until the therapist explored the process of the meeting with them. The therapist was annoyed with himself for having permitted the letter to be read, and annoyed with Maria for having put him in that position. The group members were angry at the therapist for having given Maria permission, and at Maria both for consuming so much time and for relating to them in the frustrating, impersonal manner of letter reading. Once the anger had been directed away from the oblique target of the letter’s contents onto the appropriate targets—the therapist and Maria—steps toward conflict resolution could begin. << Permanent conflict abolition, let us note, is not the final goal of the therapy group. Conflict will continually recur in the group despite successful resolution of past conflicts and despite the presence of considerable mutual respect and warmth. Although some people relish conflict, the vast majority of group members (and therapists) are highly uncomfortable when expressing or receiving anger. The therapist’s task is to harness conflict and use it in the service of growth. One important principle is to find the right level; too much or too little conflict is counterproductive. The leader is always fine-tuning the dial of conflict. When there is persistent conflict, when the group cannot agree on anything, the leader searches for resolution and wonders why the group denies any commonality. But when the group consistently agrees on everything, the leader searches for diversity and differentiation. Thus, group leaders need to titrate conflict carefully. Generally, it is unnecessary for the leader to evoke conflict deliberately; if the group members are interacting with one another openly and honestly, conflict will emerge. More often, the therapist must intervene to keep conflict within constructive bounds.41 Keep in mind that the therapeutic use of conflict, like all other behavior in the here-and-now, is a two-step process: experience (affect expression) and reflection upon that experience. You may control conflict by switching the group from the first to the second stage. Often a simple, direct appeal is effective: for example, “We’ve been expressing some intense negative feelings here today as well as last week. To protect us from overload, it might be valuable to stop what we’re doing and try together to understand what’s been happening and where all these powerful feelings come from.” Group members will have different capacities to tolerate conflict. One client responded to the therapist’s “freezing the frame” (shifting the group to a reflective position) by criticizing the therapist for cooling things off just when things were getting interesting. Another member immediately commented that she could barely tolerate more tension and was grateful for a chance to regroup. It may be useful to think of the shift to process as creating a space for reflection—a space in which members may explore their mutual contributions to the conflict. The creation of this space for thoughtful reflection may be of great import—indeed, it may make the difference between therapeutic impasse and therapeutic growth.42 Receiving negative feedback is painful and yet, if accurate and sensitively delivered, helpful. The therapist can render it more palatable by making the benefits of feedback clear to the recipient and enlisting that client as an ally in the process. Often you can facilitate that sequence by remembering the original presenting interpersonal problems that brought the individual to therapy. If you have obtained verbal contracts from group members early in therapy, you can refer back to these when a member is getting feedback. This point underscores the therapeutic opportunity that arises in the midst of the client’s wish to retreat or flee. For example, if at the beginning of therapy a client commented that her partner often accused her of trying to tear her down, and that she wished to work on that problem in the group, you may nail down a contract by a statement such as: “Carolyn, it sounds as though it would be helpful to you if we could identify similar trends in your relationships to others in the group. How would you feel if, from now on, we point this out to you as soon as we see it happen?” Once this contract has been agreed upon, store it in your mind and, when the occasion arises (for example, when the client receives similar feedback in the group), remind the client that, despite the discomfort, this precise feedback may be exceptionally useful to her in understanding her relationship with her partner. The principles regarding effective interpersonal feedback noted in Chapter 2, notably the here-and-now focus and the shared risk-taking of the feedback provider and feedback receiver, are instructive. Almost invariably, two group members who feel considerable mutual antagonism have the potential to be of great value to each other. Each obviously cares about how he is viewed by the other. In their anger, each will point out important (though unpalatable) truths to the other. The self-esteem of the antagonists may even be increased by the conflict. When people become angry at one another, this in itself may be taken as an indication that they are important to one another and take one another seriously. Individuals who truly care nothing for each other ignore each other. Individuals may learn another important lesson as well: that individuals may respond negatively to a trait, mannerism, or attitude of another person but still value the person. For clients who have been unable to express anger, the group may serve as a testing ground for taking risks and learning that such behavior is neither dangerous nor necessarily destructive. In Chapter 2, we described incidents cited by group members as turning points in their therapy. A majority of these critical incidents involved the first-time expression of strong negative affect. It is also important for clients to learn that they can withstand attacks and pressure from others and that they will not be silenced. Emotional resilience and healthy insulation can be products of work involving conflict.43 > Ron had struggled with debilitating chronic depression for much of his life, so much so that he could not work for several years. He was in treatment for decades and many approaches had been tried—medications, electroconvulsive therapy (ECT), and neuromodulation—with little enduring effect. Raised by a single mother who was riddled with extreme anxiety, and who in essence used him as a prop to help her manage her life, made him feel invisible. For example, he said, she would take him out of elementary school to accompany her somewhere if she needed his presence to reduce her social anxiety; and would have him sleep in her bedroom as a young teen when she had anxiety or nightmares. He had no independent existence. He often told the group that he felt as though he had worn a straitjacket throughout his life.
Ron struggled mightily to assert and take his proper space in the group. In one meeting he reported with great animation and anger that he had felt terrible after the prior week’s session and had spent twenty-four hours in a state of virtual vegetation. His reaction had been provoked by another member of the group, Bette, who had dismissed him and the comments he had made about her depression. Although Bette was absent this session, the group encouraged him to keep talking about his experience.
He dove in with uncharacteristic intensity, talking about how he had felt as invisible and silenced by Bette as he had with his mother. It shut him down and he’d lost the capacity to do anything meaningful for the entire day following the meeting. He was, however, determined to address this, and he had chosen to do so in the here-and-now. Even though Bette was away, he would not silence himself and wait one more week, although he would address it again the next week with her present. The group was enthusiastic about his protest and noted that they had not seen Ron like this before.
Despite positive feedback from around the room, Ron began to question whether he was taking up too much time—a resurgence of his pathogenic beliefs. He was encouraged to check that out with others in the group, which drew this memorable response from a co-member, Pete: “I am fully and deeply committed to you, Ron, at this moment and unaware of any other feelings in my inner world other than wanting to be present with you.” << This powerful statement underscores the importance of thoroughly processing group members’ behavior. If we are to achieve a corrective emotional experience, we need to do more than provide clients with novel experiences. We also need to challenge the tendency of clients to neglect constructive feedback that challenges their negative assumptions. In contrast to Ron and others like him who must overcome barriers to speaking up for themselves, overly aggressive individuals may learn some of the interpersonal consequences of blind outspokenness. Through feedback, they, too, come to appreciate the impact they have on others and gradually come to terms with the self-defeating pattern of their behavior. For many of these individuals, angry confrontations provide valuable learning opportunities because the group members learn to remain in mutually useful contact with one another despite their anger. Clients may be helped to express anger more directly and more fairly. Even in all-out conflict there are tacit rules of war that, if violated, make satisfactory resolution all but impossible. For example, combatants in therapy groups will occasionally take information disclosed by the other in a previous spirit of trust and use it to scorn or humiliate that person. Or they may refuse to examine the conflict because they claim to have so little regard for the other that they do not wish to waste any further time. These postures require vigorous intervention by the therapist. When therapists belatedly realize that an earlier or different intervention would have been helpful, they should acknowledge that. As Donald Winnicott once said, the difference between good parents and bad parents was not the number of mistakes they made, but what they did with them.44 We have both frequently commented to a group, “I wish I understood then what I understand now; I would have done things differently in the group.” Sometimes in unusually sustained and destructive situations the leader must forcefully assume control and set limits. The leader cannot leave a situation to the group alone if doing so gives license to an individual’s destructive behavior.45 One of the most common indirect and self-defeating modes of fighting is when the client, in one form or another, “injures” himself or herself in the hope of inducing guilt in the other—the “see what you’ve done to me?” strategy. Usually, much therapeutic work is required to change this pattern. It is generally deeply ingrained, with roots stretching back to earliest childhood (as in the common childhood fantasy of attending your own funeral and watching as parents and other grief-stricken tormentors pound their breasts in guilt). Group leaders must endeavor to turn the process of habitually disagreeing into something positive—a learning situation that encourages members to evaluate the sources of their position and to relinquish those that are irrationally based. Clients must also be helped to understand that regardless of the source of their anger, their method of expressing it may be self-defeating. Feedback is instrumental in this process. For example, members may learn that, unbeknownst to themselves, they characteristically display scorn, irritation, or disapproval. Through feedback about our facial gestures and nuances of expression, we learn that we may communicate something we do not intend, or, for that matter, something we do not even consciously experience.46 The therapist should also attempt to help the conflicting members learn more about their opponents’ position. For example, the therapist can ask a member to take the part of their opponent for a few minutes in order to apprehend the other’s reasons and feelings.47 Other group approaches have been utilized effectively in a range of settings and with clinical populations ranging from burdened caregivers of family members with dementia to war veterans suffering posttraumatic stress disorder. These groups usually combine psychoeducation (focusing on the connections between thoughts, emotions, and behavior) and skill building in addressing intense emotions.48 Emotional regulation is a learnable skill that involves muscle relaxation, deep breathing, and practice building distress tolerance. Many clients have the opposite problem to those who might benefit from learning anger management skills: they too often suppress and avoid angry feelings. In groups they learn that others in their situation would feel angry; they learn to read their own body language (“My fists are clenched so I must be angry”); they learn to magnify rather than suppress the first flickerings of anger; they learn that it is safe, permissible, and often in their best interests to feel and to express anger. Most important, their fear of such behavior is extinguished: their fantasized catastrophe does not occur when they express anger, and their comments do not result in destruction, guilt, rejection, or escalation of the anger. Strong shared affect may enhance the importance of a relationship. In Chapter 3, we described how group cohesiveness is increased when members of a group go through intense emotional experiences together, regardless of the nature of the emotion. In this manner, members of a successful therapy group are like members of a close-knit family, who may battle each other yet derive much support from their family allegiance. A dyadic relationship that has weathered much stress is likely to grow increasingly rewarding. A situation in which two individuals in group therapy experience an intense mutual hatred, and then, through some of the mechanisms we have described, resolve the hatred and arrive at mutual understanding and respect, is always of great therapeutic value. It can provide comfort to the beginning group leader to know that the two members who are most disparaging to one another early on may become the most useful members to one another over time. SELF-DISCLOSURE Self-disclosure, both feared and valued by participants, plays an integral part in all group therapies. Without exception, group therapists agree that it is important for clients to reveal personal material in the group—material that the client would rarely disclose to others. The self-disclosure may involve past or current events in one’s life, fantasy or dream material, hopes or aspirations, and current feelings toward other individuals. In group therapy, feelings toward other members often assume such major importance that the therapist must devote energy and time to creating the preconditions for disclosure: trust and cohesiveness.49 Self-Disclosure and Risk Every self-disclosure involves some risk on the part of the discloser. Disclosing material that has previously been kept secret or that is highly personal and emotionally charged obviously carries great risk. First-time disclosure—that is, the first time one has shared certain information with anyone else—feels particularly risky. The degree of risk is shaped by the discloser’s life experience. Pete’s comment in the preceding clinical illustration had a profound impact on Ron. It had a profound impact as well on Pete, whose goal in group therapy was to access his deeply shut down emotional world. The amount of risk also depends on the audience. Disclosing members, wishing to avoid shame, humiliation, and rejection, feel safer if they know that the audience is sensitive and has also previously disclosed highly personal material.50 Sequence of Self-Disclosure Self-disclosure has a predictable sequence. If the receiver of the disclosure is involved in a meaningful relationship with the discloser, the receiver is likely to reciprocate with some personal disclosure of his or her own. Now the receiver as well as the original discloser is vulnerable, and the relationship usually deepens, with the participants continuing to make slightly more open and intimate disclosures in turn until some optimal level of intimacy is reached. Thus, in the cohesive group, self-disclosure draws more disclosure, ultimately generating a constructive loop of trust, self-disclosure, feedback, and interpersonal learning.51 An illustrative example: > Halfway through a thirty-session course of group therapy, Cam, an avoidant, socially isolated thirty-year-old engineer, opened a session by announcing that he wanted to share a secret with the group: for the past several years, he had frequented strip clubs, often befriending the exotic dancers. He had a fantasy that he would rescue a dancer, who would then, in gratitude, fall in love with him. Cam went on to describe how he had spent thousands of dollars on his “rescue missions.”
The group members welcomed his disclosure, especially since it was the first substantially personal disclosure he had made in the group. Cam responded that time was running out, and he had wanted to relate to the others in a real way before the group ended. This encouraged Marie, a recovering alcoholic, to reciprocate with her own disclosure: many years before, she had worked as an exotic dancer and prostitute.
