The Theory and Practice Of Group Psychotherapy PDF

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... The Therapist Basic Tasks N OW THAT WE HAVE...

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... The Therapist Basic Tasks N OW THAT WE HAVE CONSIDERED HOW PEOPLE CHANGE IN group therapy, it is time to turn to the therapist’s role in the therapeutic process. In this chapter, we consider the basic tasks of the therapist and the techniques by which they may be accomplished. The four previous chapters contended that therapy is a complex process consisting of elemental factors that interlace in an intricate fashion. The group therapist’s job is to create the machinery of therapy, to set it in motion, and to keep it operating with maximum effectiveness. These tasks require different types of knowledge and skills but build atop a consistent therapeutic attitude and approach that we will return to again and again. Underlying all considerations of technique must be a consistent, positive, empathic, and culturally attuned relationship between therapist and client. The basic posture of the therapist to a client must be one of concern, genuineness, empathy, and emotional engagement. Nothing, no technical consideration, takes precedence over this attitude. Of course, there will be times when the therapist challenges the client, shows frustration, even suggests that if the client is not going to work, he or she should consider leaving the group. But these 1 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... efforts (which in the right circumstances may have therapeutic clout) are never effective unless they are experienced against a horizon of an accepting and caring therapist-client relationship. Research consistently demonstrates that all effective psychotherapists share these common features.1 We will discuss the techniques of the therapist in respect to three fundamental tasks: 1. Creation and maintenance of the group 2. Building a group culture 3. Activation and illumination of the here- and-now CREATION AND MAINTENANCE OF THE GROUP Group leaders are solely responsible for creating and convening the group and setting the time and place for meetings. Much of their work is performed before the first meeting, and, as we will elaborate in later chapters, their expertise in the selection and preparation of members in composing the group will greatly influence the group’s fate. In agency and institutional settings, an additional consideration includes their relationship with the administration whose practical support is essential in creating and sustaining successful therapy groups.2 Once the group begins, the therapist attends to gatekeeping, especially the prevention of member 2 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... attrition. Clients who complete the anticipated course of therapy generally improve significantly. The challenge is keeping them in treatment.3 Occasionally an individual will have an unsuccessful group experience and leave therapy prematurely. Yet such an experience may play some useful function in his or her overall course of therapy; failure in or rejection by a group may so unsettle clients as to prime them ideally for subsequent treatment. For example, in my role as the clinical supervisor and coordinator of trainee- led group therapy, I (ML) received an email from Amy, a client who had angrily dropped out of her first group experience and then attended and completed another therapy group: “Thank you for giving me a second chance with group therapy to work through my stuff. My second experience could not have been more different from the first group—I am sure I learned some things about myself after the first fiasco but I must tell you that the members of the 2nd group and I were a much better fit and the group leaders in my second group were so caring that I felt safe to open up for the first time.” Amy’s email powerfully reminds us to be open to therapy second chances. Generally, however, a client who drops out early in the course of the group should be considered a therapeutic failure. Not only does the client fail to receive benefit, but the progress of the remainder of the group is adversely affected. Stability of membership is an absolutely essential condition for successful therapy. If dropouts do occur, the therapist must, except in the case of a closed group 3 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... (see Chapter 9), add new members to maintain the group at its ideal size. Initially, the clients are strangers to one another and know only the therapist, who is the group’s primary unifying force. The members relate to one another at first through their common relationship with the therapist, and these therapist-client alliances set the stage for the eventual development of group cohesion. The therapist must recognize and deter any forces that threaten group cohesiveness. Continued lateness, absences, the formation of subgroups, disruptive extragroup socialization, and scapegoating all threaten the functional integrity of the group and require therapist intervention. Each of these issues will be discussed fully in later chapters. For now, it is necessary only to emphasize the therapist’s responsibility to supra- individual needs. Your first developmental task is to help create and maintain a physical entity: a cohesive group. There will be times when you must delay dealing with the pressing needs of an individual client, and even times when you will have to remove a member from the group for the good of the other members. A clinical vignette illustrates some of these points: > I (IY) introduced two new members, both women, into an outpatient group. This particular group, with a stable core of five men and two women, had difficulty retaining female members. Two women had dropped 4 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... out in the previous month. This meeting began inauspiciously for one of the new members when her perfume triggered a sneezing fit in one of the men, who moved his chair away from her and then, while vigorously opening the windows, informed her of his perfume allergy and of the group’s “no scent” rule. At this point another member, Mitch, arrived a couple of minutes late and, without even a glance at the two new members, announced, “I need some time today from the group. I was really shaken up by the meeting last week. I went home from the group very disturbed by the feedback about my being a time hog. I didn’t like those comments from any of you, or from you [meaning me] either. It threw me off completely and later that evening I had an enormous fight with my wife, who took exception to my reading my iPad at the dinner table, and we haven’t been speaking since.” Now this particular opening would