The Advanced Group - Theory and Practice Of Group Psychotherapy PDF

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... The Advanced Group O NCE A GROUP ACHIEVES A DEGREE OF MATURITY AND STABIL...

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... The Advanced Group O NCE 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 1 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 2 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 3 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 4 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 5 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 6 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 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 14 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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). 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 15 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... friends, and began concealing issues from the group. Ultimately, he dropped out of treatment. 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 16 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 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 20 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 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 25 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 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 29 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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; 30 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 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 33 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Douglas’s assumption of a new role (“most improved member”) was an entente between the two members achieved. 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 34 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. Maria began a group session by requesting and obtaining the therapist’s 40 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 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 45 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 46 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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.” 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 52 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. 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 64 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 65 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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 66 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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. One group member, three meetings 74 of 86 12/16/2024, 3:44 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... 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.