Marie warned Cam that he could expect nothing but disappointment and exploitation in that environment. She had never disclosed her past for fear of the group’s judgment, but she had felt compelled to respond to Cam, because she hated to see such a decent man getting into self-destructive relationships. The mutual disclosure, support, and caring in this exchange accelerated the work in the subsequent meeting for all the members. << Adaptive Functions of Self-Disclosure As disclosures proceed in a group, the members gradually grow more engaged with and more responsible toward one another. If the timing is right, nothing will commit an individual to a group more than sharing some intimate, secret material.52 Harry Stack Sullivan and Carl Rogers long ago maintained that self-acceptance must be preceded by acceptance by others; in other words, to accept oneself, one must gradually permit others to know one as one really is. A group member’s disclosures provide the opportunity for the group to offer that essential acceptance.53 Self-disclosure underpins both the group bonding and the group task components of group therapy. It benefits the individual making the self-disclosure, and it benefits the entire group as well.54 In Chapter 3, we described the relationship between self-disclosure and popularity in the group. Popularity (as determined from sociometric measurement) correlates with therapy outcome.55 Group members who disclose extensively in the early meetings are often very popular in their groups. People reveal more to individuals they like; conversely, those who reveal themselves are more likely to be liked by others.56 Several research inquiries have demonstrated that high disclosure (either naturally occurring or experimentally induced) increases group cohesiveness.57 But the relationship between liking and self-disclosure is not linear. One who discloses too much arouses anxiety in others rather than affection.58 In other words, both the content and the pace of self-disclosure need to be considered and processed within the group. Group members communicate in nonverbal ways as well as verbal ways, and the entirety of the communication should be kept in mind. Experienced group leaders maintain a process perspective and are aware: Who is saying what to whom? What is not being expressed or shared?59 Self-disclosure is an essential step in the work of therapy, but not as an end in itself. It must be fully processed by the client and the group to achieve therapeutic benefit.60 Research supports the crucial role of self-disclosure in successful therapy outcome.61 Early research showed that successfully treated participants in group therapy made almost twice as many self-disclosing personal statements during the course of therapy as clients with poorer outcomes did.62 Morton Lieberman, Matthew Miles, and I (IY) found that in encounter groups, individuals who had negative outcomes revealed significantly less of themselves than those with positive outcomes.63 The concept of transfer of learning is vital here: Not only are clients rewarded by the other group members for self-disclosure, but the behavior, thus reinforced, is integrated into their relationships outside the group, where it is similarly rewarded. Often the first step toward revealing something to a spouse or a potential close friend is disclosing it in the therapy group. Hence, to a significant degree, the impact of self-disclosure is shaped by the relationship of the individuals with one another. What is truly validating to the client is to reveal oneself and then to be accepted and supported. Once that happens, the client experiences a genuine sense of connection and of understanding.64 Keep in mind also that here-and-now (“hot-processing”) disclosure, in particular, has a far greater effect on group cohesion than then-and-there (cold-processing) disclosure.65 Often clients manifest great resistance to self-disclosure. Frequently a client’s dread of rejection or ridicule from other members coexists with the hope of acceptance and understanding.66 Group members often entertain some calamitous fantasy about self-disclosure, and to disclose and to have that calamitous fantasy disconfirmed is highly therapeutic. Contrariwise, attacking or shaming a member for a self-disclosure is terribly destructive to the individual and to the group and requires immediate exploration and repair. In one bold teaching experiment, students were asked to share a deep secret with the class. Great care was taken to ensure anonymity. Secrets were written on uniform pieces of paper, read by the instructor in a darkened classroom, so as to conceal blushing or other facial expressions of discomfort, and immediately destroyed. The secrets included various sexual preferences, illegal or immoral acts (including sexual abuse, cheating, stealing, drug dealing), psychological disturbances, abuse suffered in alcoholic families, and so on. Immediately after the reading of the secrets, there was a powerful response in the classroom: “a heavy silence… the atmosphere [was] palpable… the air warm, heavy, and electric… you could cut the tension with a knife.” Students reported a sense of relief at hearing their secrets read—as though a weight had been lifted from them. But there was even greater relief in the subsequent class discussion, in which students shared their responses to hearing various secrets and exchanged similar experiences. Many of them chose to identify which secret they wrote. The peer support was invariably positive and powerfully reassuring.67 We seek acceptance from others and are comforted in learning that the deep secrets we maintain and hold in are often shared by others. Maladaptive Self-Disclosure Self-disclosure is related to optimal psychological and social adjustment in a curvilinear fashion: too much or too little self-disclosure signifies maladaptive interpersonal behavior. Too little self-disclosure usually limits the opportunity for reality testing: those who fail to disclose themselves in a relationship generally forfeit the opportunity to obtain valid feedback. Furthermore, they prevent the relationship from developing further; without reciprocation, the other party will either desist from further self-disclosure or else abandon the relationship entirely. Group members who do not disclose themselves have little chance of genuine acceptance by the other members and therefore little chance of experiencing a rise in self-esteem.68 If a member is accepted on the basis of a false image, no enduring boost in self-esteem occurs; moreover, that person will then be even less likely to engage in valid self-disclosure because of the added risk of losing the acceptance gained through the false presentation of self.69 Some individuals dread self-disclosure, not primarily because of shame or fear of nonacceptance but because they are heavily conflicted in the area of control. To them, self-disclosure is dangerous because it makes them vulnerable to the control of others. It is only when several other group members have made themselves vulnerable through self-disclosure that such a person is willing to reciprocate. Self-disclosure blockages will impede individual members as well as entire groups. Members who have an important secret that they dare not reveal to the group may find participation on anything but a superficial level very difficult, because they will have to conceal not only the secret itself but also all possible avenues to it. In Chapter 5 we discussed in detail how, in the early stages of therapy, the therapist might best approach the individual who has a big secret. To summarize, it is advisable for the therapist to counsel the client to share the secret with the group in order to benefit from therapy. The pace and timing are up to the client, but the therapist may offer to make the act easier in some way if the client so wishes. When the long-held secret is finally shared, it is often illuminating to learn what made it possible for the client to come forward at that point in time. Despite potential frustration at the long delay in access to important client information, always welcome the disclosure. We will often make such statements as, “You’ve been coming to this group for many weeks wanting to tell us about this secret. What has changed in you or in the group to make it possible to share it today? What has happened to allow you to trust us more today?” And, later, “What will it be like to return to the group now having shared this?”70 Consider the client’s secret as having both content and process elements. Disclosing a secret can be an expression of trust; it can be a gift to the group; it can be a request for containment and support; it can represent a wish for absolution from guilt and shame. It can also be helpful to explore the secret as we would a dream (see Chapter 13). Some aspects of the secret are hidden even to the client making the disclosure and will be accessed only by joint exploration of its meaning with the group.71 Therapists sometimes unwittingly discourage self-disclosure. The most terrifying secret I (IY) have known a client to possess was in a newly formed group I supervised that was led by a neophyte therapist. This client, suffering from a postpartum psychotic illness, had murdered her two-year-old child and then attempted suicide. The courts ruled her not to be criminally responsible on account of mental illness. She was subsequently treated to good effect and had begun group therapy as part of a courageous effort at rebuilding her life. After fourteen weeks of therapy, she still had not told the group anything about herself; moreover, by her militant promulgation of denial and suppressive strategies (such as invoking astrological tables), she had impeded the work of the entire group. Despite his manifest best efforts and much of my supervisory time, the therapist had not been able to help the client (or the group) move into productive therapy. I then observed several sessions of the group through the two-way mirror and noted, to my surprise, that the client had provided the therapist with many opportunities to help her discuss the secret (for example, she made references to loss that he did not pursue). We devoted a supervisory session to the therapist’s countertransference. His feelings about his own two-year-old child and his horror (despite himself) at the client’s act had colluded with her guilt to silence her in the group. In the following meeting, the gentlest question by the therapist was sufficient to free the client’s tongue and to change the entire character of the group. In some groups, self-disclosure is discouraged by a generally judgmental climate. Members are reluctant to disclose shameful aspects of themselves for fear that others will lose respect for them. In training or therapy groups of mental health professionals, this issue is even more pressing. Since our chief professional instrument is our own person, at risk is professional as well as personal loss of respect. In a group of psychiatric residents, for example, one member, Omar, discussed his lack of confidence as a physician and his panic whenever he was placed in a life-or-death clinical situation. Ted, an outspoken, burly member, acknowledged that Omar’s fear of revealing this material was well founded, since Ted did lose respect for him; in fact, Ted doubted whether he would refer patients to Omar in the future. The other members supported Omar and condemned Ted for his judgmental position, suggesting that they would be reluctant to refer patients to him. An infinite regress of judgment can easily ensue, and it is incumbent on the therapist at these times to make a vigorous process intervention. Training groups for mental health professionals that promote open sharing of concerns about the demands of contemporary practice and the fear of burnout can provide support and enhance practitioner resilience.72 The therapist must differentiate, too, between a healthy need for privacy and neurotic compulsive secrecy. Some people (though they seldom find their way into groups) are private in an adaptive way: they share intimacies with only a few close friends and shudder at the thought of self-disclosure in a group. Moreover, they enjoy private self-contemplative activities. This is a very different thing from privacy based on fear, shame, or crippling social inhibitions. Men appear to have more difficulty with self-disclosure than women: they often view relationships from the perspective of competition and dominance rather than tenderness and connectedness.73 Too much self-disclosure can be as maladaptive as too little. Indiscriminate self-disclosure is neither a goal of mental health care nor a pathway to mental health. Some individuals make the grievous error of reasoning that if self-disclosure is desirable, then total and continuous self-disclosure must be a very good thing indeed. Life would become unbearably sticky if every contact between two people entailed sharing personal concerns and secrets. Obviously, the relationship that exists between discloser and receiver should be the major factor in determining the pattern of self-disclosure. Several studies have demonstrated this truth experimentally: individuals disclose different types and amounts of material depending on whether the receiver is a mother, father, best same-sex friend, opposite-sex friend, work associate, or spouse.74 However, some maladaptive disclosers disregard, and thus jeopardize, their relationship with the receiver. The self-disclosing individual who fails to discriminate between intimate friends and distant acquaintances perplexes associates. We have all experienced confusion or betrayal on learning that supposedly intimate material confided to us has been shared with many others. Furthermore, a great deal of self-disclosure may frighten off an unprepared recipient. In a rhythmic, flowing relationship, one party leads the other in self-disclosures, but never by too great a leap. In group therapy, members who reveal early and promiscuously will often drop out soon in the course of therapy. Group members should be encouraged to take risks in the group, but if they reveal too much too early, they may feel so much shame and exposure that any interpersonal rewards are offset. Furthermore, their overabundant self-disclosure may threaten others who would be willing to support them but are not yet prepared to reciprocate.75 High disclosers are then placed in a position of such great vulnerability in the group that they may choose to flee. Pacing is essential. As we discussed in Chapter 5, a shift from vertical disclosure, regarding the content of the disclosure (what happened? who did what to whom?), to horizontal disclosure, regarding the process of the disclosure (how is it to share this with us?), is a way to maximize engagement and ensure a workable pace. All of these observations suggest that self-disclosure is a complex social act that is situation and role bound. One does not self-disclose in solitude: time, place, and person must always be considered. Appropriate self-disclosure in a therapy group, for example, may be disastrously inappropriate in other situations, and appropriate self-disclosure for one stage of a therapy group may be inappropriate for another stage. These points are particularly evident in the case of self-disclosure of feelings toward other members. It is our belief that the therapist should help the members be guided as much by responsibility to others as by freedom of expression. We have seen vicious, destructive events occur in groups under the aegis of honesty and self-revelation: “You told us that we should be honest about expressing our feelings, didn’t you?” But, in fact, we always selectively reveal our feelings. There are always layers of reactions toward others that we rarely share—feelings about unchangeable attributes, physical characteristics, deformity, professional or intellectual mediocrity, social class, lack of charm, and so on. Part of the benefit of group therapy lies in the fact that clients develop the skills required to be authentic, empathic, and nuanced in the kind of feedback they give others. One member noted that she never had any doubts about what was right or wrong and never hesitated to say so—until she joined the group and appreciated how harsh and insensitive she was to others. The newly acquired uncertainty was unsettling, but it clearly had a positive impact on her personal and professional relationships. For some individuals, disclosure of overtly hostile feelings comes easily in the guise of being “honest.” But they find it more difficult to reveal underlying meta-hostile feelings—feelings of fear, envy, guilt, or sadistic pleasure in vindictive triumph. And how many individuals find it easy to disclose negative feelings but avoid expressing positive ones—feelings of admiration, concern, empathy, physical attraction, or love? A group member who has just disclosed a great deal faces a moment of vulnerability and requires support from the members and/or the therapist. Regardless of the circumstances, no client should be attacked for making an important self-disclosure. A clinical vignette illustrates this point: > Five members were present at a meeting of a year-old group. (Two members were out of town, and one was ill.) One member, Joel, began the meeting with a long, rambling statement about feeling uncomfortable in a smaller group. Ever since Joel had entered the group, his style of speaking had turned members off. Everyone found it hard to listen to him and longed for him to stop. But no one had really dealt honestly with these vague, unpleasant feelings about him until this meeting, when, after several minutes, Betsy interrupted him. She said, “I’m going to scream—or burst! I can’t contain myself any longer! Joel, I wish you’d stop talking. I can’t bear to listen to you. I don’t know who you’re talking to—maybe the ceiling, maybe the floor, but I know you’re not talking to me. I care about everyone else in this group. I think about them. They mean a lot to me. I hate to say this, but for some reason, Joel, you don’t matter to me.”
Stunned, Joel attempted to understand the reason behind Betsy’s feelings. Other members agreed with Betsy and suggested that Joel never said anything personal. It was all filler, all cotton candy—he never revealed anything important about himself; he never related personally to any of the members of the group. Spurred, and stung, Joel took it upon himself to go around the group and describe his personal feelings toward each of the members.
I (IY) thought that, even though Joel revealed more than he had before, he still remained in comfortable, safe territory. I asked, “Joel, if you were to think about revealing yourself on a 10-point scale, with 1 representing cocktail-party stuff and 10 representing the most you could ever imagine revealing about yourself to another person, how would you rank what you did in the group over the past ten minutes?” He thought about it for a moment and said he guessed he would give himself a 3 or a 4. I asked, “Joel, what would happen if you were to move it up a rung or two?”
He deliberated for a moment and then said, “If I were to move it up a couple of rungs, I would tell the group that I was an alcoholic.”
This was a staggering revelation. Joel had been in the group for a year, and no one else in the group—including me or my co-therapist—had known this. Furthermore, it was vital information. For weeks, Joel had bemoaned the fact that his wife was pregnant and had decided to have an abortion rather than have a child by him. The group was baffled by her behavior and over the weeks had become highly critical of his wife; some members even questioned why Joel stayed in the marriage. The new information that Joel was an alcoholic provided a crucial missing link. Now his wife’s behavior made sense!
