The Theory and Practice Of Group Psychotherapy PDF

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... - 13 - Specialized Formats and Procedural...

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... - 13 - Specialized Formats and Procedural Aids A NUMBER OF IMPORTANT VARIABLES MAY IMPACT THE FAMILIAR group therapy format in which one therapist meets with six to eight members: the client may concurrently be in individual treatment, for example, or may be attending a twelve-step group in addition to the therapy group. The group may also be led by co-therapists instead of one. We shall discuss each of these in this chapter and describe as well some specialized techniques and approaches that may facilitate the course of therapy. CONCURRENT INDIVIDUAL AND GROUP THERAPY First, some definitions. Conjoint therapy refers to a treatment format in which the client is seen by one therapist in individual therapy and a different therapist (or two, if co-therapists) in group therapy. In combined therapy, the client is treated by the same therapist simultaneously in individual and 1 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... group therapy. Little systematic data exists about the added value of concurrent group and individual therapy relative to each delivered alone, although most studies show comparable effectiveness for group and individual therapy.1 Despite the widespread practice of concurrent individual and group treatment, little research data exist to guide therapists. Therefore, we offer some guidelines and principles that arise from our clinical experience and the literature.2 Whenever we integrate two treatment modalities, we must first consider their compatibility. More is not always better! Are the different treatments working at cross-purposes, or do they enhance one another? If compatible, are they complementary, working together by addressing different aspects of the client’s therapy needs? Typically, we think of group therapy addressing interpersonal issues in the here-and- now and individual therapy addressing early life dynamics and intrapsychic issues.3 Integration of these two perspectives may strengthen each modality. The relative frequencies of the two types of concurrent therapy are unknown, although it is likely that in private practice combined therapy is more commonly employed than conjoint therapy.4 The opposite appears to be true in institutional and mental health treatment settings.5 By no means should one consider conjoint and combined therapy to be equivalent. They have exceedingly different features and clinical indications, and we 2 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... shall discuss them separately. Conjoint Therapy We believe that, with some exceptions, conjoint individual therapy is not essential to the practice of group therapy. If members are selected with a moderate degree of care, a weekly therapy group is ample therapy and should benefit the great majority of clients. But there are exceptions. The characterologically difficult client, whom we discussed in Chapter 12, frequently needs to be in concurrent individual and group therapy. In fact, the earliest models of concurrent group and individual therapy developed in response to the needs of these challenging clients, and concurrent treatment for these clients has evolved in both dynamically oriented and mentalization-based treatments.6 Clients with a history of childhood sexual abuse or who have other major issues around shame also often require concurrent therapy.7 Individual treatment can help clients develop tailored approaches to emotional self- regulation that may help them continue in their group during storms of affect and distress. Group members frequently go through a severe life crisis (for example, bereavement or divorce) that requires temporary individual therapy support. Some clients are so fragile or blocked by anxiety or fearful of aggression that individual therapy is required to enable them to participate in the group. From time to time, individual therapy is required to prevent a client from dropping out of the group, 3 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... or to monitor more closely a suicidal or impulsive client. > Joan, a young woman with borderline personality disorder participating in her first therapy group, was considerably threatened by the first few meetings. She felt increasingly alienated because her bizarre fantasy and dream world seemed so far from the experience of the other members. In the fourth meeting, she verbally attacked one of the other members and was attacked in return. For several nights thereafter, she had terrifying nightmares. In one, her mouth turned to blood, an image that appeared to be related to her fear of being verbally aggressive and destructive. In another, she was walking along the beach when a huge wave engulfed her—this related to her fear of losing her boundaries and identity in the group. In a third dream, Joan was held down by several men who guided the therapist’s hands as he performed an operation on her brain—obviously related to her fears of therapy and of the therapist being overpowered by the male members of the group. Joan’s hold on reality grew more tenuous, and it seemed unlikely that she could continue in the group without added support. Concurrent individual therapy with another therapist was arranged, and it helped her to contain her anxiety and 4 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... remain in the group. Jim was referred to a group by his psychoanalyst, who had treated him for six years and was now terminating analysis.8 Despite considerable improvement, he still had not mastered the symptom for which he had originally sought treatment: fear of women. He found it difficult even to give direction to his female administrative assistant. In one of his first group meetings, he was made extremely uncomfortable by a woman in the group who complimented him. He stared at the floor for the rest of the session, and afterward called his analyst to say that he wanted to drop out of the group and reenter analysis. His analyst discussed