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 Transference and Transparency H AVING DISCUS...

The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... The Therapist Transference and Transparency H AVING DISCUSSED THE MECHANISMS OF THERAPEUTIC CHANGE in group therapy, the tasks of the therapist, and the techniques by which the therapist accomplishes these tasks, we now turn from what the therapist must do in the group to how the therapist must be in the group. To what degree are you free to be yourself? How “honest” can you be? How do you utilize transparency and judicious self-disclosure effectively as a therapeutic tool? Any discussion of the group therapist’s scope and presence must begin with an examination of transference, which can be either an effective therapeutic tool or shackles that encumber your every movement. In his first and extraordinarily prescient essay on psychotherapy—the final chapter of Studies on Hysteria (1895)—Freud noted several possible impediments to the formation of a good working relationship between client and therapist.1 Most of them could be resolved easily, but one stemmed from deeper sources and resisted efforts to banish it from the therapeutic work. Freud labeled this impediment transference, since it consisted of attitudes toward the therapist that had been “transferred” from earlier attitudes toward important figures in the client’s life. These feelings toward the therapist 1 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... were “false connections”—new editions of old impulses. Contemporary definitions of transference characterize it as a common relational phenomenon with both conscious and unconscious roots. Transference stems from the client’s fears, wishes, and developmental gaps. Today’s relationships are distorted by echoes of the past and reinforced by the client’s selective inattention to experiences that disconfirm these distortions.2 Group therapy adds the dimension of peer or horizontal transference to the more familiar vertical transference to the group leader.3 Freud soon realized that transference was far from an impediment to therapy; on the contrary, if used properly, it could be the therapist’s most effective tool.4 Many of today’s psychotherapeutic approaches, including cognitive therapy, acknowledge a concept similar to transference but may refer to it as the client’s “schema.”5 Contemporary psychodynamic psychotherapy suffuses the work of virtually all effective therapists. Effective therapists use the therapy relationship as a window into understanding and addressing the early, shaping influences and pathogenic beliefs that affect our clients.6 The ultimate objectives for the client are to: (1) reconfigure a new view of self; (2) establish a different relational experience with the therapist than with significant others in the past; and (3) translate that new understanding of self and other into a new narrative, new behavior, and adaptive function.7 We can see here the hallmarks of the 2 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... corrective emotional experience described earlier. Hannah Levenson described it as the “gift that keeps on giving,” because it emancipates the client from the past and encourages continued growth and development even after therapy concludes.8 Considerable evolution in theory and technique has occurred in psychoanalysis and psychodynamic therapy over the past half century, with a powerful focus on the actual therapeutic relationship augmenting, but not discarding, the earlier focus on interpretation of transference. This focus emphasizes the therapist’s presence, emotional availability, and use of self in place of the opaque, emotionally aloof therapist.9 This is well captured by Stephen Mitchell: Many patients are now understood to be suffering not from conflictual infantile passions that can be tamed and transformed through reason and understanding but from stunted personal development. Deficiencies in caregiving in the earliest years are understood to have contributed to interfering with the emergence of a fully centered, integrated sense of self, of the patient’s own subjectivity. What the patient needs is not clarification or insight so much as a sustained experience of being seen, personally engaged, and, basically valued and cared about.10 Mitchell and many others argue that the “curative” factor in both individual and group therapy is the relationship, which requires the 3 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... therapist’s authentic engagement and empathic attunement to the client’s internal emotional and subjective experience.11 Note that this new emphasis on the nature of the relationship means that psychotherapy has changed its focus from a one-person psychology (emphasizing the client’s pathology) to a two-person psychology (emphasizing mutual impact and shared responsibility for the relationship).12 In this model, the therapist’s emotional experience in the therapy is a relevant and powerful source of data about the client. How to make wise use of this data will be elaborated shortly when we discuss countertransference. Psychoanalysts and psychodynamic therapists have disagreed about the degree of permissible therapist disclosure—ranging from extensive disclosure to complete opaqueness.13 But they agree that transference is “inappropriate, intense, ambivalent, capricious, and tenacious,” and they also largely agree that transference, and well- timed, accurate, and empathic interpretation of transference, should be central to treatment.14 The difference between group therapists who consider the resolution of therapist-client transference as the paramount therapeutic factor and those who attach equal importance to the interpersonal learning that ensues from relationships between members and from other therapeutic factors is more than theoretical; in practice, they use markedly different techniques.15 Emphasizing the transference to the leader makes 4 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... the group leader-centric and obscures attention to other group dynamics and group forces. Contemporary group therapy recognizes the value of focusing both on transference reactions to the group leader and to group peers.16 The following vignette from a session led by a traditional group analyst who made only therapist- related transference interpretations illustrates this point: > In one group