My initial response was one of anger. I recalled all those futile hours when Joel had led the group on a wild goose chase. I was tempted to exclaim, “Damn it, Joe, all those wasted meetings talking about your wife! Why didn’t you tell us this before?” But fortunately, I recognized that this was just the time to bite my tongue! The important thing was not that Joel had withheld this information earlier, but that he had now told us. Rather than being punished for his previous concealment, he should be reinforced for having made a breakthrough. He had been willing to take an enormous risk in the group. The proper technique consisted of supporting Joel and facilitating further horizontal disclosure, that is, ask him to talk more about his experience of disclosure. << It is not uncommon for members to withhold information, as Joel did, with the result that the group spends time inefficiently. Obviously, this has a number of unfortunate implications, not the least of which is the toll it takes on the self-esteem of the withholding member, who knows he or she is being duplicitous—acting in bad faith toward the other members. Often group leaders do not know the extent to which a member is withholding, but as soon as they begin doing concurrent group and individual (or combined) therapy with the client, they are amazed at how much new information the client reveals. In Chapter 7 we discussed aspects of group leader self-disclosure. The therapist’s transparency, particularly within the here-and-now, can be an effective way to encourage member self-disclosure.76 But therapist transparency must always be guided by the principle of deepening the group work and being alert to one’s impact on the group. The general who, after making an important tactical decision, goes around wringing his hands and expressing his uncertainty will undercut the morale of his entire command. Similarly, the therapy group leader should obviously not disclose feelings that would undermine the effectiveness of the group, such as impatience with the group, a preoccupation with a client or a group seen earlier in the day, or any of a host of other personal concerns.77 TERMINATION We now return our attention to group development with a focus on the concluding phase of group therapy: termination, a critically important but frequently neglected part of treatment.78 Group therapy termination is particularly complex: Members may leave because they have achieved their goals, they may drop out prematurely, the entire group may end, the therapist may leave a continuing group, or there may even be traumatic endings, such as in the form of a client suicide. Feelings about termination must be explored from different perspectives: that of the individual member, that of the therapist, and that of the group as a whole. Even the word termination has unfavorable connotations. It is often used in such negative contexts as what we do with an unwanted pregnancy or a poorly performing employee.79 In contrast, a mutual, planned ending to therapy is a positive, integral part of the therapeutic work that includes a review and consolidation of work done, mourning, and celebration of the commencement of the next phase of life. The ending should be clear and focused—not a petering out. Confronting the end of therapy is a boundary experience, a confrontation with limits.80 It reminds us of the precious nature of our relationships and the requirement to conclude with as few regrets as possible about work undone, emotions unexpressed, or feelings unstated. In addition, there are clear tasks associated with the ending phase of therapy. These include the consolidation of gains, the resolution of remaining relationship issues, and planning for the future without the group.81 When a Client Terminates from the Group If properly understood and managed, termination can be an important force in the process of change. Throughout, we have emphasized that group therapy is a highly individual process. Each client will enter, participate in, use, and experience the group in a uniquely personal manner. The end of therapy is no exception. Only general assumptions about the length and overall goals of therapy may be made. Though third-party insurers decree that most therapy groups be brief and problem oriented, we have presented evidence in Chapter 9 that brief group approaches may effectively offer benefit beyond symptomatic relief alone and can launch important growth for our clients. There is also evidence, however, that therapy is most effective when the end of treatment is collaboratively determined by the client and the therapist, guided by the client’s progress and not arbitrarily imposed by a third party.82 Third-party payers are most interested in what will be most useful for the majority of a large pool of clients. Psychotherapists are less interested in statistics and aggregates of clients than in individual distressed clients in their office. How much therapy is enough? That is not always an easy question to answer. The growing use of measurement-based care (see Chapter 13) can provide client outcome data to assist in guiding these decisions.83 Although remoralization and recovery from acute distress often occur quickly, a substantial change in character structure generally requires twelve to twenty-four months—or more—of weekly therapy. Clients with chronic depression and a complex interplay of personality difficulties and trauma may require much longer periods in treatment.84 The goals of therapy have never been stated more succinctly than by Freud: “To be able to love and to work.”85 Freud believed that therapy should end when there is no prospect for further gains and the individual’s pathology has lost its hold. Some theorists would add other goals: the ability to love oneself and to allow oneself to be loved; to be more flexible; to learn to play; to discover and trust one’s own values; and to achieve greater self-awareness, greater interpersonal competence, and more mature defenses.86 Some group members may achieve a great deal in a few months, whereas others require years of group therapy. Some individuals have far more ambitious goals than others; it would not be an exaggeration to state that some individuals, satisfied with their therapy, terminate it in approximately the same state in which others begin therapy. Some clients may have highly specific goals in therapy and, because much of their psychopathology is ego-syntonic, choose to limit the amount of change they are willing to undertake. Others may be hampered by important external circumstances in their lives. All therapists have had the experience of helping a client improve to a point at which further change would be countertherapeutic. For example, a client might, with further change, outgrow his or her spouse, such that continued therapy would result in the rupture of a marital relationship unless concomitant changes occurred in the spouse. Without that, the therapist may be well advised to settle for the positive changes that have taken place, even though the personal potential for greater growth is clear. Termination of professional treatment is but a stage in the individual’s course of growth. Clients continue to change, and one important effect of successful therapy is to enable individuals to use their psychotherapeutic resources constructively in their personal environment. Moreover, treatment effects may be time delayed. We have seen many successful clients in long-term follow-up interviews who have not only continued to change after termination but who, after they have left the group, recall an observation or interpretation made by another member or the therapist that only then—months, even years, later—becomes meaningful to them. Others carry the group within them and utilize the adage we noted before—“What would the group say?”—whenever they are challenged in their life. Setbacks, too, occur after ending therapy. From time to time, successfully treated clients encounter severe stress and need short-term individual help. In addition, members may experience anxiety and depression after leaving a group. A period of mourning is an inevitable part of the termination process. Current loss may evoke memories of earlier losses, which may be so painful that the client truncates the termination work. Indeed, some cannot tolerate the process and will withdraw prematurely with a series of excuses. This must be challenged: the client needs to internalize the positive group experience and the members and leader; without a proper separation process that is worked through, the internalization will be compromised, and the client’s future growth constricted.87 Some therapists find that termination from group therapy is less problematic than termination from long-term individual therapy. In the latter, clients often become extremely dependent on the therapeutic situation. Group therapy participants are usually more aware that therapy is not a way of life but a process with a beginning, a middle, and an end. In the open therapy group, there are many living reminders of this therapy sequence. Members see new members enter and improved members graduate, and they observe the therapist beginning the process over and over again to help new members through difficult phases of therapy. Not infrequently, a group places subtle pressure on a member not to leave because the remaining members will miss that person’s presence and contributions. There is no doubt that members who have worked in a therapy group for many months or years acquire interpersonal and group skills that make them particularly valuable to the other members. Therapists, also, may so highly value such a member’s contributions that they are slow in encouraging him or her to terminate. Of course, there is no justification for such a posture, and therapists should explore this issue openly as soon as they become aware of it. Many therapists have noted that a “role suction” operates at such times: once the senior member leaves, another member begins to exercise skills acquired in the group. Therapists, like other members, will feel the loss of departing members, and by expressing their feelings openly can do some valuable modeling for the group, demonstrating that the therapy and the relationships matter, not just to the clients but to them, the therapists, as well. Some socially isolated clients may postpone termination because they have been using the therapy group for social reasons rather than as a means for developing the skills to create a social life for themselves in their home environment. The therapist must help these members focus on transfer of learning and encourage risk-taking outside the group. Others unduly prolong their stay in the group because they hope for some guarantee that they are indeed safe from future difficulties. They may suggest that they remain in the group for a few more months, until they start a new job, or get married, or graduate from college. If the improvement base seems secure, however, these delays are generally unnecessary. Members must be helped to come to terms with the fact that one can never be certain; one is always vulnerable. Not infrequently, clients experience a brief recurrence of their original symptomatology, including dismissive or clinging attachment behaviors, shortly before termination.88 There are times when this regression can serve as a last opportunity to revisit the concerns that led to treatment initially and promote some relapse prevention work. It is helpful to remember that good work in therapy rarely gets undone by the ending process, and the return of old behaviors provides an opportunity for more complete working through and consolidation. Rather than prolong their stay in the group, the therapist should help the clients understand this event for what it is: protest against termination. > One group member, three meetings before termination, reexperienced much of the depression and sense of meaninglessness that had brought him into therapy. The symptoms rapidly dissipated with the therapist’s interpretation that he was searching for reasons not to leave the group. That evening, the client dreamed that the therapist offered him a place in another group in which he would receive training as a therapist. The client felt that he had duped the therapist into thinking he was better. The dream represents an ingenious stratagem to defeat termination and offers two alternatives: the client goes into another of the therapist’s groups, in which he receives training as a therapist, or he has duped the therapist and has not really improved (and thus should continue in the group). Either way, he does not have to terminate. << Some members improve gradually, subtly, and consistently during their stay in the group. Others improve in dramatic bursts. We have known many members who, though hardworking and committed to the group, made no apparent progress whatsoever for six, twelve, even eighteen months, and then suddenly, in a short period of time, seemed to transform themselves. As we tell our students and trainees, change is often slow. Do not look for immediate gratification from clients. If your clients build solid, deep therapeutic foundations, change is sure to follow. So often we think of this as just a platitude designed to bolster neophyte therapists’ morale. But we must not forget that it is true. Do not sell the ending phase short; the last four to eight sessions are often a time when much of the prior work consolidates and clients evolve from feeling that they are renters of the psychotherapeutic endeavor to owners. The same staccato pattern of improvement is often true for the group as a whole. Sometimes groups struggle and lumber on for months with no visible change in any member, and then suddenly enter a phase in which everyone seems to get well together. Scott Rutan uses the apt metaphor of building a bridge during a battle.89 The leader labors mightily to construct the bridge, and may, in the early phases, suffer casualties (dropouts). But once the bridge is in place, it escorts many individuals to a better place. There are certain clients for whom even a consideration of termination is problematic. These clients are particularly sensitized to abandonment; their self-regard is so low that they consider their illness to be their only currency in their traffic with the therapist and the group. In their minds, growth is associated with dread, since improvement would result in the therapist leaving them. Therefore, they must minimize or conceal progress. Of course, it is not until much later that they discover the key to this paradox: once they truly improve, they will no longer need the therapist! One useful sign suggesting readiness for termination is that the group becomes less important to the client. One terminating member commented that Mondays (the day of the group meetings) were now like any other day of the week. When she began in the group, she lived for Mondays, with the rest of the days inconsequential wadding between meetings. The group members are an invaluable resource in helping one another decide about termination, and a unilateral decision made by a member without consulting the other members is often premature. Usually a decision to leave is made jointly by the member, the group, and the group therapist, with planning in advance to ensure that there is adequate time to do the psychological work of ending. In our open-ended groups, it is common for a client to give notice of termination four to eight sessions in advance.90 There are times when clients make an abrupt decision to terminate membership in the group immediately. We have often found that such individuals find it difficult to express gratitude and positive feeling; hence they attempt to abbreviate the separation process as much as possible. These clients must be helped to understand and correct their jarring, unsatisfying method of ending relationships. In fact, for some, the dread of ending dictates their whole pattern of avoiding connections and intimacy. To ignore this phase is to neglect an important area of human relations. Ending is, after all, a part of almost every relationship, and throughout one’s life one must say good-bye to important people. A meaningful relationship should be honored and concluded with dignity. Many terminating members attempt to lessen the shock of departure by creating links to the group that they can use in the future. They seek assurances that they may return; they collect the cellphone numbers and email addresses of the other members, “friend” one another on social media, or arrange social meetings to keep themselves informed of important events in the group. These efforts are only to be expected, and yet the therapist must not collude in the denial of termination. On the contrary, you must help the members explore it to its fullest extent. Clients who complete individual therapy may return, but clients who leave the group can never return. They are truly leaving because the group will never be the same group again. It will be irreversibly altered: new members will enter the group; new problems will emerge for discussion; relationships will evolve. The present cannot be frozen; time flows on inexorably. These facts are soon evident to the remaining members. There is no better stimulus than a departing member to encourage the group to deal with issues of loss, separation, death, aging, the rush of time, and the contingencies of existence. Termination is thus more than an extraneous event in the group. It is the microcosmic representation of some of life’s most crucial and painful issues. The remaining group members will need some sessions to work through their feelings of loss and to deal with many of these issues. The loss of a member provides an unusual work opportunity for individuals sensitized to loss and abandonment. Since they have compatriots sharing their loss, they mourn in a communal setting and witness others encompassing the loss and continuing to grow and thrive.91 After a member leaves the group, it is generally wise not to bring in new members without a hiatus of one or more meetings. Not only does this provide time for further working through of the impact of the departure, but it reminds the group that group members are not replaceable with a call to “central intake.” A member’s departure is often an appropriate time for others to take inventory of their own progress in therapy. Members who entered the group at the same time as the terminating member may feel some pressure to move more quickly. More competitive members may rush toward termination prematurely. Senior members may feel envy or react with shame, experiencing the success of the co-member as a reminder of their own deficiencies and failings. In extreme cases, the envy-ridden group member may seek to devalue and spoil the achievement of the graduating member. Newer members may feel inspired or awed, but doubt whether they will ever be able to achieve what they have just witnessed. Should the group engage in some form of ritual to mark the termination of a member? Sometimes a member or several members may present a gift to the graduating member or bring coffee and cake to the final meeting. How best to proceed?92 There are a range of perspectives on this question that reflect the way our models, experiences, and personhood influence our practice. Our perspective is that these rituals are acceptable, perhaps even desirable, as long as they are examined and processed in the group.93 We therapists must also look to our own feelings during the termination process, because occasionally we unaccountably and unnecessarily delay a client’s termination. Some perfectionist therapists may unrealistically expect too much change and refuse to accept anything less than total resolution. Moreover, they may lack faith in a client’s ability to continue growing after the termination of formal therapy.94 Other clients bring out Pygmalion pride in us: we find it difficult to part with someone who is, in part, our own creation: saying good-bye to some clients is like saying good-bye to a part of ourselves. Furthermore, it is a permanent good-bye. If we have done our job properly, the client no longer needs us and breaks all contact. The suicide of a group therapy client is, thankfully, uncommon. However, in the career of a mental health professional and group therapist who may also be supervising group therapy trainees, it does occur. One in two psychiatrists and one in six psychologists will experience a suicide in their practice over time.95 It is a painful and potentially traumatic event. Although the suicide of one man in a group I (ML) was supervising happened many years ago, I still recall it vividly and its impact lingers with me as well as with the two therapists who led the group, who are now colleagues. The client was depressed, had lost his business, and was going through a divorce as well, but did not manifest despair in the group and appeared to be forward thinking. He ended his life on the filing date for his income taxes. A client suicide shakes a therapist’s foundations and generates feelings of guilt, shame, fear, anger, and incompetence. It can impact how one practices, leading a therapist to avoid higher-risk clients.96 It is exceptionally challenging to work with group therapy clients who have lost a member to suicide. Sharing this painful news is an urgent imperative but can be complicated ethically and legally because of the disclosure of private client health information. It is advisable to discuss this issue with the privacy officer at one’s institution or with the relevant professional oversight committee. We recommend that you enlist collegial support as you prepare to inform a group about a member’s suicide. It is essential to be able to discuss, reflect on, and address your own reactions. Group members’ reactions will be intense and will cover the range of emotions described above. In addition, group members may fear for their own safety and identify with the deceased group member. Anger at the client, at treatment, and at the group therapist is to be expected. The group therapist needs to be able to join the group in grief without becoming paralyzed or frozen. Therapeutic presence and therapeutic containment can stabilize the group, maintain group integrity, promote member safety, and support the members’ grieving process. The surviving group members’ existential confrontation with mortality may strengthen their commitment to their treatment and safeguard the group from fragmenting into a state of hopelessness and futility. When the Therapist Departs from the Group In training programs, it is common practice for trainees to lead a group for six months to a year and then pass it on to a new student as their own training takes them elsewhere. The departure of the group leader is generally a difficult period for the group members, who often respond with repeated absences and threatened departure of their own. It is a time for the departing therapist to attend to any unfinished business he or she has with any of the members. Some members feel that this is their last chance and share hitherto concealed material. Others experience a return of earlier symptoms, as though to say, “See what your departure is doing to me!”97 Therapists must deal with all of these concerns. The