The Theory and Practice of Group Psychotherapy (34 page)

• Clients must first recognize what they are doing with other people (ranging from simple acts to complex patterns unfolding over a long time).

• They must then appreciate the impact of this behavior on others and how it influences others’ opinion of them and consequently its impact on their own self-regard.

• They must decide whether they are satisfied with their habitual interpersonal style.

• They must exercise the will to change.

• They must transform intent into decision and decision into action.

• Lastly, they must solidify the change and transfer it from the group setting into their larger life.

Each of these stages may be facilitated by some specific cognitive input by the therapist, and I will describe each step in turn. First, however, I must discuss several prior considerations: How does the therapist recognize process? How can the therapist help the members assume a process orientation? How can therapists increase the client receptivity of their process commentary?

Recognition of Process

Before therapists can help clients understand process, they must themselves learn to recognize it: in other words, they must be able to reflect in the midst of the group interaction and wonder, “Why is
this
unfolding in this group in this particular way and at this particular time?Ӡ The experienced therapist does this naturally and effortlessly, observing the group proceedings from several different perspectives, including the specific individual interactions and the developmental issues in the group (see chapter 11). This difference in perspective is the major difference in role between the client and the therapist. Consider some clinical illustrations:

• At one meeting, Alana discloses much deep personal material. The group is moved by her account and devotes much time to listening, to helping her elaborate more fully, and to offering support. The therapist shares in these activities but entertains many other thoughts as well. For example, the therapist may wonder why, of all the members, it is invariably Alana who reveals first and most. Why does Alana so often put herself in the role of the group member whom all the members must nurse? Why must she always display herself as vulnerable? And why today? And that last meeting! So much conflict! After such a meeting, one might have expected Alana to be angry. Instead, she shows her throat. Is she avoiding giving expression to her rage?

• At the end of a session in another group, Jay, a young, rather fragile young man who had been inactive in the group, revealed that he was gay—his first step out of the closet. At the next meeting the group urged him to continue. He attempted to do so but, overcome with emotion, blocked and hesitated. Just then, with indecent alacrity, Vicky filled the gap, saying, “Well, if no one else is going to talk, I have a problem.”

Vicky, an aggressive forty-year-old cabdriver, who sought therapy because of social loneliness and bitterness, proceeded to discuss in endless detail a complex situation involving an unwelcome visiting aunt. For the experienced, process-oriented therapist, the phrase “I have a problem” is a double entendre. Far more trenchantly than her words, Vicky’s behavior declares, “I have a problem,” and her problem is manifest in her insensitivity to Jay, who, after months of silence, had finally mustered the courage to speak.

It is not easy to tell the beginning therapist how to recognize process; the acquisition of this perspective is one of the major tasks in your education. And it is an interminable task: throughout your career, you learn to penetrate ever more deeply into the substratum of group discourse. This deeper vision increases the keenness of a therapist’s interest in the meeting. Generally, beginning students who observe meetings find them far less meaningful, complex, and interesting than do experienced therapists.

Certain guidelines, though, may facilitate the neophyte therapist’s recognition of process. Note the simple nonverbal sense data available.† Who chooses to sit where? Which members sit together? Who chooses to sit close to the therapist? Far away? Who sits near the door? Who comes to the meeting on time? Who is habitually late? Who looks at whom when speaking? Do some members, while speaking to another member, look at the therapist? If so, then they are relating not to one another but instead to the therapist through their speech to the others. Who looks at his watch? Who slouches in her seat? Who yawns? Do the members pull their chairs away from the center at the same time as they are verbally professing great interest in the group? How quickly do the group members enter the room? How do they leave it? Are coats kept on? When in a single meeting or in the sequence of meetings are they removed? A change in dress or grooming not uncommonly indicates change in a client or in the atmosphere of the entire group. An unctuous, dependent man may express his first flicker of rebellion against the leader by wearing jeans and sneakers to a group session rather than his usual formal garb.

A large variety of postural shifts may betoken discomfort; foot flexion, for example, is a particularly common sign of anxiety. Indeed, it is common knowledge that nonverbal behavior frequently expresses feelings of which a person is yet unaware. The therapist, through observing and teaching the group to observe nonverbal behavior, may hasten the process of self-exploration.