have been a good one for most group meetings. It had many things going for it. The client stated that he wanted some time. (The more members who come to the group asking for time and eager to work, the more energized a meeting will be.) Also, he wanted to work on issues that had been raised in the previous week’s meeting. (As a general rule, the more group members work on 5 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... continuing themes from meeting to meeting, the more effective the group becomes.) Furthermore, he began the meeting by attacking me, the therapist, and that was a good thing; this group had been treating me much too gently. Mitch’s attack, though uncomfortable, was, I felt certain, going to produce important group work. I had many different options in the meeting, but one task had highest priority: maintaining the functional integrity of the group. I had introduced two female members into a group that had had some difficulty retaining women. And how had the members of the group responded? Not well! They had virtually disenfranchised the new members. After the sneezing incident, Mitch had not even acknowledged their presence and had launched into a discussion of his marriage—a subject that, though personally important, inherently excluded the new women by referring to the previous meeting. It was important, then, for me to find a way to address this task and, if possible, also to address the issues Mitch had raised. Earlier in this book I offered the basic principle that therapy should strive to turn all issues into here-and-now issues. It would have been folly to deal explicitly with Mitch’s fight with his wife. The data that Mitch would have given about his wife would have been biased and he might well have “yes, but-ted” the group into submission. 6 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Fortunately, however, there was a way to tackle both issues at once. Mitch’s treatment of the two women in the group bore many similarities to his treatment of his wife at the dinner table. He had been as insensitive to their presence and needs as to his wife’s. In fact, it was precisely his insensitivity that the group had confronted the previous meeting. Therefore, about a half hour into the meeting, I pried the group’s focus away from Mitch and his wife by saying, “Mitch, I wonder what hunches you have about how our two new members are feeling in the group today?” This inquiry led Mitch into the general issue of empathy and his inability or unwillingness in many situations to enter the experiential world of the other. Fortunately, this tactic not only turned the other group members’ attention to the way they all had ignored the two new women, but also helped Mitch work effectively on his core problem: his failure to recognize and appreciate the needs and wishes of others. Even if it were not possible to address some of Mitch’s central issues around empathy and his self-absorption, I still would have opted to attend to the integration of the new members. The integration of new members and the physical survival of the group takes precedence over other tasks. In the first session of a group of business executives meeting for a five-day intensive communication training program that I (IY) 18 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... was co-leading, an aggressive, swaggering twenty-five-year-old group member who had obviously been drinking heavily proceeded to dominate the meeting and make a fool of himself. He boasted of his accomplishments, belittled the group, monopolized the meeting, and interrupted, outshouted, and insulted every other member. All attempts to deal with the situation—feedback about how angry or hurt he had made others feel, interpretations about the meaning and cause of his behavior—failed. Then my co-leader commented sincerely, “You know what I like about you? Your fear and lack of confidence. You’re scared here, just like me. We’re all scared about what will happen to us this week.” That statement permitted the client to discard his facade and, eventually, to become a valuable group member. Furthermore, the leader, by modeling an empathic, nonjudgmental style, helped establish a gentle, accepting group culture. In one group, Les, a young man, had made little movement for months despite vigorous efforts by the leader. In virtually every meeting the leader attempted to bring Les into the discussion, but to no avail. Instead, Les became more defiant and withholding, and the therapist became more active and insistent. Finally, Joan, another member, commented to the therapist that he was like a stubborn father treating Les like a stubborn son, and was bound and determined to make Les change. Les, she added, was relishing the role of the rebellious son who was determined to defeat his father. Joan’s comment rang true for the therapist; it clicked with his internal experience, and he acknowledged this to the group and thanked Joan for her comments. One group member, Mark, spoke slowly and methodically about his intense social anxiety and avoidance. Marie, a, chronically depressed and bitter young woman, bristled at his long and labored elaboration of his difficulties. At one point she wondered aloud why others seemed to be so encouraging of Mark and excited about his speaking, whereas she felt so impatient with the slow 27 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... pace of the group. She was concerned that she could not get to her personal agenda: to learn to make herself more likable. The feedback she received surprised her. Many members felt alienated from her because she rarely empathized with others. What was happening in the meeting with Mark was a case in point, they told her. For many members Mark’s self-disclosure in the meeting was a great step forward for him. What interfered with her seeing what others saw? That was the critical question, and exploring that question ultimately led to important learning for Marie. Vijay, a forty-two-year-old police officer, sought group therapy after an episode of domestic violence. He felt enormous shame about his behavior and realized he did not know how to deal with strong emotion. He was spared criminal proceedings on the condition he participate in group and individual therapy. Although willing to tell the group about the violence, he refused to tell the group about his occupation, despite members’ mounting curiosity and rampant guessing. For months, he denied its relevance and was firm and fixed in maintaining this secret. I (ML) knew about his profession but felt I had no choice but to wait for him to share this information. He was otherwise clearly engaged with the group and working on emotional recognition and self-expression. After a short leave to attend his grandmother’s