more complete their ending with the group, the greater the potential for an effective transfer of leadership. The same principles apply in situations in which a more established leader needs to end his leadership owing to a move, an illness, or a professional change. If the group members decide to continue, it is the leader’s responsibility to secure new leadership. The transition process takes considerable time and planning, and the new leader must set about as quickly as possible to take over group leadership. One reported approach is for the new leader to meet with all the group members individually in a pregroup format as described in Chapter 9, while the original leader is still meeting with the group. After the first leader leaves, the new leader begins to meet with the group at the set group time or at a mutually agreed-upon new time.98 The departing group leader’s denial of loss, particularly when retiring from practice, may lead him or her to underestimate the work and time required for the group to address the loss and anger at ending.99 At other times, illness or an accident precludes proper planning. To avoid leaving one’s group abandoned, therapists should consider writing a professional will. Ann Steiner, a practicing clinical psychologist, has articulately described such a guide. The purpose of such a will is to ensure that you have addressed the continuing care needs of your clients in an ethical fashion. This includes a plan for one’s clients to be contacted in the event the therapist is unable to do so and provided with options for care.100 When the Whole Group Terminates Groups terminate for various reasons. Brief therapy groups, of course, have a preset termination date. Often, external circumstances dictate the end of a group: for example, groups in college counseling centers usually run through a semester or two. Open groups often end only when the therapist retires or leaves the area (although the group may continue if there is a co-therapist). Occasionally, a therapist may decide to end a group because the great majority of its members are ready to terminate at approximately the same time. Often a group avoids the difficult and unpleasant work of termination by denying or ignoring it, and the therapist must keep the task in focus for them.101 In fact, it is essential for the leader of the brief therapy group to remind the group regularly of the approaching termination and to keep members focused on the attainment of goals. Groups hate to die, and members generally try to avoid the ending. They may, for example, pretend that the group will continue in some other setting—for example, reunions or regularly scheduled social meetings. But the therapist is well advised to confront the group with reality: the end of a group is a real loss. It never really can be reconvened, and even if relationships are continued in pairs or small fragments of the group, the entire group as the members then know it—in this room, in its present form, with the group leaders—will be gone forever. The therapist must call attention to maladaptive modes of dealing with the impending termination. Some individuals have always dealt with the pain of separating from those they care about by becoming angry or devaluing the others. Some choose to deny and avoid the issue entirely. If anger or avoidance is extreme—manifested, for example, by tardiness or increased absence—the therapist must confront the group with this behavior. Usually with a mature group, the best approach is direct: reminding the members that it is their group, and they must decide how they want to end it. Pain over the loss of the group is dealt with in part by a sharing of past experiences. Exciting and meaningful past group events are remembered in the final meetings: members remind one another of the way they were then; personal testimonials are invariably heard. It is important that the therapist not bury the group too early, or the group will limp through ineffective lame-duck sessions. You must find a way to hold the issue of termination before the group and yet help the members keep working until the very last minute. Often it is useful to enquire into members’ feelings of regret about any issues not yet addressed. Some leaders of effective time-limited groups have sought to continue the benefits of the group by helping it move into an ongoing leaderless format. The leader may facilitate the transition by attending the meetings as a consultant at regular but decreasing intervals, such as biweekly or monthly. In our experience, it is particularly desirable to make such arrangements when the group is primarily a support group and constitutes an important part of the members’ social lives—for example, groups of elderly clients who, through the death of family members, friends, and acquaintances, are isolated. Others have reported the successful launching of ongoing leaderless groups for men, for women, for AIDS sufferers, for Alzheimer’s caregivers, and for the bereaved. Cancer support groups often continue to good effect after the formal duration of the treatment has concluded.102 Keep in mind that the therapist, too, experiences the discomfort of termination. Throughout the final group stage, we can facilitate the group work by disclosing our own feelings. Therapists, as well as members, will miss the group. We are not impervious to feelings of loss and bereavement. We have grown close to the members and we will miss them as they miss us. To us as well as to the client, termination is a jolting reminder of the built-in cruelty of the psychotherapeutic process. Such openness on the part of the therapist invariably makes it easier for the group members to make their good-bye more complete. For us, too, the group has been a place of anguish, conflict, fear, and also great beauty. Some of life’s truest and most poignant moments occur in the small and yet limitless microcosm of the therapy group. Footnotes i This is the same Ginny with whom I coauthored a book about our psychotherapy: I. Yalom and G. Elkin, Every Day Gets a Little Closer: A Twice-Told Therapy (New York: Basic Books, 1975; reissued 1992). Chapter 12 The Challenging Group Member WE HAVE YET TO ENCOUNTER A CLIENT WHO COASTS through therapy like a newly christened ship gliding smoothly into the water. Each group member must be a challenge: the success of therapy depends on the members encountering and then mastering fundamental life problems in the here-and-now of the group. Only in that way can therapy be helpful; the clinical challenge is in fact the therapeutic opportunity. Each client’s clinical concerns are overdetermined and unique. In light of this, our intent is not to provide a compendium of solutions to all possible problems. Instead we aim to describe a strategy and set of techniques that will enable a therapist to address challenges that arise in the group. The term “challenging group member” is itself problematic because it can narrow our focus and reduce our understanding. Keep in mind that the challenging group member rarely exists in a vacuum but is often an amalgam of several components: the client’s own traits and psychodynamics, the group’s dynamics, and the client’s interactions with co-members and the therapist. By overestimating the contributions of the client’s character and underestimating the role of the interpersonal context, we pathologize clients and place them at risk for scapegoating.1 At the same time, certain behavioral constellations merit particular attention because of their common occurrence and their utility in explicating therapeutic principles for group leaders. Accordingly, in this chapter, we turn our attention to common problematic clients: the monopolist, the silent client, the boring client, the help-rejecting complainer, the acutely psychotic or bipolar client, the schizoid client, and the characterologically difficult client (the borderline client and the narcissistic client). Although diagnostic classifications and nomenclature evolve over time, these clinical prototypes seem to persist. These clients often cause serious difficulties when they engage interpersonally with fellow group members, and they will also likely cause therapists to experience strong countertransference reactions. Keep in mind that these group members often direct attention away from their core vulnerabilities as they enact their difficulties rather than explore them.2 THE MONOPOLIST The bête noire of many group therapists is the habitual monopolist, a person who seems compelled to chatter on incessantly. These individuals are anxious if they are silent; if others get the floor, they reinsert themselves through a variety of techniques: rushing in to fill the briefest silence, responding to every statement in the group, continually addressing the problems of other group members with a chorus of “I’m like that, too.” The monopolist may persist in describing conversations with others in endless detail, gossiping, or presenting accounts of online or social media stories that are only slightly relevant to the group.3 Some monopolists hold the floor by assuming the role of interrogator. One member barraged the group members with so many questions and “observations” that it occluded any opportunity for other members to interact or reflect. Finally, when angrily confronted by co-members about her disruptive effect, she explained that she dreaded silence because it reminded her of the “calm before the storm”—the silence preceding her father’s explosive, violent rages. Some clients who have a dramatic flair monopolize the group by means of the crisis method: they regularly present the group with major life upheavals, which always seem to demand urgent and lengthy attention. The other members are cowed into silence, their problems seeming trivial in comparison. (“It’s not easy to interrupt Game of Thrones,” as one group member put it.) Although a group may welcome and even encourage the monopolist in the initial meetings, the effect on the group is quickly countertherapeutic. The mood soon turns to one of frustration and anger. Other group members are often disinclined to silence a member for fear that they will then be obliged to fill the silence; they anticipate the obvious rejoinder of, “All right, I’ll be quiet. You talk.” It is not possible to talk easily in a tense, guarded climate. Members who are not particularly assertive may smolder quietly or make indirect hostile forays. Generally, oblique attacks on the monopolist will only aggravate the problem and fuel a vicious circle. If the monopolist’s compulsive speech is an attempt to deal with anxiety, and he or she begins to sense the growing tension and resentment in the group, his or her anxiety rises, and the compulsive tendency to speak only increases. Unresolved tension arising from this dynamic will eventually wear away at group cohesion and manifest in signs of group disruption such as absenteeism, dropouts, fighting, and divisive subgrouping. When the group does finally confront the monopolist, it often takes the form of an explosive, brutal outburst by a group spokesperson, who then usually receives unanimous support from the other members. We have even witnessed a group giving the spokesperson a round of applause—a sure sign that a problem has been addressed far too late. The monopolist may then sulk, be completely silent for a meeting or two (“See what they do without me?”), or leave the group. In any event, little that is therapeutic has been accomplished for anyone. How can the therapist interrupt the monopolist in a therapeutically effective fashion? Despite the strongest urge to shout the client down or to silence the client by edict, such an assault has little value (except as a temporary catharsis for the therapist). The client is not helped: no learning has accrued; the dynamics underlying the monopolist’s compulsive speech persist and will, without doubt, erupt again in further monopolistic volleys or force the client out of the group. Neither is the group helped; regardless of the circumstances, the others are threatened by the fact that the therapist has silenced one of its members in such a heavy-handed manner. A seed of caution and fear is implanted in each member’s mind as they imagine a similar fate befalling them. Nevertheless, monopolistic behavior must be checked, and generally it is the therapist’s task to do so. Although therapists generally do well to wait for the group to handle many other group problems, the monopolistic member is one problem that groups, especially young groups, often cannot handle. Monopolistic clients pose a threat to the group’s procedural underpinnings; group members are encouraged to speak, yet this particular member must be silenced. The therapist must prevent the development of therapy-obstructing norms and at the same time prevent the monopolistic client from committing social suicide. A two-pronged approach is most effective: consider both the monopolizer and the group that has allowed itself to be monopolized. This approach reduces the hazard of scapegoating and illuminates the role played by the group in each member’s behavior. From the standpoint of the group, bear in mind that individual and group psychology are inextricably interwoven. No monopolistic client exists in a vacuum: the client always abides in a dynamic equilibrium with a group that permits or encourages such behavior.4 So the therapist may inquire why the group permits or encourages one member to carry the burden of the entire meeting. This inquiry may startle the members, who have perceived themselves only as passive victims of the monopolist. Or we might inquire if others experience the desire to hold everyone’s attention by talking through the whole meeting.5 After the initial protestations are worked through, the group members may benefit from examining their use of the monopolist in avoiding their own disclosures. Part of the power of group therapy is the way a single group phenomenon may evoke many different reactions. Some group members may be relieved at not having to speak in the group. They may let the monopolist do all the self-disclosure, or appear foolish, or act as a lightning rod for the group members’ anger, while they themselves assume little responsibility for the group’s therapeutic tasks. Prompted to disclose and discuss their reasons for inactivity, group members’ personal commitment to the therapeutic process is often augmented. They may, for example, discuss their fear of asserting themselves, or of harming the monopolist, or of being attacked in retaliation by another member or by the therapist. Or they may wish to avoid seeking the group’s attention lest their own neediness or narcissism be exposed. Or they may secretly revel in the monopolist’s plight, and enjoy being a member of the victimized and disapproving majority. The disclosure of any of these issues by an uninvolved client signifies greater engagement in therapy. > In one group a submissive, chronically depressed woman, Katie, exploded in an uncharacteristic expletive-filled rage at the monopolistic behavior of another member. As she explored her outburst, Katie quickly recognized that her rage was really inwardly directed, stemming from her own stifling of her own voice, her own passivity, her avoidance of her own emotions. “My outburst was twenty years in the making,” Katie added as she apologized and thanked her startled “antagonist” for crystallizing this awareness. << The group approach to this problem must be complemented by work with the monopolistic individual. The basic principle is a simple one: you do not want to silence the monopolist; you do not want to hear less from the client—you want to hear more. This seeming paradox is resolved when we consider that the monopolist uses compulsive speech for self-concealment. The issues the monopolist presents to the group do not accurately reflect deeply felt personal concerns but are selected for other reasons: to shield, entertain, gain attention, justify a position, present grievances, and so on. The monopolist sacrifices the opportunity for therapy to their insatiable need for attention or control. The essential message to monopolists must be that, through such compulsive speech, they hold the group at arm’s length and prevent others from relating meaningfully to them. You do not reject the monopolist, but instead issue an invitation to the monopolist to engage more fully in the group. If you harbor only the singular goal of silencing the client, then you have, in effect, submitted to your countertransference and abandoned the therapeutic goal; you might as well remove the member from the group. At times, despite considerable therapist care, the client will continue to hear only the message, “So, you want me to shut up!” Such clients may ultimately leave the group, often in embarrassment or anger. Although this is an unsettling event, the consequences of therapist inactivity are far worse. Though the remaining members may express some regret at the departure of the member, it is not uncommon for them to acknowledge that they were on the verge of leaving themselves had the therapist not intervened. In addition to their grossly maladaptive interpersonal behavior, monopolists have a major social sensory impairment. They seem peculiarly unaware both of their interpersonal impact and of the response of others to them. Moreover, they lack the capacity or inclination to empathize with others. These are bread-and-butter issues in group therapy, but only if they can be addressed. Data from a preliminary study supports this conclusion.6 Group members and student observers of a series of group sessions of a therapy group were asked to fill out questionnaires at the end of each group meeting. One of the areas explored was group activity. Both the participants and the observers were asked to rank the group members, including themselves, for the total number of words uttered during a meeting. There was excellent reliability in the activity ratings among group members and observers, with two exceptions: (1) the ratings of the therapist’s activity by the clients showed large discrepancies (a function of transference); and (2) monopolistic clients placed themselves far lower on the activity rankings than did the other members, who were often unanimous in ranking a monopolist as the most active member in the meeting. The therapist, then, must help monopolists be self-observant by encouraging the group to provide them with continual empathic feedback about their impact on the others.7 Relating this feedback to the initial therapy goals of these clients is also helpful. For instance, saying, “You want to get close to people,” “You want to be less isolated,” or “You want feedback about what goes wrong in your relationships” can help the client see the difficult confrontation as an opportunity. Without this sort of guidance from the leader, the group may provide the feedback in a disjunctive, explosive manner, which only makes the monopolist defensive. > In his initial interview, Matthew, who would later become a monopolist in the group, complained about his relationship with his wife, who, he claimed, often abruptly resorted to such sledgehammer tactics as publicly humiliating him or accusing him of being irresponsible and dishonest in front of his adult children.
Within the first few meetings of the group, a similar sequence unfolded in the social microcosm of the group: because of his monopolistic behavior, judgmental attitude, and inability to hear the members’ response to him, the group pounded harder and harder, until finally, when he was forced to listen, their sledgehammer message sounded cruel and humiliating. << Often the therapist must help increase a client’s receptivity to feedback. You may have to be forceful and directive, saying, for example, “Charlotte, I think it would be best now for you to stop speaking because I sense there are some important feelings about you in the group that would be very helpful for you to know.” You should also help the members disclose their responses to Charlotte rather than their interpretations of her motives. As described earlier, in the sections on feedback and interpersonal learning, it is far more useful and acceptable to offer a statement such as, “When you speak in this fashion I feel…” rather than “You are behaving in this fashion because…” Clients often perceive interpretations about motivations as accusatory, but find it more difficult to reject the validity of others’ subjective responses, particularly when echoed by other group members. Too often in group therapy, we confuse or interchange the concepts of cause, interpersonal manifestation, and response. The cause of monopolistic behavior may vary considerably from client to client: some individuals speak in order to control others; some so fear being influenced or penetrated by others that they compulsively defend each of their statements; and some so overvalue their own ideas and observations that they cannot delay and all thoughts must be immediately expressed. Still others are simply desperate for the group’s attention. Generally, the cause or actual intent of the monopolist’s behavior is not well understood until much later in therapy, and interpretation of the cause may offer little help in the early management of disruptive behavior patterns. It is far more effective to concentrate on the client’s manifestation of self in the group and on the other members’ response to his or her behavior. Members must be confronted gently but repeatedly with the paradox that however much they may wish to be accepted and respected by others, they persist in behavior that generates only irritation, rejection, and frustration. That feedback can be truly impactful and empathetic.8 A clinical illustration of many of these issues occurred in a therapy group in a psychiatric hospital/prison in which sexual offenders were incarcerated: > Walt, who had been in the group for seven weeks, launched into a familiar, lengthy tribute to the remarkable improvement he had undergone. He described in exquisite detail how he had not understood the damaging effects of his behavior on others, and how now, having achieved such understanding, he was ready to leave the hospital.
The therapist, alert to the group process, observed that some of the members were restless. One softly pounded his fist into his palm, while others slumped back in a posture of indifference and resignation. The therapist intervened by asking the group members about their response to Walt’s account. All agreed they had heard it at every meeting—in fact, they had heard Walt speak this way in the very first meeting. Furthermore, they had never heard him talk about anything else and knew him only as a story. The members discussed their irritation with Walt, their reluctance to confront him for fear of seriously injuring him, of losing control of themselves, or of painful retaliation. Some spoke of their hopelessness about ever reaching Walt, and of the fact that he related to them only as stick figures without flesh or depth. Still others noted their terror of speaking and revealing themselves in the group; therefore, they welcomed Walt’s monopolization. A few members expressed their total lack of interest or faith in therapy and therefore failed to intercept Walt because of apathy.