session, two male members were absent, and four women members bitterly criticized the one male client present, who was gay, for his detachment and narcissism, which precluded any interest in the lives or problems of others. The therapist suggested that the women were attacking the male client because he did not desire them sexually, and that, moreover, he was not the real target; the women really wanted to attack the therapist for his refusal to engage them sexually. I (ML) met with a therapy group two days after I had published a column about my father in a large circulation newspaper. He had passed away three months before, and I had been close to him. I was very pleased that I could tell his compelling story and heartened that it had been selected for publication in the paper’s prominent “Lives Lived” column. The group knew of my father’s death because, when he died, I had explained to them why I would be missing two meetings. My announcement had not drawn much attention at the time, beyond some expressions of condolence. The publication of my column, however, provoked a variety of responses by group members. At the start of the meeting, Karen, an often hostile and dismissive woman, angrily commented to me, “Have you not learned anything about keeping your private life private? It is inappropriate for you to share with the public, particularly your patients, this kind of personal detail about your father and your family. I do not want to see it, read it, or know this; you are imposing yourself on us.” Sue, who was depressed and socially anxious, commented, “I wanted to express my condolences to you more fully when your father passed away, but I hesitated to 11 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... do so, thinking that nothing I could offer would be meaningful or helpful to you. I want to express those condolences now—I don’t want to miss that opportunity twice.” Bob, an older man recovering from alcohol addiction, commented, “I was pleased to read about your father and wished that I had grown up with a father like the man you had described. I felt sad for myself, but reading that column helped me understand you better and made me feel closer to you.“ Danny, an isolated, passive man, asked me, “How did you manage with your grief? How did the loss of your father affect you? My sorrow over my father’s death feels present every day of my life.” Angry, self-absorbed Rob interjected, “Enough of this already—we are not here to talk about you, Molyn. I imagine you must be enjoying all the attention. We are here to talk about us, so let’s get to it.” Daniela, new to the group, emailed me (ML) prior to her third meeting, noting she would be unavoidably late by ten minutes. She was still uncomfortable sitting in the chairs that faced the one-way mirror, behind which sat observers, and asked whether I 16 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... could secure a chair for her with its back to the mirror? Email was clearly not the vehicle to address my dilemma of both wanting to support Daniela—and her early anxiety about self-exposure—and also wanting to explore the dynamic processes carried by her request. Would I look out for her? Could she make a special request? Did she warrant extra attention and care? What did it mean for her to ask? What did Daniela anticipate others would say in response to her request of the group leader? I responded simply acknowledging her message and telling her that I looked forward to seeing her in the group and talking further. Daniela’s seemingly innocent request led to a rich exploration of sibling transferences, parental favoritism, competition for group and therapist attention and care, and my dilemma. At the end of the session Daniela stated that she learned a lot from the meeting, and joked that she could save herself a lot of stress by coming on time, while acknowledging, more seriously, that this was exactly the kind of work she needed to do. She had long wrestled with the apprehension of asking for care and recognition, and this seemingly simple request of the therapist opened up an important discussion of her deep longings. In a second pregroup preparation meeting, I (ML) asked Ron, a middle-aged executive with chronic depression and a history of adversarial relationships, how he felt our first meeting had gone. Ron responded that he was very angry that I had presumed power over him and diminished him. He said he had come for a second meeting largely to voice his outrage. I was stunned, expressed my concern and regret for generating that kind of reaction, and said I hoped we could explore what happened. Ron responded, “I offered you my permission to speak with my individual therapist who referred me to you. That was a big step for me in trusting you— and then you responded (here he mimicked a high-handed tone) ‘I don’t need your permission to speak with him.’ That pissed me off big time. Here I was offering you a gift of my trust and you were telling me you could do what you want anyways.” I responded, “I am so sorry that you felt that, but I am very grateful that you have returned today to talk with me, rather than blowing this and me off. I did not mean to 25 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... make you feel diminished. I am sorry that it felt like a power move on my part. What I had hoped to convey was that I assumed that permission was a component of the referral process and that as your group therapist I anticipated I would work collaboratively with your individual therapist in your interest. I want to understand what happened between us, and believe we can both learn from it.” Ron accepted the apology, calmed considerably, and added, “Isn’t it funny how power became such a hot issue so quickly? That happens to me a lot.” Students who have observed a therapy group through a one-way mirror reverse roles at the end of the meeting. Here, the clients are permitted to observe while the therapist and the students discuss or rehash the meeting. Or, in inpatient groups, the observers enter the room twenty minutes before the end of the session to discuss their observations of the meeting. In the final 29 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... ten minutes, the group members react to the observers’ comments.37 At a university training center, a tutorial technique has been employed in which four psychiatric residents meet regularly with an experienced