funeral in India, his birthplace, he returned to the group and declared, “I want to shed my remaining secrets—I am a police officer and I have behaved dishonorably. Going home for the 29 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... funeral made me realize how destructive it can be to keep secrets. I had been estranged from my parents for years because of my father’s physical abuse, but I had been very close to his mother as a boy. Visiting back home I learned for the first time that my grandmother was Muslim and that even her name was shunned in my family’s Hindu village. “My grandmother’s religion was a deeply shameful and lethally dangerous secret. No one ever spoke of it. I also learned for the first time that, because of his mother’s religion, my father was discriminated against and bullied mercilessly as a child. Learning these things was eye-opening, and I felt, for the first time in my life, compassion for my father. I understood how the brutality my father experienced contributed to his becoming a brutal father and husband. I see now that shutting down many areas of my own world and silencing myself has made me abusive as well.” He became quite emotional in the meeting, and the group members—many of whom had already suspected he was a police officer—helped him look at this as an unlocking from the various cul-de-sacs in his emotional world. At the end of the session, the group told him they felt incredibly close to him and were honored by his trust. Lisa, a client in a six-month, time-limited group, had practiced as a psychologist for a few years, but had given up her practice fifteen years earlier to enter the business world, where she soon became extraordinarily successful. She entered the group because of dissatisfaction with her 32 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... social life. Lisa felt lonely and alienated. She knew that she, as she put it, played her cards “too close to the vest”—she was cordial to others and a good listener but tended to remain distant. She attributed this to her enormous wealth, which she felt she must keep concealed so as not to elicit envy and resentment from others. By the fifth month, Lisa had yet to reveal much of herself. She retained her psychotherapeutic skills, and this proved helpful to many members, who admired her greatly for her unusual perceptiveness and sensitivity. But she had replicated her outside social relationships in the group, and she felt hidden and distant from the other members. She requested an individual session with the group leader to discuss her participation in the group. During that session the therapist exhorted Lisa to reveal her concerns about her wealth and, especially, her psychotherapy training, warning her that if she waited too much longer, someone would throw a chair at her when she finally told the group she had once been a therapist. Finally, Lisa took the plunge and in the very few remaining meetings did more therapeutic work than in all the earlier meetings combined. In a new therapy group, there were two particularly hostile members, and by the third meeting there was a considerable amount of open sniping, sarcasm, and conflict. The fourth meeting was opened by 45 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... Sofia (one of these two members), who emphasized how unhelpful the group had been to her thus far. Sofia had a way of turning every positive comment made to her into a negative, combative one. She complained, for example, that she could not express herself well, and that there were many things she wanted to say but was so inarticulate she couldn’t get them across. When another member of the group disagreed and stated that she found Sofia to be extremely articulate, Sofia challenged the other member for doubting her judgment about herself. Later in the group, she complimented another member by stating, “Ilene, you’re the only one here who’s ever asked me an intelligent question.” Obviously, Ilene was made quite uncomfortable by this hexed compliment. At this point I (IY) felt it was imperative to challenge the norms of hostility and criticism that had developed in the group and I intervened forcefully by asking Sofia, “What are your guesses about how your statement to Ilene makes others in the group feel?” Sofia hemmed and hawed but finally offered that they might possibly feel insulted. I suggested that she check that out with the other members of the group. She did so and learned that her assumption was correct. Not only did every member of the group feel insulted, but Ilene also felt irritated and put off by the statement. I then 46 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... inquired, “Sofia, it looks as though you’re correct: you did insult the group. Also, it seems that you knew that this was likely to occur. But what’s puzzling is the payoff for you. What do you get out of it?” Sofia suggested two possibilities. First, she said, “I’d rather be rejected for insulting people than for being nice to them.” That seemed a piece of twisted logic but nonetheless comprehensible. Her second statement was, “At least this way I get to be the center of attention.” “Like now?” I asked. She nodded. “How does it feel right now?” I wondered. Sofia said, “It feels good.” “How about in the rest of your life?” I asked. She responded sadly, “It’s lonely. In fact, this is it. This group—you folks, are the people in my life.” I ventured, “Then this group is a really important place for you?” Sofia nodded. I commented, “Sofia, you’ve always stated that one of the reasons you’re critical of others in the group is that there’s nothing more important than total honesty. If you want to be absolutely honest with us, however, I think you’ve got to tell us also how important we are to you and how much you like being here. That you never do, and I wonder if you can begin to investigate why it is so painful or dangerous for you to show others here how important they are to you.” By this time Sofia had become much more conciliatory, and I was able to obtain more leverage by enlisting her agreement 47 of 48 12/16/2024, 3:24 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... that her hostility and insults did constitute a problem for her and that it would help her if we called her on it—that is, if we instantaneously labeled any insulting behavior on her part. It is always helpful to obtain this type of contract from a member: consent that in future meetings, the therapist can confront the member about some particular aspect of behavior that the member has asked to be called to his or her attention. Since such clients will then experience themselves as allies in this spotting and confrontative process, they are far less likely to feel defensive about the intervention.