Thus, the process was overdetermined: a host of interlocking factors resulted in a dynamic equilibrium of monopolization. By halting the runaway process, and uncovering and working through the underlying factors, the therapist obtained maximum therapeutic benefit from a potentially crippling group phenomenon. Each member moved closer to group involvement. Walt was no longer enabled to participate in a fashion that could not possibly be helpful to him or the group. << It is essential to guide the monopolistic client into the self-reflective process of therapy. We urge such clients to reflect on the type of response they hoped to receive from the group and then compare that with what actually occurred when they were given feedback. How do they explain that discrepancy? What role did they play in it? Would they like to change the way they relate to others? Often monopolistic clients may devalue the importance of the group’s reaction to them. They may suggest that the group consists of disturbed people, or protest, “This is the first time something like this has ever happened to me.” If the therapist has prevented scapegoating, then this statement is always untrue: the client is in a particularly familiar place. What is different in the group is the presence of norms that permit the others to comment openly on the behavior. The therapist increases therapeutic leverage by encouraging these clients to examine and discuss interpersonal difficulties in their lives: loneliness, lack of close friends, not being listened to by others, being shunned without reason—all the reasons for which therapy was first sought. Once these are made explicit, the therapist can more convincingly demonstrate to monopolistic clients the importance and relevance of examining their in-group behavior. Good timing is necessary: there is no point in attempting to do this work with a closed, defensive individual in the midst of a firestorm. Repeated, compassionate, and properly timed interventions are required. THE SILENT CLIENT The silent member is a less disruptive but often equally challenging problem for the therapist. How concerned should we be? Perhaps the client profits silently. A story, probably apocryphal, that has circulated among group therapists for decades tells of an individual who attended a group for a year without uttering a word. At the end of the fiftieth meeting, he announced to the group that he would not return; his problems had been resolved, he was due to get married the following day, and he wished to express his gratitude to the group for the help they had given him. Let’s examine this issue more closely. Some reticent members may profit from vicariously engaging in treatment through identifying with active members with similar problems. It is possible that changes in behavior and in risk-taking can gradually occur in such a client’s relationships outside the group, although the person remains silent and seemingly unchanged in the group. The encounter group study that Morton Lieberman, Matthew Miles, and I (IY) conducted indicated that some of the participants who changed the most seemed to have a particular ability to maximize their learning opportunities in a short-term group (thirty hours) by engaging vicariously in the group experience of other members.9 In general, though, the evidence indicates that the more active and influential a member is in the group, the more likely it is that he or she will benefit. Research in experiential groups demonstrates that for the vast majority of participants, regardless of what the participants say, the more words they speak, the greater the positive change in their picture of themselves.10 Other research demonstrates that vicarious experience, as contrasted with direct participation, was ineffective in producing either significant change, emotional engagement, or attraction to the group process.11 A member who is persistently silent also fails to contribute to the work of others, which undermines the cohesion of the group. This silent member can become an object of projection, seen as sitting in judgment of group members. There is much clinical consensus that silent members do not profit from the group. Group members who self-disclose very slowly may never catch up to the rest of the group and at best achieve only minimal gains.12 The greater the verbal participation, the greater the sense of involvement and the more that clients are valued by others and ultimately by themselves. Self-disclosure is not only essential to the development of group cohesion, it is directly correlated to positive therapeutic outcome, as is the client’s “work” in therapy. We urge therapists not to be lulled by the legendary story of the silent member who got well. A silent client is a problem client and rarely benefits significantly from the group. The hazard is particularly acute in time-limited groups as there is less opportunity for late starters to catch up before the group concludes. Silence, if unchallenged by the therapist or group, may reinforce the client’s pathogenic beliefs and assumptions. Clients may be silent for many reasons. Some may experience a pervasive dread of self-disclosure: every utterance, they feel, may commit them to progressively more disclosure. Others may feel so conflicted about aggression that they cannot undertake the self-assertion inherent in speaking. Some are waiting to be activated and brought to life by an idealized caregiver. Some have lived with no independent voice, and engage in their relationships only through echoing, never initiating. Others, who demand nothing short of perfection in themselves, never speak for fear of falling shamefully short, whereas others attempt to maintain control through a lofty, superior silence. One group member claimed he was silent because his psychotic mother had criticized him for making any noise when chewing his food. Sometimes a client is especially threatened by a particular member in the group and habitually speaks only in the absence of that member. Others participate only in smaller meetings or in alternate (leaderless) meetings. Still others may silently sulk to punish others or to force the group to attend to them.13 Culture may also play a role for some members in discouraging public emotional expression and encouraging respectful deference to authority.14 Clients with a history of trauma may also remain silent and avoid emotional expression as a way of trying to maintain safety and reduce their exposure to traumatic triggers related to anger or attack.15 Group dynamics may also play a role. Group anxiety about potential aggression or about the availability of emotional supplies in the group may push a vulnerable member into silence to reduce the tension or competition for attention. Distinguishing between a transient “state” of silence or a more enduring “trait” of silence is therefore quite useful. The important point, though, is that silence is behavior and, like all other behavior in the group, has meaning in the here-and-now as a representative sample of the client’s way of relating to his or her interpersonal world. The therapeutic task, therefore, is not only to change the behavior (that is essential if the client is to remain in the group) but to explore the meaning of the behavior. It may seem a relief to have silent members join one’s group, because they do not immediately seem to place urgent demands on the group leaders. In truth this is a countertherapeutic stance, conveying the sense that silence is welcome, acceptable, and even desirable. Proper clinical management depends in part on the therapist’s understanding of the dynamics of the silence. A course must be steered between two undesirable outcomes: placing undue pressure on the client, or allowing the client to slide into an extreme isolate role. The therapist may periodically include the silent client by commenting on nonverbal behavior: that is, when, by gesture or demeanor, the client is evincing interest, tension, sadness, boredom, or amusement. Not infrequently, a silent member introduced into an ongoing group will feel awed by the clarity, directness, and insight of more experienced members. It is often helpful for the therapist to point out that many of these admired veteran group members also struggled with silence and self-doubt when they began.16 Even if repeated prodding or cajoling is necessary, the therapist should encourage client autonomy and responsibility by repeated process checks. “Is this a meeting when you want to be prodded?” “How did it feel when Mike put you on the spot?” “Did he go too far?” “Can you let us know when we make you uncomfortable?” “What’s the ideal question we could ask you today to help you come into the group?” “What will it feel like to go home tonight knowing that you took some risks with us?” “What do you think it means to us?” The therapist should seize every opportunity to reinforce the client’s activity and underscore the value of pushing against his or her fears (pointing out, for example, the feelings of relief and accomplishment that follow his risk-taking).17 If a client resists all these efforts and maintains a very limited participation even after three months of meetings, our experience has been that the client’s prognosis is poor. The frustrated group will tire of coaxing the silent member. In the face of the group’s disapproval, the client becomes more marginalized and even less likely to participate. Concurrent individual sessions may be useful in helping the client at this time. If this fails, the therapist may need to consider withdrawing the client from the group. Occasionally, entering a second therapy group at a later time may prove profitable, since the client now has the lived experience of the hazards of silence. THE BORING CLIENT Rarely does anyone seek therapy because of being boring. Yet, in different garb, the complaint is not uncommon. Clients complain that they never have anything to say to others; that they are left standing alone at parties; that no one ever invites them more than once; that others use them only for sex; that they are inhibited, shy, empty, or bland. Being boring, like being silent or monopolizing, is to be taken seriously. It is an important problem, whether the client explicitly identifies it as such or not. In the social microcosm of the therapy group, these members re-create their problems and bore the members of the group—and the therapist. The therapist dreads a small meeting in which only two or three boring members are present. If they were to terminate, one imagines they would simply slip away, leaving nary a ripple in the pond. Boredom is a highly individualized experience. In general, the boring group therapy client is massively inhibited, lacks spontaneity, and never takes risks. Their utterances are always “safe” (and, alas, always predictable). Before speaking, they scan the faces of the other members to determine what is expected of them to say, and they squelch contrary sentiments. Social styles of boring patients may vary: one may be silent, another stilted and hyperrational, another timid and self-effacing, still another dependent, demanding, or pleading. What they share in common is limited access to emotions. Thinking dominates feeling: the cognitive, left hemisphere of the brain dominates the emotional, right hemisphere.18 Some boring clients are in fact alexithymic—an affective difficulty stemming from cognitive processing deficits around emotions.19 The alexithymic client is concrete, lacks imaginative capacity, and focuses on details, not emotional experience. Individual therapy with such clients can be painfully slow and arid. Group therapy alone, or concurrent with individual therapy, may be particularly helpful in promoting emotional expressiveness, because group members will model how to engage with and express emotions and lend support to others.20 The inability to read their own emotional cues also may make these individuals vulnerable to medical and psychosomatic illness.21 Group therapy, because of its ability to increase emotional awareness and expression, can reduce alexithymia and has been shown to improve medical outcomes, for example in heart disease.22 Effective group therapy with this population is marked by slow, deliberate expansion of the client’s emotional world rather than a sudden transformative breakthrough. Group leaders and members often work hard to encourage spontaneity in boring clients. They ask such clients to share fantasies about members, to scream, to curse—anything to pry something unpredictable from them. > One client, Nora, drove the group to despair with her constant clichés and self-deprecatory remarks. After many months in the group, her outside life began to change for the better, but each report of success was accompanied by the inevitable self-derogation. She was accepted by an honorary professional society (“That is good,” she said, “because it is one club that can’t kick me out”); she received her graduate degree (“but I should have finished earlier”); she looked better physically (“shows you what a good sunlamp and make-up can do”); she had been asked out by several new men in her life (“must be slim pickings in the market”); she obtained a good job (“it fell into my lap”); she had had her first orgasm with a man (“give the credit to marijuana”).
The group tried to increase Nora’s awareness of her self-effacement. An engineer in the group suggested bringing an electric buzzer to ring each time she knocked herself. Another member, Ed, trying to shake Nora into a more spontaneous state, commented on her bra, which he felt could be improved. He said he would bring her a present, a new bra, next session. Sure enough, the following session he arrived with a huge box, which Nora said she would prefer to open at home. So, there it sat, looming in the group and, of course, inhibiting any other topic.
She was finally prevailed upon to open the gift and did so laboriously and with enormous embarrassment. The box contained nothing but Styrofoam stuffing. Ed explained that this was his idea for Nora’s new bra: that she should wear no bra at all. Nora promptly thanked him for the trouble he had taken. The incident launched much work for both members. The group told Nora that, though Ed had humiliated and embarrassed her, she had responded by apologizing to him. She had politely thanked someone who had just given her a gift of precisely nothing! The incident created the first robust spark of self-observation in Nora. She began the next meeting with, “I’ve just set the world ingratiation record. Last night I received a scam call about money I allegedly owed, and I apologized to the man. I said, ‘I’m sorry but you must have the wrong number.’” << The underlying dynamics of the boring patient vary enormously from individual to individual. Many have a core dependent position and dread rejection and abandonment so much that they are compulsively compliant, eschewing any aggressive remark that might initiate retaliation. They mistakenly confuse healthy self-assertion with aggression, and by refusing to acknowledge their own vitality, desires, spontaneity, interests, and opinions, they bring to pass (by boring others) the very rejection and abandonment they had hoped to forestall.23 If you, as the therapist, are bored with a client, your boredom is important information. The therapy of all challenging clients necessitates thoughtful attention to your countertransference. Therapist countertransference is always a source of valuable data about the client, never more so than with those clients whose behavior challenges our therapeutic effectiveness. Managing countertransference effectively is strongly correlated with better clinical success. Any unusual therapist reaction or behavior signals that interpersonal pulls are being generated, and therapists must take care to examine their feelings before responding.24 Always assume that if you are bored by the member, so are others. You must counter your boredom with curiosity. Ask yourself: “What makes the person boring? When am I most and least bored? How can I find the person—the real, the lively, spontaneous, creative person—within this boring shell?” No urgent “breakthrough” technique is indicated. Since the boring individual is tolerated by the group much better than the abrasive, narcissistic, or monopolistic client, you can take your time. Lastly, keep in mind that the therapist must take a Socratic posture with these clients. Our task is not to put something into the individual but quite the opposite, to let something out that was there all the time. Thus, we do not attempt to inspirit boring clients, or inject color, spontaneity, or richness into them, but instead to remove the obstacles to free expression of the creative, vital parts they have squelched. THE HELP-REJECTING COMPLAINER The help-rejecting complainer, a variant of the monopolist, was first identified and named by my (IY) mentor Jerome Frank in 1952.25 Since then the behavior pattern has been recognized by many group clinicians, and the term appears frequently in the psychiatric and psychotherapy literature.26 In this section, we discuss the rare fully developed help-rejecting complainer; however, this pattern of behavior is not a distinct, all-or-nothing clinical syndrome. Individuals may arrive at this style of interaction through various psychological pathways. Some may persistently manifest this behavior in an extreme degree with no external provocation, whereas others may demonstrate only a trace of this pattern. Still others may become help-rejecting complainers only at times of particular stress. Closely associated with help-rejecting complaining is the expression of emotional distress through somatic complaints, often in the form of perplexing, medically unexplainable symptoms.27 Help-rejecting complainers (or HRCs) show a distinctive behavioral pattern in the group: they implicitly or explicitly request help from the group, by presenting problems or complaints, and then reject any help offered. HRCs continually present problems in a manner that makes them appear insurmountable. In groups they often focus wholly on the therapist in a tireless campaign to elicit intervention or advice, and appear oblivious to the group’s reaction to them. They base their relationship to the other members along the singular dimension of being more in need of aid than the other members. HRCs rarely show competitiveness in any area—except when another member makes a bid for the therapist’s or group’s attention by presenting a problem. Then HRCs often attempt to belittle that person’s complaints by comparing them unfavorably with their own. They tend to exaggerate their problems and to blame others, often authority figures on whom they depend in some fashion. When the group and the therapist do respond to the HRC’s plea, the entire bewildering configuration takes form as the client rejects the help offered. The rejection is unmistakable, though it may assume many varied and subtle forms: sometimes the advice is rejected overtly; sometimes indirectly; sometimes, while accepted verbally, it is never acted upon; and if it is acted upon, it inevitably fails to improve the member’s plight. The effects on the group are obvious: the other members become irritated, frustrated, and confused. The HRC seems like an unstoppable whirlpool, sucking the group’s energy. Faith in the group process suffers as members experience a sense of impotence and despair at making their own needs appreciated by the group. Cohesiveness is undermined as members disengage in frustration. The dynamics that underpin the behavioral pattern of the HRC appear to be an attempt to resolve highly conflicted feelings about dependency. On the one hand, the HRC feels helpless, insignificant, and totally dependent on others, especially the therapist, for a sense of personal worth and security. Any notice or attention from the therapist temporarily enhances the HRC’s self-worth. On the other hand, the HRC’s dependent position is vastly confounded by a pervasive distrust and enmity toward authority figures. Consumed with need, the HRC turns for help to a figure he or she anticipates will be unwilling or unable to help. These clients may best be understood through an attachment paradigm. The HRC experiences two forms of attachment insecurity at the same time. The first form is that of individuals who are anxiously attached, who seek closeness and reassurance, often exaggerating their distress to ensure that their caregivers will respond to them. The second form is the avoidant, dismissively attached individual, who resists and rejects care. The HRC combines these, experiencing both simultaneously in a style referred to as fearful attachment. These clients experience care providers as both the sought-after solution and the dreaded source of mistreatment. The interpersonal consequences are enormously frustrating, and therapists may feel they are trying to pick up mercury: whatever they do misses the mark.28 What inevitably follows is a vicious cycle of seeking and being disappointed—one that has been spinning for much of the client’s life. The HRC is an exceedingly difficult clinical challenge. Many such clients have won a pyrrhic victory over therapist and group by failing in therapy. This is a loss for all. Any chance at successful treatment is predicated upon the group leader understanding the simultaneous wish the HRC carries for care and the dread of that care being unreliable, hurtful, or destructive. Patiently building a relationship with the HRC is essential, and it is easier to achieve if both the hope and dread can be acknowledged and validated as genuinely felt and not as a client manipulation to defeat the treatment. The HRC solicits advice not only for its potential value but also in order to spurn it. Acknowledging the pain of this bind, of longing for care and simultaneously being unable to use it effectively when offered, may reduce tension in the group and create more space for trust to develop. Although the therapist and the group’s advice, guidance, and treatment may be rejected, retaliation merely completes the vicious circle: the anticipation of ill treatment and abandonment that such clients experience is once again realized, and they feel justified in their hostile mistrust; as a result, they are able to affirm once again that no one can ever really understand them. A nonblaming, nonfaulting therapeutic stance is critically important. Aim to mobilize the major group therapeutic factors in the service of the client. When a cohesive group has been formed, and the client—through universality, identification, and catharsis—has come to value membership in the group, then the therapist can encourage interpersonal learning by continually focusing on feedback and process, in much the same manner as we have described in discussing the monopolistic client. Helping help-rejecting clients see their interpersonal impact on the other members is a key step for them. Coming to examine their characteristic pattern of relationships makes way for them to build safe connections and make different relationship choices. THE ACUTELY PSYCHOTIC CLIENT Many groups are designed specifically to work with clients with major mental illness. In fact, when one considers groups on psychiatric wards, partial hospitalization units, veterans’ hospitals, and aftercare programs, the total number of therapy groups for severely impaired clients is substantial.29 We will discuss groups composed for hospitalized clients in Chapter 15; for now we will consider the issue of what happens to the course of an interactive therapy group of higher-functioning individuals when one of its member develops an acute psychotic illness during treatment. The fate of this client, the response of the other members, and the effective options available to the therapist all depend in part on timing—that is, when in the course of the group the psychotic episode occurs. In general, the members of mature groups in which the client has long occupied a central, valued role are far more likely to be tolerant and effective during the crisis. In Chapter 8, we emphasized that in the initial screening, the client with severe and persistent mental illness should be excluded from standard outpatient interactional group therapy. Other group modalities are much better suited for these individuals.30 However, it is common practice to refer clients with apparently stable bipolar disease or other severe mood disorders in remission to interactional group therapy to address the interpersonal consequences of their illness. Combining group work with the care provided by a physician or psychiatrist who is prescribing and managing the client’s mood-stabilizing medications can be very effective. At times, despite cautious screening, an individual decompensates in the early stages of therapy, perhaps because of unanticipated stress from life circumstances, or from the group, or perhaps because of poor adherence to a medication regimen. This always creates substantial problems for the newly formed group—and, of course, for the client, who is likely to slide into a deviant role in the group and eventually terminate treatment, often much the worse for the experience. As we have stressed throughout this book, the early stages of the group are a time of great flux and great importance. The young group is easily influenced, and norms that are established early are often exceedingly durable. A compelling sequence of events unfolds as, in a few weeks, an aggregate of anxious, distrustful strangers evolves into an intimate, mutually helpful group. Any event that consumes an inordinate amount of time early on and diverts energy from the tasks of the developmental sequence is potentially destructive to the group. Some of the relevant problems are illustrated by the following clinical example: > Sandy was a thirty-seven-year-old housewife who had once, several years before, suffered a major treatment-resistant depression requiring hospitalization and electroconvulsive therapy. She sought group therapy at the insistence of her individual therapist, who thought that an understanding of her interpersonal relationships would help her to improve her relationship with her husband and overcome her shame and isolation.