the situation with the group therapist and agreed to resume individual treatment with Jim on the condition that he return to the group as well. For the next few months, they had an individual session following each group session. The two therapists collaborated well, and the group therapist was able to increase support sufficiently to enable Jim to continue in the group. Within a few months, Jim was able to reach out emotionally to female group members for the first time, and he gradually grew more at ease with women in the real world. After seven meetings, David, a somewhat obsessional fifty-year-old confirmed bachelor, was on the verge of dropping out. The group had given him considerable feedback about several annoying characteristics he had: his frequent use of 14 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... euphemisms; his concealment behind long, boring, repetitious anecdotes; and his persistence in asking distracting and irrelevant questions. Because David seemed untouched by the feedback, the group ultimately backed away and began to “mascot” him—tolerating him in a good- natured fashion, but not taking him seriously. In an individual session, he lamented being “out of the loop” in the group and questioned whether he should continue. He also mentioned that he had not been wearing his hearing aid to the group, because of his fear of being ridiculed or stereotyped. Under ordinary circumstances, David would likely have dropped out of the group, but I (IY) could explore in his individual therapy many of the disturbing group events as well as the meaning of his being “out of the loop.” It turned out to be a core issue for David. Throughout his childhood and adolescence, he had felt socially shunned, and ultimately he had resigned himself to it. He became a loner and entered a profession (freelance IT consultant) that permitted a solitary, unattached lifestyle. At my urging, he used his hearing aids in the group and expressed his feelings there of being out of the loop. His self-disclosure —and, even more important, his examination of his own role in putting himself out of the loop—were sufficient to 15 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... reverse the process and bring him into greater engagement with the group. He remained in combined therapy with much profit for a year. Steven had for years engaged in many extramarital encounters but refused to take safer-sex precautions. In individual therapy I (IY) discussed this with him for months from every possible vantage point. We discussed his grandiosity and sense of immunity from biological law, his selfishness, and his concerns about impotence with a condom. I communicated my concern for him, for his wife, and for his sex partners. I expressed paternal feelings: both sadness at his self-destructiveness and outrage at his selfish behavior. All to no avail. When I placed Steven in a therapy group, he did not discuss his sexual risk-taking behavior, but some relevant experiences occurred. 16 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... On a number of occasions, he gave feedback to women members in a cruel, unfeeling manner. Gradually, the group confronted him on this and reflected on his uncaring, even vindictive, attitudes to women. Most of his group work centered on his lack of empathy. Gradually, he learned to enter the experiential worlds of others. The group was time limited (six months), and many months later in individual therapy, when we again focused in depth on his sexual behavior, Steven recalled, with considerable impact, how the group members had accused him of being uncaring. He was now able to consider his choices in the light of his lack of loving, and only then did his behavioral pattern change. Sam, a man who entered therapy because of his inhibitions and general flatness, encountered his lack of openness and his rigidity far more powerfully in the therapy group than in the individual format. He kept three particularly important secrets from the group: that he had been trained as a therapist and practiced for a few years; that he had retired after inheriting a large fortune; and that he felt superior and held others in contempt. He kept secrets in the group (as he did in his social life), convincing himself that self-revelation would result in greater distance from others: he believed he would 17 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... be stereotyped in one way or another, and “used,” envied, revered, or hated. After three months of participation in a newly formed group, Sam became painfully aware of how he had re-created in the group the same onlooker role he assumed in his real life. All the members had started together, and all the others had revealed themselves and participated in a personal, uninhibited manner; he alone had chosen to stay outside the circle. In our individual work, I (IY) urged Sam to reveal himself in the group. In session after session, I felt like a cornerman in a boxing ring exhorting him to take a chance. In fact, as the group meetings went by, I told him that delay was making things much worse. If he waited much longer to tell the group he had been a therapist, he would get a lot of flak when he did. (Sam had been receiving a steady stream of compliments about his perceptivity and sensitivity.) Finally, Sam took the plunge and revealed his secrets. Immediately, he and the other members began to relate in a more genuine fashion. His disclosure enabled other members to reveal more about themselves. A member who was a student therapist discussed her fear of being judged for making superficial comments; another revealed that she was a closet snob, and a wealthy member revealed his concerns about others’ envy. Still others discussed 18 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... strong, previously hidden feelings about money—including their anger at the therapist’s fees. After the group ended, Sam continued to discuss these interactions in his individual therapy and to take new risks with me as well. The members’ acceptance of him after his disclosures was powerfully affirming. Previously, they