clinician who conducts an interview in front of a one-way mirror. The client is often invited to observe the post- interview discussion. Tom, one of two group co-therapists, began a meeting by addressing a client who had been extremely distressed at the previous meeting. He asked him how he was feeling and whether that session had been helpful to him. The co-therapist then said, “Tom, I think you’re doing just what I was doing a couple of weeks ago—pressing the clients to tell me how effective our therapy is. We both seem on a constant lookout for reassurance. I think we are reflecting some of the general discouragement in the group. I wonder whether the members may be feeling pressure that they have to improve to keep up our spirits.” In an ongoing group, a member reported to the group that she had seen a YouTube video of a lecture on group therapy and a group demonstration given by their group leader. She distributed the link to the group and wanted to discuss why the group leader 30 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... was more relaxed and personable in the video than in their therapy group. What accounted for the difference? Four members—Don, Rolando, Janelle, and Martha—were present at the twenty- ninth meeting of the group. One member and my co-therapist were absent; one other member, Peter, had dropped out of the group at the previous meeting. The first theme that emerged was the group’s response to Peter’s termination. The group discussed this gingerly, from a great distance, and I commented that we had, it seemed to me, never honestly discussed our feelings about Peter when he was present, and that we were avoiding them now, even after his departure. Among the responses was Martha’s comment that she was glad he had left, that she had felt they couldn’t reach him, and that she didn’t feel it was worth it to try. She then commented on his lack of education and noted her surprise that he had even been included in the group —an oblique swipe at the therapists. I felt the group had not only avoided discussing Peter but had also declined to 37 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... confront Martha’s judgmental attitude and incessant criticism of others. I thought I might help Martha and the group explore this issue by asking her to go around the group and describe those aspects of each person she found herself unable to accept. This task proved very difficult for her, and she generally avoided it by phrasing her objections in the past tense, as in, “I once disliked some trait in you but now it’s different.” When she had finished with each of the members, I pointed out that she had left me out; indeed, she had never expressed her feelings toward me except through indirect attacks. She proceeded to compare me unfavorably with the co- therapist, stating that she found me too retiring and ineffectual; she then immediately attempted to undo the remarks by commenting that “Still waters run deep,” and recalling examples of my sensitivity to her. The other members suddenly volunteered to tackle the same task and, in the process, revealed many long-term group secrets: Don’s passivity, Janelle’s sloppy and inappropriate attire, and Rolando’s lack of empathy with the women in the group. Martha was compared to a golf ball: “tightly wound up with an enamel cover.” I was attacked by Rolando for my deviousness and lack of interest in him. The members then asked me to go 38 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... around the group in the same manner as they had done. Being fresh from a seven- day T-group and no admirer of generals who led their army from the rear, I took a deep breath and agreed. I told Martha that her quickness to judge and condemn others made me reluctant to show myself to her, lest I, too, be judged and found wanting. I agreed with the golf-ball metaphor and added that her inclination to be critical made it difficult for me to approach her, save as an expert technician. I told Don that I felt his gaze on me constantly; I knew he desperately wanted something from me, and that the intensity of his need and my inability to satisfy that need often made me very uncomfortable. I told Janelle that I missed a spirit of opposition in her; she tended to accept and exalt everything that I said so uncritically that it became difficult at times to relate to her as an autonomous adult. The meeting continued at an intense, involved level, and at its end the observers expressed grave concerns about my behavior. They felt that I had irrevocably relinquished my leadership role and become a group member, that the group would never be the same, and that, furthermore, I was placing my co-therapist, who would return the following week, in an untenable position. In fact, none of these predictions materialized. In subsequent meetings, the 39 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... group plunged more deeply into work; several weeks were required to assimilate the material generated in that single meeting. My co-therapist and the other member who had missed the session were quickly able to catch up. In addition, the group members, following the model of the therapist, related to one another far more forthrightly than before and made no demands on me or my co-therapist for escalated self-disclosure. An illustrative example of therapist disclosure that facilitated therapy occurred in a meeting when all three women members discussed their strong sexual attraction to me (IY). Much work was done on the transference aspects of the situation, on the women being attracted to a man who was obviously professionally off-limits and 40 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... unattainable, older, in a position of authority, and so on. I then pointed out that there was another side to it. None of the women had expressed similar feelings toward my co- therapist (also male); furthermore, other female clients who had been in the group previously had had the same feelings. I could not deny that it gave me pleasure to hear these sentiments expressed, and I asked them to help me look at my blind spots: What was I doing unwittingly to encourage their positive response to me? My request opened up a long and fruitful discussion of the group members’ feelings about both therapists. There was much agreement that the two of us were very different: I was vainer, took much more care about my physical appearance