In the early meetings of the group, Sandy was an active member. She tended to reveal far more intimate details of her history than the other members. Occasionally, she expressed anger toward another member, and then she engaged in excessively profuse apologies coupled with self-deprecatory remarks. By the sixth meeting, her behavior was becoming quite inappropriate. She discoursed at great length on her son’s urinary problems, for example, describing in intricate detail the surgery that had been performed to relieve his urethral stricture. At the following meeting, she noted that the family cat had also developed a blockage of the urinary tract; she then urged the other members to describe their pets.
By her eighth meeting, Sandy was becoming increasingly manic. She behaved irrationally, insulting other members of the group, openly flirting with the men, to the point of stroking their bodies, and finally lapsing into pressured speech, inappropriate laughter, and tears. One of the co-therapists finally escorted her from the group room and took her to the emergency room. She was hospitalized; remained in a manic, psychotic state for a month; and then gradually recovered on a new medication regimen.
The members were obviously extremely uncomfortable during Sandy’s final meeting. Their feelings ranged from bafflement and fright to annoyance. After she was escorted out, some expressed their feelings of guilt, worried that, in some unknown manner, they may have triggered her behavior. Others spoke of their fear of her. One member recalled someone he knew who had become threatening and brandished a gun following a psychotic breakdown.
During the subsequent meeting, one member expressed his conviction that no one could be trusted: even though he had known Sandy for seven weeks, her behavior proved to be totally unpredictable. Others expressed their relief that they were, in comparison, psychologically healthy, and still others, in response to their fears of similarly losing control, employed considerable denial and veered away from discussing these problems. Some expressed a fear that if Sandy returned she would make a shambles of the group. Others expressed their diminished faith in group therapy; one member asked for transcranial magnetic stimulation treatment instead, and another brought in an article from a scientific journal claiming that psychotherapy was ineffective. A loss of faith in the co-therapists and their competence was expressed in one member’s dream, where one of the co-therapists was in the hospital and the client rescued him.
Over the next few weeks, all these themes went underground, and the meetings became listless, shallow, and intellectualized. Attendance dwindled, and the group seemed resigned to its own impotence. At the fourteenth meeting, the co-therapists announced that Sandy was improved and would return the following week. A vigorous, heated discussion ensued. The members feared that:
• They would upset Sandy. An intense meeting would make her ill again and, to avoid that, the group would be forced to move slowly and superficially.
• Sandy would be unpredictable. At any point she might lose control and display dangerous, frightening behavior.
• Sandy would, because of her lack of control, be untrustworthy. Nothing in the group would remain confidential.
At the same time, the members expressed considerable anxiety and guilt for wishing to exclude Sandy from the group. Soon, tension and a heavy silence prevailed. The group’s extreme reaction persuaded the co-therapists to delay reintroducing Sandy (who continued in concurrent individual treatment) for a few weeks.
When Sandy finally did reenter the group, she was treated as a fragile object, and the entire group interaction was guarded and defensive. By the twentieth meeting, five of the seven members had dropped out of the group, leaving only Sandy and one other member.
The co-therapists reconstituted the group by adding five new members. It is of interest that, despite the fact that only two of the old members and the co-therapists continued in the reconstituted group, the old group culture persisted—a powerful example of the staying power of norms even in the presence of a limited number of culture-bearers.31 The group dynamics had locked the group and Sandy into severely restricted roles and functions. Sandy was treated so delicately by even the new members that the group moved slowly, floundering in politeness and social conventionality. Finally, in one group meeting, the co-therapists confronted the issue openly. They discussed their own fears of upsetting Sandy and thrusting her into another psychological decompensation. Only then were the members themselves able to deal with their feelings and fears about her. At that point, the group moved ahead more quickly. Sandy remained in the reconstituted group for a year and made significant improvements in her ability to relate with others and in her self-concept. << An entirely different situation may arise when an individual who has been an involved, active group member for many months decompensates into a psychotic state. Other members are then primarily concerned for that member rather than for themselves or for the group. Since they have previously known and understood the now acutely ill member, they often react with great concern and interest; the client is less likely to be viewed as a strange and frightening object to be avoided. Stigma regarding mental illness continues to be prominent, even in health care, particularly for trainees. A colleague and I (IY) observed that medical students assigned for the first time to a psychiatric ward regarded the psychotic patients as extremely dangerous, frightening, unpredictable, and dissimilar to themselves. After five weeks, the students’ attitudes had changed considerably: they were less frightened of their patients and realized that psychotic individuals were just confused, deeply anguished human beings, more like themselves than they had previously thought.32 Although some members are able to continue relating to a distressed group member, others may experience a personal upheaval and begin to fear that they, too, might lose control, and slide into a similar disturbed state. Hence, the therapist does well to anticipate and express this fear to the others in the group. When faced with an acutely psychotic client in a group, many therapists revert to a medical model and symbolically dismiss the group by intervening forcefully in a one-to-one fashion. In effect, they say to the group, “This is too serious a problem for you to handle.” Such a maneuver, however, is often antitherapeutic: the client is frightened, and the group infantilized. It has been our experience that a mature group is perfectly able to deal with the psychiatric emergency and to consider every contingency and take every action that the therapist might have considered. Consider the following clinical example: > In the forty-fifth meeting of a group, Roberta, a forty-three-year-old divorced woman, arrived a few minutes late in a disheveled, tearful, and obviously disturbed state. Over the previous few weeks, she had gradually been sliding into a depression, but now the process had suddenly accelerated. During the early part of the meeting she wept continuously and expressed feelings of great loneliness and hopelessness as well as an inability to love, hate, or, for that matter, have any deeply felt emotion. She described feeling great detachment from everyone, including the group, and, when prompted, discussed suicidal ruminations.
The group members responded to Roberta with great empathy and concern. They inquired about events during the prior week and helped her discuss two important occurrences that seemed related to the depressive crisis. First, for months she had been saving money for a summer trip to Europe, but she now feared she would not be able to go. During the past week, her seventeen-year-old son had decided to decline a summer camp job, and he refused to search for other jobs. In Roberta’s eyes, this turn of events jeopardized her trip. Second, after months of hesitation, she had decided to attend a dance for divorced middle-aged people, and it proved to be a disaster. No one had asked her to dance, and she had ended the evening consumed with feelings of total worthlessness.
The group helped Roberta explore her relationship with her son, and for the first time she expressed considerable anger at him for his lack of concern for her. With the group’s assistance, she attempted to explore and express the limits of her responsibility toward him. It was difficult for Roberta to discuss her experience at the dance because of the shame and humiliation she felt. Two other women in the group, one single and one divorced, empathized deeply with her and shared their experiences and reactions to the scarcity of suitable males. The group also reminded Roberta of the many times during sessions when she had interpreted every minor slight as a total rejection and condemnation.
Finally, after much attention, care, and warmth had been offered her, one of the members pointed out to Roberta that the experience of the dance was being disconfirmed right in the group: several people who knew her well were deeply concerned and involved with her. Roberta rejected this idea by claiming that the group, unlike the dance, was an artificial situation, in which people followed unnatural rules of conduct. The members quickly pointed out that quite the contrary was true: the dance—the contrived congregation of strangers, the attractions based on split-second, skin-deep impressions—was the artificial situation, and the group was the real one. It was in the group that she was more completely known.
Roberta, suffused with feelings of worthlessness, then berated herself for her inability to feel reciprocal warmth and involvement with the group members. One of the members quickly intercepted this maneuver by pointing out that Roberta experienced considerable empathy for the other members, evidenced by her facial expressions and body postures. But then Roberta let her “shoulds” take over and insisted that she should feel more warmth and more love than anyone else. The net effect was that the real feeling she did have was rapidly extinguished by the winds of her impossible self-demands.
In essence, what then transpired was Roberta’s gradual recognition of the discrepancy between her public and private esteem. Near the end of the meeting, Roberta burst into tears, and she wept for several minutes. The group members were reluctant to leave but did so once they had convinced themselves that suicide was no longer a serious consideration. Throughout the next week, they maintained an informal vigil, each calling or texting Roberta at least once as she stabilized. The group therapist also followed up with Roberta to ensure that she received urgent care in the form of clinical support and medications. << A number of important and far-reaching principles emerge from this illustration. Early in the session, the therapist realized the important dynamics operating in Roberta’s depression. Had he chosen to do so, he might have made the appropriate interpretations to allow the client and the group to arrive much more quickly at a cognitive understanding of the problem. But that would have detracted considerably from the meaning and value of the meeting for Roberta as well as for the other members. For one thing, the group would have been deprived of an opportunity to experience its own potency. Every success adds to the group’s cohesiveness and enhances the self-regard of each of the members. It is difficult for some therapists to refrain from interpretation, and yet it is essential to learn to sit on your wisdom. There are times when it is foolish to be wise and wise to be silent. At times, as in this clinical episode, the group will perform the appropriate action; at other times, the group may decide that the therapist must act. But there is a vast difference between a group’s hasty decision, stemming from infantile dependence and unrealistic appraisal of the therapist’s powers, and a decision based on the members’ thorough investigation of the situation and mature appraisal of the therapist’s expertise. This point leads us to an important principle of group dynamics, one substantiated by considerable research: A group that reaches an autonomous decision based on a thorough exploration of the pertinent problems will employ all of its resources in support of its decision; a group that has a decision thrust upon it is likely to resist that decision and be even less effective in making valid decisions in the future.33 Although the acutely ill group member is the urgent priority, the group and its members may also have a unique opportunity to deepen their own psychotherapeutic work at the same time. The implications for group therapy are apparent: members who personally participate in planning a course of action will be more committed to the enactment of the plan. They will, for example, invest themselves more fully in the care of a distressed member if they recognize that it is their problem and not the therapist’s alone. Sharing intense emotional experiences often strengthens ties among group members. The danger to the group occurs when the acutely psychotic client consumes such a massive amount of energy for such a prolonged period that it causes other members either to drop out, to deal with the disturbed individual in a cautious manner, or to ignore the member altogether. These methods never fail to aggravate the problem. In such critical situations, one important option always available to the therapist is to see the acutely disturbed client in individual sessions for the duration of the crisis (an option we will discuss more fully in the discussion of combined therapy; see Chapter 13). However, the group should thoroughly explore the implications and share in the decision to have one member see the therapist separately while also still participating in the group. What happens if a group member requires hospitalization? In this event, we strongly urge that the group leader visit the client in the hospital. > Julia, a thirty-eight-year-old woman, entered group therapy to address her social isolation and her sense of herself as defective because of her long-standing bipolar disorder. She had been doing well on mood stabilizers, but several months into the group she began to wean herself off her medications, believing that she no longer required them. She soon became progressively paranoid and agitated in the group, and her individual therapist arranged for her admission as an involuntary patient to an acute care psychiatric unit.
I (ML) visited Julia during her month-long hospital admission. She exclaimed at how moved she was by my visiting her and how heartening it was to feel that she was remembered. My visit made her eventual return to the group easier. When she returned, she expressed embarrassment about her behavior when she had been manic, but was grateful that the group had not rejected her. For several months following, Julia referred to the importance of my hospital visit. << The client with acute bipolar affective disorder is best managed pharmacologically and is not a good candidate for interactionally oriented treatment at this stage. It is obviously unwise to allow the group to invest much energy and time in treatment that has such little likelihood of effectiveness. There is mounting evidence, however, for the effectiveness of using specific, homogeneous groups to treat clients with bipolar illness. These groups offer psychoeducation about the illness and stress the importance of pharmacotherapy adherence and maintenance of a healthy lifestyle, along with biological daily rhythm and self-regulation routines. Such groups are best employed in conjunction with pharmacotherapy during the maintenance phase of treatment. Substantial benefits from these groups have been demonstrated, including improved pharmacotherapy adherence, reduced mood disturbance, fewer illness relapses, less substance abuse, and improved psychosocial functioning.34 THE SCHIZOID CLIENT Many years ago, in a previous edition of this book, I (IY) began this section with the following sentence: “The schizoid condition, the malady of our times, perhaps accounts for more patients entering therapy than does any other psychopathological configuration.” This no longer rings true. The fashions of mental illness change, and diagnostic criteria and clinical presentations change over time, which is yet another reason why we should approach our diagnostic assumptions with humility. Today, clients more commonly enter treatment because of depression, anxiety, substance abuse, eating disorders, and sequelae of sexual and physical abuse. It is also worth noting that many individuals diagnosed in the past with schizoid personality might today be diagnosed with Asperger syndrome (AS) or, as it is now reclassified in DSM-5, autism spectrum disorder (ASD). We see an explosive increase in the frequency of the ASD diagnosis.35 Although the strict diagnostic criteria distinguish the schizoid client from the ASD client, the clinical distinction is less clear-cut for these individuals when we consider their pursuit of group therapy. Clinically, both the schizoid client and the ASD client may present with impaired relationship capacities, social failure, isolation, social awkwardness, misreading of social cues, impediments to empathy, impaired processing of emotions in themselves and others, and a wish for more connection. Group therapies structured for ASD clients are developing slowly but are not yet widely accessible. Therefore, it is not uncommon to have high-functioning ASD individuals referred to interpersonal group therapy.36 > Gene, a twenty-eight-year-old man, arrived for his initial consultation for outpatient group therapy with his community caseworker. He had asked the caseworker to attend because he had previously experienced discrimination when pursuing mental health care, having been told he was not suitable for the treatment he sought.