had accepted him for his helpful insights, but that acceptance meant little to him, because he knew it was rooted in his bad faith: his false presentation of himself and his concealment of his training, wealth, and personal traits. During a group meeting, my co-leader, a resident, asked me (ML) why I seemed so quick to jump in with support whenever one of the men, Rob, received critical feedback. The question caught me off guard. I 33 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... commented first that I had not noticed that until she drew it to my attention. I then invited feedback from others in the group, who agreed with her observation. It soon became clear to me that I was indeed overly protective of Rob, and I commented that although he had made substantial gains in controlling his anger and explosiveness, I still regarded him as fragile and I felt I needed to protect him from overreacting. Rob thanked me and my co-leader for our openness and added that, although he may have needed extra care in the past, he no longer did at this point. Our own initial experience of co-therapy together reminds us of these principles. During my training, Irv invited me (ML) to co- lead an ongoing group of group therapists that he had been leading by himself. It was daunting to enter a group whose members were themselves experienced group leaders. Often a group member would carry the most recent edition of this book—which they had assigned their own students—into the session. 36 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... The group clients were exceedingly constrained and deferential to Irv, afraid to challenge one another or speak to the competitiveness they felt. Our hope was that shifting to co-leadership might help mobilize the group and unlock some of the unspoken tensions. For the first several sessions after my entry, every comment I made landed like a lead balloon in the oppressively quiet group. A bit exasperated, I finally proclaimed that the group members were stuck and afraid to take risks, leaving everything to “Irv, the wizened group leader.” That seemed to help unlock the group somewhat, and later, in our postgroup discussion, Irv asked me if I was aware of my competitive feelings toward him, adding with humor that he assumed I intended to say, “Irv, the wise group therapist,” not “wizened,” i.e., shriveled. Alas, one cannot lie to one’s unconscious, as my slip of the tongue betrayed, in this instance, to good effect. In a meeting just preceding the entry of two new members to the group, one self- absorbed man, Jeff, reported his first dream to the group after several months of participation. “I am polishing my new BMW to a high sheen. Then, just after I clean the car interior to perfection, seven people dressed as clowns arrive, get into my car carrying all sorts of food, and mess it up. I just stand there watching and fuming.” Both he and the group members presented associations to the dream around an old theme for Jeff—his frustrating pursuit of perfection and need to present a perfect image to the world. The leader’s inquiry about “why this dream now?” led to more significant insight. Jeff said that over the past few months he had begun to let the group into his less-than-perfect “interior” world. Perhaps, he said, the dream reflected his fear that the new members coming the next week would not take proper care of his interior. He was not alone in this anxiety: other members also worried that the new members might spoil the group. I am walking with my younger sister. As we walk, she grows smaller and smaller. Finally, I have to carry her. We arrive at the group room, where the members are sitting around sipping tea. I have to show the group my sister. By this time, she is so small she is in a package. I unwrap the package but all that is left of her is a tiny bronze head. My husband locks me out of our grocery store. I am very concerned about the perishables spoiling. He gets a job in another store, where he is busy taking out the garbage. He is smiling and enjoying this, though it is clear he is being a fool. There is a young, attractive male clerk there who winks at me, and we go out dancing together. There are two rooms side by side with a mirror in my house. I feel there is a burglar in the next room. I think I can pull the curtain back and see a person in a black mask stealing my possessions. Sara, an eighty-two-year-old woman with anxiety and depression participating in a day hospital for seniors, told her group that she was intensely anxious about attending her granddaughter’s wedding five days hence. Getting dressed up and being exposed to a large crowd of people filled her with dread. As she spoke, Sara started to panic, hyperventilate, and cry. While the group therapists tried to be reassuring, Sara’s neighbor, an eighty-five-year-old woman, Doris, reached over, grabbed her hand, and lovingly stated: “You know what to do Sara; you know to breathe deeply, focus on your breath, and make yourself feel better. There is nothing to fear; I know how much you want to attend the wedding. I am going to breathe with you right now and I want you to join me. You have practiced this and now we will use it. You are not alone here.” As Doris began to breathe deeply and slowly, others around the group circle joined in. Twelve group members, including the two group leaders, held hands around the circle and echoed Doris’s pace of breathing. Sara slowly calmed, regained her composure, and said, “Thank you so much for reminding me of that. It always helps but I forget about it when I start to get anxious. I felt so overwhelmed and alone.” The remainder of the session focused on the sense of effectiveness the group 69 of 78 12/16/2024, 3:48 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... members felt in working together and supporting one of their members. Sara committed to practicing her breathing exercises daily and to making a plan to have a close friend come over before the wedding to help her get ready. She promised to give the group a full report on the wedding, which she subsequently did with much gratitude.