and clothes, and had an exactitude and preciseness about my statements that created about me an attractive aura of suaveness and confidence. The other therapist was sloppier in appearance and behavior; he spoke more often when he was unsure of what he was going to say; he took more risks and was willing to be wrong, and, in so doing, was more often helpful to the clients. The feedback sounded right to me. I had heard it before and told the group so. I thought about their comments during the week and, at the following meeting, thanked the group members and told them that they had been helpful to me. After an angry exchange between two members, Barbara and Mae, the group found it difficult to repair the damage Barbara had experienced. Although Barbara was eventually able to work through her differences with Mae, Barbara continued to struggle with how she had been left so unprotected by me (ML). Numerous attempts at explanation and understanding failed to break the impasse, until I stated, “I regret what happened very much. I have to acknowledge that Mae’s criticism of you took me by surprise—it hit like a tropical storm, and I was at a loss for words. It took me some time to regroup, but by then the 42 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... damage had been done. If I knew then what I know now, I would have responded differently. I am sorry for that.” Rather than feeling that I was not competent because I had missed something of great importance, Barbara felt relieved and said that what I’d said was exactly what she needed to hear. Barbara did not need me to be omnipotent—she wanted me to be human, to be able to acknowledge my error, and to learn from what had happened so that it would be less likely to occur in the future. Another illustrative clinical example occurred in the group of women survivors of sexual abuse described earlier in this chapter. The ongoing, withering anger toward me (IY, and, to a slightly lesser degree, toward my female co-therapist) had gotten to us, and toward the end of one meeting, we both openly discussed our experience in the group. I revealed that I felt demoralized and deskilled, that everything I tried in the group had failed to be helpful, and furthermore that I felt anxious and confused in the group. My co-leader discussed similar feelings: her discomfort about the competitive way the women related to her, and about the continual pressure placed on her to reveal any abuse that she may have experienced. We told them that their relentless anger and distrust 43 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... of us was fully understandable in the light of their past abuse, but that, nonetheless, we both wanted to shriek, “These were terrible things that happened to you, but we didn’t do them.” This episode proved to be a turning point for the group. There was still one member (who reported having undergone savage ritual abuse as a child) who continued in the same vein—“Oh, you’re uncomfortable and confused? What a shame! But at least now you know how it feels.” The others, however, were deeply affected by our admission. They were astounded to learn of our discomfort and of their power over us, and gratified that we were willing to relinquish authority and relate to them in an open, egalitarian fashion. From that point on, the group moved into a far more profitable work phase. A group therapy trainee, Samantha, raised the question, in supervision, of whether or not to share news of her impending wedding and week-long honeymoon with the group. She and I (ML) discussed the fact that it was likely impossible to conceal this information: the group would notice her wedding band when she returned to the next meeting. So why the hesitancy? What would be the 47 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... impact of not disclosing this news? In supervision we discussed several salient points. This was a positive development in her life. We expected our clients to share everything with us, and our reluctance to share this kind of news with them would separate us from them. Instead, we could honor their openness with us by reciprocating with information that was in essence public information. Sharing the news of the wedding did not mean talking about the attributes of her partner, or how she had worried she would never find a match. But it did mean respecting the group and trusting them to respond in ways that would be welcoming, or benign, or at most grist for discussion. We talked as well about the importance of reducing our clients’ shame by our humanness. If we purport ourselves to never being touched by life for better or for worse, it reduces our clients’ willingness to share their disappointments, discouragement, or feelings of shame. Therapist humanness begets therapy humanness. The group responded at the next session with congratulations, wishing Samantha well, thanking her for sharing her good news, and then getting on with their work—a constructive contrast to sitting together and colluding in avoiding an evident fact in the room. Client feedback about therapist transparency is even more impactful when it is provided before therapy ends. Nearing the end of his tenure as a co-leader trainee in an ongoing group, Niran, a Southeast Asian man, teared up, uncharacteristically, as he spoke about leaving the group: “I feel privileged to have worked with this group; I learned a great deal that will help my future clients, and I developed as a group leader— I hope. I also hope I have contributed to the group. I will miss you all.” One of the group members, Binh, a reserved, anxious, and depressed man, also Southeast Asian, and normally very distant from his emotions, responded that Niran’s openness in the meeting was a gift to him: “I think you and I are alike. It is not easy to show what we feel; that is not how we were raised. Even though you are younger than I am, your manner here reminded me of my father’s silent inscrutability. He was always 50 of 60 12/16/2024, 3:28 PM The Theory and Practice Of Group Psychotherapy https://sdc-evs.ebscohost.com/EbscoViewerService/ebook?ststoken=A... so silent and distant from his emotions, but every once in a while, he exploded in rage. That is why your showing me warmth and decency means so much to me.” Niran welcomed the feedback and spoke about how touched he was by Binh ’s comments, saying he would carry that message with him in his future work.