Gene conveyed a sense of social oddness and awkwardness: his eye contact was poor, and he wore a long bright yellow raincoat throughout the entire consultation. At the same time, he expressed an earnest wish to alleviate his loneliness. He felt that he would benefit from exposure to others interacting normally, rather than being with others who suffered impairments similar to his.
Gene entered an interpersonal psychotherapy group that was time limited, meeting weekly for eight months, and proved to be a regular and reliable participant. He described a lifetime of people avoiding him because they saw him as odd or mentally ill. Now, he was eager to understand how he alienated others and was keen to improve his social skills.
In his early group sessions, he disclosed excessively and indiscriminately about his isolation, his sexual frustration, and his disappointment that others did not appreciate his special abilities. He missed social cues and, if not interrupted by the group leaders, would have talked throughout the entire meeting.
Despite appropriate preparation for the group, he sought to meet members outside the meetings, and the leaders had to reinforce boundaries time and again. Gradually, Gene learned how to share time and to offer help to others. Although the group feedback at times was heavy handed, he listened, and over the course of the group sessions he began to make eye contact, pose more appropriate questions to others, and allow time for people to respond before jumping to the next question. He also assimilated feedback about how his intense gazing at women’s bodies made them feel sexually objectified and was “creepy.”
The group members treated Gene firmly, respectfully, and affectionately, and ultimately expressed their pleasure in witnessing Gene’s interpersonal growth. In the concluding session, Gene told the group this was his first positive experience as a member of any type of group. He also brought in a list of all the lessons he had learned, expressing his deep appreciation to the group members and his intention to build upon what he had learned. << Even though the schizoid condition is no longer the malady of our times, schizoid individuals are still common visitors to therapy groups. They are emotionally blocked, isolated, and distant and often seek group therapy out of a vague sense that something is missing: they cannot feel, cannot love, cannot play, cannot cry. They are spectators of themselves; they do not inhabit their own bodies; they do not experience their own experience. No one has described the experiential world of the schizoid individual more vividly than Jean-Paul Sartre in The Age of Reason: He closed the paper and began to read the special correspondent’s dispatch on the front page. Fifty dead and three hundred wounded had already been counted, but that was not the total, there were certainly corpses under the debris. There were thousands of men in France who had not been able to read their paper that morning without feeling a clot of anger rise in their throat, thousands of men who had clenched their fists and muttered: “Swine!” Mathieu clenched his fists and muttered: “Swine!” and felt himself still more guilty. If at least he had been able to discover in himself a trifling emotion that was veritably if modestly alive, conscious of its limits. But no: he was empty, he was confronted by a vast anger, a desperate anger, he saw it and could almost have touched it. But it was inert—if it were to live and find expression and suffer, he must lend it his own body. It was other people’s anger. Swine! He clenched his fists, he strode along, but nothing came, the anger remained external to himself. Something was on the threshold of existence, a timorous dawn of anger. At last! But it dwindled and collapsed, he was left in solitude, walking with the measured and decorous gait of a man in a funeral procession in Paris. He wiped his forehead with his handkerchief, and he thought: One can’t force one’s deeper feelings. Yonder was a terrible and tragic state of affairs that ought to arouse one’s deepest emotions. It’s no use, the moment will not come.37 Schizoid individuals are often in a similar predicament in the therapy group. In virtually every group meeting, they have confirmatory evidence that the nature and intensity of their emotional experience differs considerably from that of the other members. Puzzled at this discrepancy, they may conclude that the other members are melodramatic, excessively labile, phony, overly concerned with trivia, or simply of a different temperament. Eventually, however, schizoid clients, like Sartre’s protagonist, Mathieu, begin to wonder about themselves, and begin to suspect that somewhere inside themselves is a vast frozen lake of feeling. In one way or another, by what they say or do not say, schizoid clients convey this emotional isolation to the other members. In Chapter 2 we described a male client who could not understand the members’ concern about the therapist leaving the group or a member’s obsessive fears about her boyfriend being killed. He saw people as interchangeable. He had his need for a minimum daily requirement of affection but had little concern about the source of the affection. He was “bugged” by the departure of a therapist only because it would slow down his therapy; he did not share the grief expressed by other members over the loss of the human being who had been their therapist. A schizoid member in another therapy group, chided by the group because of his lack of empathy toward two highly distressed members, responded, “So, they’re hurting. There are millions of people hurting all over the world at this instant. If I let myself feel bad for everyone who is hurting, it would be a full-time occupation.” Most of us get a rush of feelings and then try to comprehend the meaning of the feelings. In schizoid clients, feelings come much later—they are awarded priority according to the dictates of rationality. The group is often keenly aware of discrepancies among a member’s words, experiences, and emotional responses. They may read the schizoid member’s emotions from postural or behavioral cues. Indeed, such individuals may relate to themselves in a similar way and join into the investigation, commenting, for example, “My heart is beating fast, so I must be frightened,” or “My fist is clenched, so I must be mad.” In this regard they share a common difficulty with the alexithymic clients described earlier. The response of the other members is predictable, proceeding from curiosity and puzzlement through disbelief, solicitude, irritation, and frustration. They will repeatedly inquire, “What do you feel about…?” and only much later come to realize that they were demanding that this member quickly learn to speak a foreign language. At first, members become very active in helping to resolve what appears to be a minor affliction, telling schizoid clients what to feel and what they would feel if they were in that situation. Eventually, the group members grow weary of the project and frustration sets in; then they redouble their efforts—almost always without noticeable results. Ultimately, they resort to the sledgehammer approach. The therapist must avoid joining in the quest for a breakthrough. We have never seen a schizoid client significantly change by virtue of a dramatic incident. Change is a prosaic process of grinding labor, repetitive small steps, and almost imperceptible progress. It is tempting and potentially useful to employ some activating, nonverbal, or gestalt techniques to hasten a client’s movement. These approaches may speed up the client’s recognition and expression of nascent or repressed feelings. But keep in mind that schizoid clients need more than new skills: they need a new internalized experience of the world of relationships—and that requires time, patience, and perseverance. In Chapter 6, we described several here-and-now activating techniques that are also useful in work with the schizoid client. Work energetically in the here-and-now. Encourage the client to differentiate among the group members; despite his or her protestations, the client does not feel precisely the same way toward everyone in the group. Help such members move into feelings they pass off as inconsequential. When the client admits, “Well, I may feel slightly irritated or slightly hurt,” suggest staying with these feelings. You might suggest, “Describe exactly what it is like.” Invite the client to imagine what others in the group are feeling. Try to cut off the client’s customary methods of dismissal of his or her feelings: “Somehow, you’ve gotten away from something that seemed important. When you were talking to Julie, I thought you looked near tears. Can you talk about what was going on inside?”38 Encourage the client to observe his or her body. Often the client may not experience affect but will be aware of the affective autonomic equivalents: tightness in the stomach, sweating, throat constriction, flushing, and so on. Gradually the group may help the client translate those physical feelings into their psychological meaning. Therapists must beware of assessing events solely according to their own experiential world. As we have discussed previously, clients may experience the identical event in totally different ways. An event that is seemingly trivial to the therapist or to one of the group members may be an exceedingly important experience to another member. A slight show of irritation by a restricted schizoid individual may be a major breakthrough for that person. In the group, these individuals, like many others described in this chapter, are high risk and high reward. Those who can manage to continue in the group without becoming discouraged by their inability to change their relationship style quickly are almost certain to profit considerably from the group therapy experience. THE CHARACTEROLOGICALLY DIFFICULT CLIENT The final two types of challenging clients in group therapy we shall discuss are the borderline client and the narcissistic client. Clinicians are acutely aware of the prevalence of these personality disorders at large, as they represent between 6 and 13 percent of the general population.39 These clients are often discussed together in the clinical literature under the rubric of the characterologically difficult—or what were formerly known as cluster B—client.40 But traditional DSM diagnostic criteria do not do justice to the complexity of these clients, failing to capture their inner psychological experience adequately.41 Most characterologically difficult clients have problems with how they perceive and interpret themselves and others, how they function interpersonally, impulsivity, and regulation of affect.42 Their pathology is thought to be based on serious difficulties in the first few years of life. They lack internal soothing or comforting parental representations: their internal world is inhabited by abandoning, withholding, and disappointing caregiver representations. Often lacking the ability to integrate ambivalent feelings and interpersonal reactions, they split the world into black and white, good and bad, loving and hating, idealizing and devaluing. At any given time they have little recall of feelings other than the powerful ones they feel at that moment. Prominent difficulties include rage, vulnerability to abandonment and to narcissistic injury, and a tendency toward projective identification.43 Often the characterologically difficult client has experienced traumatic abuse early in life as well, which further amplifies the challenge in treatment. In some samples the comorbidity of posttraumatic stress disorder (PTSD) and borderline personality disorder exceeds 50 percent. When the traumatic experiences and consequent symptoms—chiefly intrusive reexperiencing of the trauma, avoidance of any reminder of the trauma, and general hyperarousal—have a profound combined impact on the individual, the term “complex PTSD” is often applied. This term captures the way in which the traumatic events and psychological reactions to these events shape the individual’s personality.44 Characterologically difficult clients are prevalent in almost every clinical setting. They are often referred to groups by individual therapists when (1) the transference has grown too intense for dyadic therapy; (2) the client has become so defensively isolated that group interaction is required to engage the client; (3) therapy has proceeded well but a plateau has been reached, and interactive experience is necessary to produce further gains. The Borderline Client For decades, psychotherapists have known about a large cluster of individuals who are unusually difficult to treat and who fall in between the major diagnostic criteria of severity of impairment: they are more disorganized than neurotic clients but more integrated than psychotic clients. A thin veneer of integration conceals a primitive personality structure. Under stress, these borderline clients are highly unstable; some develop brief psychotic episodes. DSM-5 diagnostic criteria for clients with borderline personality disorder note a multiplicity of difficulties centered around a pervasive pattern of instability in the individual’s interpersonal relationships, self-image, affects, and control over impulses.45 The diagnosis still lacks precision, has unsatisfactory reliability, and often serves as a catchall for a personality disorder that clinicians cannot otherwise diagnose.46 It will, in all likelihood, undergo further transformation in future classificatory systems. There is considerable debate about the psychodynamics and the developmental origins of the borderline personality disturbance.47 This debate is tangential to group therapy practice, however, and need not be discussed here. What is important for the group therapist, as we have stressed throughout this book, is not the elusive and unanswerable question of how one got to be the way one is, but the nature of the current forces, both conscious and unconscious, that influence the way the client relates to others. There has recently been an explosion of interest in the diagnosis, psychodynamics, and effective therapeutic treatment of the borderline client, including much new literature on group therapy.48 Group therapists have developed an interest in these clients for two major reasons. First, because borderline personality disorder is difficult to diagnose in a single screening session, many clinicians unintentionally introduce borderline clients into therapy groups consisting of clients functioning at a higher level of integration. Second, there is growing evidence that specialized group therapy is an effective form of treatment for these clients. Some impressive research results have emerged from homogeneous and intensive partial hospitalization programs. These groups offer the borderline individual containment, emotional regulation training, emotional support, and interpersonal learning. They also demand personal accountability in an environment that counters regression and unhealthy intensification of transference reactions. Significant and enduring improvements in mood, psychosocial stability, and self-harm behavior have been reported.49 The majority of borderline clients, however, are likely to be treated in heterogeneous outpatient groups, and research indicates that these clients highly value their group therapy experience.50 Keep in mind that the borderline client’s pathology places great demands on the treating therapist, who is often frustrated by the client’s inability to make gains in therapy. At times the therapist may experience strong wishes to rescue these clients, even to modify the traditional procedures and boundaries of the therapeutic situation. Many individual therapists suggest group therapy for borderline clients not because these clients work well or easily in therapy groups but because they are so extraordinarily difficult to treat in individual therapy. Therapists often find it difficult to deal with the demands and the primitive anger of the borderline client, particularly since the client so often acts them out (for example, through absence, lateness, drug abuse, or self-harm). Crippling transference and countertransference problems regularly emerge in both individual and group therapy, but the group setting provides some added capacities: for example, other members may provide their own views of the course of group events, and peer support lessens the borderline client’s dependence on the therapist. The borderline client’s primitive affects and highly distorted perceptual tendencies greatly influence the course of group therapy and severely tax the resources of the group. The duration of therapy is long: there is considerable clinical consensus that borderline clients require many years of therapy and will generally stay in a group longer than any of the other members. Separation anxiety and the fear of abandonment play a crucial role in the dynamics of the borderline client. A threatened separation (the therapist’s vacation, for example—and sometimes even the end of a session) characteristically evokes severe anxiety and triggers the characteristic defenses of this syndrome: splitting,i projective identification, devaluation, and flight.51 The therapy group may assuage separation anxiety in two ways. First, one or (preferably) two group therapists are introduced into the client’s life, thus shielding the client from the great dysphoria occurring when the individual therapist is unavailable. Second, the group itself becomes a stable entity in the client’s life, one that exists even when some of its members are absent. Repeated loss (that is, the termination of members) within the secure continued existence of the group helps these clients come to terms with their extreme sensitivity to loss. The therapy group offers a singular opportunity to mourn the loss of an important relationship in the comforting presence of others who are simultaneously dealing with the same loss. Real relationships can offset the intense hunger the borderline client feels, but in a more mutual, less intense fashion.52 Once the borderline client develops trust in the group, he or she may serve as a major stabilizing influence. Because borderline clients’ separation anxiety is so great and they are so anxious to preserve the continued presence of important figures in their environment, they help keep the group together, often becoming the most faithful attendees and chiding other members for being absent or tardy. One of the major advantages of a therapy group for the treatment of a borderline client is the powerful reality testing provided by the ongoing stream of feedback and observations from the members. Thus, regression is far less pronounced for these clients in group therapy than in individual therapy. Clients gain the capacity to think about their own and others’ inner experience. Making sense of the interpersonal world of the group paves the way to build trust in their capacity to engage the world more fully.53 > Margie, forty-two, was referred to the group by her individual therapist, who had been unable to make headway with her. Margie’s feelings toward her therapist alternated between great rage at him and hunger for him. The intensity of these feelings was so great that little work could be done, and the therapist was on the verge of discontinuing therapy. Placing her in a therapy group was his last resort.
Upon entry into the group, Margie refused to talk for several meetings because she wanted to determine how the group ran. After four meetings in silence, she suddenly unleashed a ferocious attack on one of the group co-leaders, labeling him as cold, powerful, and rejecting. She offered no reasons or data for her comments aside from her gut feeling about him. Furthermore, she expressed contempt for those members of the group who felt affection for him.
