The Theory and Practice of Group Psychotherapy PDF

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... In the Beginning T HE WORK OF THE GROUP THERAPIST BEGINS LONG BEF...

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... In the Beginning T HE 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 1 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 2 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 3 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 4 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 5 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 6 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 7 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 8 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 9 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 10 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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, 11 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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, 12 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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, 13 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 14 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 15 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 16 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 17 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 18 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 19 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 20 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 21 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 22 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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-group consciousness;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 23 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 24 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 25 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 26 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 27 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 28 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 29 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 30 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 31 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 32 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 33 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 34 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 35 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 36 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 37 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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, 38 of 77 12/16/2024, 3:41 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Sara, entered group therapy to deal with chronic depression, much of which was rooted in her submission to the demands of her elderly parents