Her feelings for the other leader were quite the opposite; she experienced him as soft, warm, and caring. Other members were startled by her black-and-white view of the co-therapists and urged her, unsuccessfully, to work on her great propensity for judgment and anger. Her positive attachment to the one leader contained her sufficiently to permit her to continue in the group—and allowed her to tolerate her intense hostile feelings toward the other leader and to work on other issues in the group—though she continued to snipe intermittently at the hated leader.
A notable change occurred with the “bad” therapist’s vacation. When Margie expressed a fantasy of wanting to kill him, or at least to see him suffer, members expressed astonishment at the degree of her rage. Perhaps, one member suggested, she hated him so much because she badly wanted to be closer to him and was convinced it would never happen. This feedback had a dramatic impact on Margie. It touched not only on her feelings about the therapist but also on deep, conflicted feelings about her mother. Gradually, her anger softened, and she described her longing for a different kind of relationship with the therapist. She expressed sadness also at her isolation in the group and described her wish for more closeness with other members. Some weeks after the return of the “bad” therapist, her anger had diminished sufficiently to work with him in a more productive manner. << This example illustrates how, in a number of ways, the group therapy situation can reduce intense and crippling transference distortions. First, other members offered different views of the therapist, which ultimately helped Margie correct her distorted views. Second, borderline clients who develop powerful negative transference reactions are able to continue working in the group because they so often develop opposite, positive feelings toward the group members or co-therapist—which is why many clinicians strongly advise a co-therapy format in the group treatment of borderline clients.54 It is also possible for a client to rest temporarily, to withdraw, or to participate in a less intensified fashion in the therapy group. Such respites from intensity are rarely possible in the one-to-one format. The work ethic of psychotherapy is often more readily apparent in a group. Individual therapy with borderline clients may be marked by the fragility of the therapeutic alliance and repeated ruptures and emotional storms.55 Some clients lose sight of the goal of personal change and instead expend their energy in therapy seeking revenge for inflicted pain or demanding gratification from the therapist. Witnessing other members working on therapy goals in the group often supplies them with an important corrective to a derailed therapy. Since the borderline individual’s core problems lie in the sphere of intimacy, the therapeutic factor of cohesiveness is often of decisive import. If these clients are able to accept the reality testing offered by the group, and if their behavior is not so disruptive as to cast them in a deviant or scapegoat role, then the group may become a holding environment—an enormously important, supportive refuge from the stresses that borderline clients experience in everyday life. Borderline clients’ sense of belonging is augmented by the fact that they are often a great asset to the therapy group. These individuals have great access to affect, as well as to unconscious needs, fantasies, and fears, and they may loosen up a group and facilitate the therapeutic work of inhibited, constricted individuals. Of course, this can be a double-edged sword. Some group members may be negatively affected by a borderline client’s intense rages and negativity, which can undermine the work of co-members who are themselves victims of abuse or trauma.56 The borderline client’s vulnerability and tendency to distort are so extreme that concurrent or combined individual therapy is often required. Many therapists suggest that the most common reason for treatment failure of borderline clients in therapy groups is the omission of adjunctive individual therapy.57 If conjoint therapy is used, it is particularly important for the group and the individual therapists to be in ongoing communication. The dangers of splitting are real, and it is important that the client experience the therapists as a solid, integrated team. The decision to include a borderline client in a group depends on the characteristics of the particular individual being screened rather than on the broad diagnostic category. The therapist has to assess not only a client’s ability to tolerate the intensity of the therapy group but also the group’s ability to tolerate the demands of that particular client at that point. Most heterogeneous outpatient groups can, at best, manage only one or possibly two borderline individuals. A mature group offers better prospects of therapeutic gains for these challenging clients than does a newly formed, young group. Other major considerations influencing the selection process are the same as those described in Chapter 8. It is particularly important to assess the possibility of the client becoming a deviant in the group. Rigidity of behavioral patterns, especially patterns that antagonize other people, should be scrutinized carefully. Clients who are markedly grandiose, contemptuous, and disdainful are unlikely to have a bright future in a group. It is necessary for a client to have the capacity to tolerate minimal amounts of frustration or criticism without serious acting out. Attention to emotional regulation and affect tolerance strategies can be very helpful and may augment or preface the interpersonal group work.58 The Narcissistic Client The term narcissistic may be used in different ways. It is useful to think about narcissistic clients representing a range and dimension of concerns rather than a narrow diagnostic category.59 Although there is a formal diagnosis of narcissistic personality disorder, there are many more individuals with narcissistic traits who create characteristic interpersonal problems in the course of group therapy. Here again we see the four key domains of difficulty we noted earlier in this section: perceiving and interpreting self and others, interpersonal function, impulse control, and affect regulation.60 Many individuals with narcissistic difficulties present with features of grandiosity, a need for admiration from others, and a lack of empathy. These individuals also tend to have a shallow emotional life, derive little enjoyment from life other than tributes received from others, and tend to depreciate those from whom they expect little narcissistic gratification.61 Their self-esteem is brittle and easily diminished, often generating outrage at the source of insult. Noah, the self-absorbed group member described in detail in the preceding chapter on the advanced group, exemplifies this clinical presentation and the countertransference elicited. Appropriate narcissism, a healthy love of oneself, is essential to the development of self-respect and self-confidence. Excessive narcissism takes the form of loving oneself to the exclusion of others, of losing sight of the fact that others are sentient beings, that others, too, construct and experience a unique world. The narcissistic client often has a stormier but more productive course in group than in individual therapy. In fact, the individual format provides so much gratification that the core problem emerges much more slowly: the client’s every word, feeling, fantasy, and dream is acknowledged; much is given to and little demanded from the client. In the group, however, the client is expected to share time; to understand, empathize with, and help others; to form relationships; to be concerned with the feelings of others; to receive constructive but sometimes critical feedback. Narcissistic individuals often feel most alive when on stage: they judge the group’s usefulness on the basis of how many minutes of group and therapist time they have obtained at a meeting. They guard their specialness fiercely and often object when anyone points out similarities between themselves and other members. For the same reason, they also object to being included with the other members in group-as-a-whole interpretations. They may have a negative response to some crucial therapeutic factors—for example, cohesiveness and universality. To belong to a group, to be like others, may be experienced as a homogenizing and diminishing experience. Hence the group experience readily brings the narcissistic client’s difficulties in relationships to light. Other members may feel unsympathetic to the narcissistic member because they rarely see the vulnerability and fragility that reside beneath the grandiose and exhibitionistic behavior, a vulnerable core that the narcissistic client often keeps well hidden.62 > Vicky was highly critical of the group format and frequently expressed her preference for the one-to-one therapy format. She often supported her position by citing psychoanalytic literature critical of the group therapy approach. She felt bitter at having to share time in the group. For example, three-fourths of the way through a meeting, the therapist remarked that he perceived Vicky and John to be under much pressure. John had begun in the preceding session to talk about his mounting feelings of worthlessness. They both admitted that they needed and wanted time in the meeting that day. After a moment’s awkwardness, John gave way, saying he thought his problem could wait until the next session. Vicky consumed the rest of the meeting, and at the following session she continued where she had left off. When it appeared that she had every intention of using the entire meeting again, one of the members commented that John had been left hanging in the last session. But there was no easy transition, since, as the therapist pointed out, only Vicky could entirely release the group, and she gave no sign of doing so graciously (she had lapsed into a sulking silence).
Nonetheless, the group turned to John, who was in the midst of a major life crisis. John presented his situation, but no good work was done. At the very end of the meeting, Vicky began weeping silently. The group members, thinking that she was weeping for John, turned to her. But she was weeping, she said, for all the time that was wasted on John—time that she could have used so much better. What Vicky could not appreciate for at least a year in the group was that this type of incident did not indicate that she would be better off in individual therapy. Quite the contrary: the fact that such difficulties arose in the group was precisely the reason that the group format was especially indicated for her. << Though narcissistic clients are frustrated by their bids for attention being so often thwarted in the group as well as in their outside life, that very frustration constitutes a major advantage for the group therapeutic mode. Furthermore, the group is catalyzed as well: some members profit from having to take assertive stands against the narcissist’s greediness, and members who are too nonassertive may use aspects of the narcissistic client’s demanding behavior as modeling. Another narcissistic patient, Ruth, who sought therapy for her inability to maintain deep relationships, participated in the group in a highly stylized fashion: she insisted on filling the members in every week on the minute details of her life and especially on her relationships with men, her most pressing problem. Many of these details were extraneous, but she was insistent on a thorough recitation (much like the “watch me” phase of early childhood). Aside from watching her, there seemed no way the group could relate to Ruth without making her feel deeply rejected. Some narcissistic individuals who have a deep sense of specialness and entitlement feel not only that they deserve maximum group attention but also that it should be forthcoming without any effort on their part. They expect the group to care for them, to reach out for them despite the fact that they reach out for no one in return. They expect gifts, surprises, compliments, concern, though they give none. They expect to be able to express anger and scorn but to remain immune from retaliation. They expect to be loved and admired for simply being there. We have seen such expectations especially pronounced in individuals who have been praised all their lives simply by virtue of their appearance and their presence.63 The narcissistic client’s lack of awareness of, or empathy for, others in the group is obvious. After several meetings, members begin to note that although the client does personal work in the group, he or she never questions, supports, or assists others. The client may describe his or her own life experiences with great enthusiasm, but is a poor listener and grows bored when others speak. One narcissistic man often fell asleep in the meeting if the issues discussed were not immediately relevant to him. When confronted about his sleeping, he would ask for the group’s forbearance because of his long, hard day (even though he was frequently unemployed, a phenomenon he attributed to the failure of potential employers to recognize his unique skills). There are times when it is useful to point out that there is only one relationship in life where one individual can constantly receive without reciprocating to the other—the young infant with his or her mother. Many therapists distinguish between the overgratified narcissistic individual who has an overinflated sense of self and the undergratified narcissistic individual, who tends to feel more deprived and enraged, even explosive. The group behavior of the latter is misunderstood by the other members, who interpret the anger as an attack on the group rather than as a last-ditch attempt to defend the otherwise unprotected self. Consequently, undergratified narcissistic individuals are given little nurturance for their unspoken wounds and deficits and are at risk of bolting from the group. It is essential that therapists maintain an empathic connection to these clients and focus on their subjective worlds, particularly when they feel diminished or hurt. Their protestation may well be understood as the persistent hope for care, rather than resignation to despair of submission and compliance. At times, the group leader may even need to advocate for these provocative members and encourage the other members to try to understand their emotional experience.64 Recognize your own countertransference and use it to interrupt negative interpersonal cycles. One group member, Rona, consistently criticized the group members and therapist for “not getting it.” Despite valiant efforts to the contrary, session after session was marked by Rona’s anger and ended with group members feeling invalidated and incompetent. It was only after reflecting on my (ML) fantasy of how the group would be better if Rona were to leave that my awareness crystallized. This was projective identification in action. Rona’s mother had abandoned her at a young age, and upon returning some time later was invalidating toward Rona and hostile to her emotional needs. Rona’s presence made her feel guilty, an emotion the mother rejected wholly. Now Rona was treating us exactly the way her mother had treated her, hoping against hope for a different outcome. As we began to unpack our experience of Rona’s invalidation of the group members, and of me, we were able to restore an empathic link to Rona. Her rejection of us was a window into how she felt with her mother. This deepened our understanding and we signaled that we were not going to respond by rejecting her. As she came to understand that we were sticking by her, she calmed enormously and became more able to take in our care. > Sal, a narcissistic man, was insulting, unempathic, and highly sensitive to even the mildest criticism. In one meeting, he lamented at length that he never received support or compliments from anyone in the group, least of all from the therapists. In fact, he could remember only three positive comments to him in the many group meetings he had attended. One member responded immediately and straightforwardly: “Oh, come on, Sal, get off it. Last week both of the therapists supported you a whole lot. In fact, you get more stroking in this group than anyone else.” Every other member of the group agreed, and they offered several examples of positive comments that had been given to Sal over the past few meetings.
Later in the same meeting, Sal responded to two incidents in a highly maladaptive fashion. Two members were locked in a painful battle over control. Both were shaken and extremely threatened by the degree of anger expressed, both their own and their antagonist’s. Many of the other group members offered observations and support. Sal’s response was that he didn’t know what all the commotion was about; in his view, the two were “jerks” for getting themselves so upset about nothing at all.
A few minutes later, Farrell, a member who had been very concealed and silent, was pressed to reveal more about herself. With considerable resolve, and for the first time, she disclosed intimate details about a relationship she had recently entered into with a man. She talked about her fear that the relationship would collapse. Moreover, she desperately wanted children, but she had once again started a relationship with a man who made it clear that he did not want children. Many members of the group responded empathically and supportively to her disclosure. Sal was silent, and when called upon he stated that he could see Farrell was having a hard time talking about this, but couldn’t understand why, because “it didn’t seem like a big-deal revelation.” Farrell responded, “Thanks, Sal, that makes me feel great—it makes me want to have nothing to do with you. I’d like to put as much distance as possible between the two of us.”
The group’s response to Sal in both of these incidents was immediate and direct. The two people he had accused of acting like jerks let him know that they felt demeaned by his remarks. One commented, “If people talk about some problem that you don’t have, then you dismiss it as being unimportant or jerky. Look, I don’t have the problems that you have about not getting enough compliments from the therapists or other members of the group. It simply is not an issue for me. How would you feel if I called you a jerk every time you complained about that?” << This meeting illustrates several features of group work with a characterologically difficult client. Sal was inordinately adversarial and had developed an intense and disabling negative transference in several previous attempts in individual therapy. In this session, he expressed distorted perceptions of the therapists (that they had given him only three compliments in dozens of sessions, when in fact they had been strongly and consistently supportive of him). In individual therapy, Sal’s distortion might have led to a major impasse, because his transferential distortions were so marked that he did not trust the therapists to provide an accurate view of reality. Therapy groups have a great advantage in the treatment of such clients because, as illustrated in this vignette, group therapists do not have to serve as the sole champions of reality: the other group members assume that role and commonly provide powerful and accurate reality testing to the client. Sal, like many other narcissistic patients, was overly sensitive to criticism. (Such individuals are emotionally like the hemophiliac patient, who bleeds at the slightest injury and lacks the resources to staunch the flow of blood.)65 The group members were aware that Sal was highly vulnerable and tolerated criticism poorly. Yet they did not hesitate to challenge him directly and compassionately. Although Sal was wounded in this meeting, as in so many others, he also heard the larger message: the group members took him seriously and respected his ability to take responsibility for his actions. We believe that it is crucially important that a group assume such an honest and direct stance toward these vulnerable clients. Honest and caring confrontation is different from confrontations driven by the wish to retaliate, punish, or humiliate the narcissistic member.66 Once a group begins to ignore or patronize a narcissistic individual, therapy for that client is certain to fail. THE MAJOR TASK FOR THE GROUP THERAPIST WORKING WITH ALL of these problematic clients is neither precise diagnosis nor a formulation of early causative dynamics. Whether the diagnosis is borderline or narcissistic personality disorder, the primary issue is the same: the therapeutic management of the highly vulnerable individual in the here-and-now of the therapy group. Group therapy can illuminate interpersonal pathology exceedingly well. It then needs to be matched with sensitive and supportive psychotherapeutic work. Footnotes i Splitting is a psychological defense in which the individual separates positive emotions and relationship experiences from negative ones. This results in dramatic and polarizing states and swings from idealizing and loving to devaluing and hating. Ambivalence is severely diminished and the client’s world is experienced as black and white.