Assume that every communication has meaning and salience within the individual’s interpersonal schema until proven otherwise. Make use of your own reactions to each client as a source of process data.
¹²
Keep attending to the reactions that group members elicit in one another. Which seem consensual reactions shared by most, and which are unique or idiosyncratic reactions?
¹³

Sometimes the process is clarified by attending
not only to what is said but also to what is omitted
: the female member who offers suggestions, advice, or feedback to the male members but never to the other women in the group; the group that never confronts or questions the therapist; the topics (for example, the taboo trio: sex, money, death) that are never broached; the individual who is never attacked; the one who is never supported; the one who never supports or inquires—all these omissions are part of the transactional process of the group.

• In one group, for example, Sonia stated that she felt others disliked her. When asked who, she selected Eric, a detached, aloof man who habitually related only to those who could be of use to him. Eric bristled, “Why me? Tell me one thing I’ve said to you that makes you pick me.” Sonia stated, “That’s exactly the point. You’ve never said anything to me. Not a question, not a greeting. Nothing. I just don’t exist for you. You have no use for me.” Eric, later, at a debriefing session after completing therapy, cited this incident as a particularly powerful and illuminating instruction.

Physiologists commonly study the function of a hormone by removing the endocrine gland that manufactures it and observing the changes in the hormone-deficient organism. Similarly, in group therapy, we may learn a great deal about the role of a particular member by observing the here-and-now process of the group when that member is absent. For example, if the absent member is aggressive and competitive, the group may feel liberated. Other members, who had felt threatened or restricted in the missing member’s presence, may suddenly blossom into activity. If, on the other hand, the group has depended on the missing member to carry the burden of self-disclosure or to coax other members into speaking, then it will feel helpless and threatened when that member is absent. Often this absence elucidates interpersonal feelings that previously were entirely out of the group members’ awareness. The therapist may then encourage the group to discuss these feelings toward the absent member both at that time and later in his or her presence. A common myth that may need to be dispelled is that talking about a group member when he is not present at a meeting is politically or socially incorrect. It is not “talking behind someone’s back” and it should not lead to scapegoating, provided that the group adopts the practice of sharing the discussion with that member at the following meeting.

Similarly, a rich supply of data about feelings toward the therapist often emerges in a meeting in which the therapist or a co-therapist is absent. One leader led an experiential training group of mental health professionals composed of one woman and twelve men. The woman, though she habitually took the chair closest to the door, felt reasonably comfortable in the group until a leaderless meeting was scheduled when the therapist was out of town. At that meeting the group discussed sexual feelings and experiences far more blatantly than ever before, and the woman had terrifying fantasies of the group locking the door and raping her. She realized how the therapist’s presence had offered her safety against fears of unrestrained sexual behavior by the other members and against the emergence of her own sexual fantasies. (She realized, too, the meaning of her occupying the seat nearest the door!)

Search in every possible way to understand the relationship messages in any communication. Look for incongruence between verbal and nonverbal behavior. Be especially curious when there is something arrhythmic about a transaction: when, for example, the intensity of a response seems disproportionate to the stimulus statement, or when a response seems to be off target or to make no sense. At these times look for several possibilities: for example,
parataxic distortion
(the responder is experiencing the sender unrealistically), or
metacommunication
(the responder is responding, accurately, not to the manifest content but to another level of communication), or
displacement
(the responder is reacting not to the current transaction but to feelings stemming from previous transactions). A disproportionately strong emotional reaction—what one group member called “A Big Feeling”—may be the tip of an iceberg of deeper, historical concerns that get reactivated in the present.

Common Group Tensions

Remember that, to some degree, certain tensions are always present in every therapy group. Consider, for example, tensions such as the struggle for dominance, the antagonism between mutually supportive feelings and sibling rivalrous ones, between greed and selfless efforts to help the other, between the desire to immerse oneself in the comforting waters of the group and the fear of losing one’s precious individuality, between the wish to get better and the wish to stay in the group, between the wish that others improve and the fear of being left behind. Sometimes these tensions are quiescent for months until some event wakens them and they erupt into plain view.

Do not forget these tensions. They are omnipresent, always fueling the hidden motors of group interaction. The knowledge of these tensions often informs the therapist’s recognition of process. Consider, for example, one of the most powerful covert sources of group tension:
the struggle for dominance
. Earlier in this chapter, I described an intervention where the therapist, in an effort to steer a client into the here-and-now, gave her a grade for her work in the group. The intervention was effective for that particular person. Yet that was not the end of the story: there were later repercussions on the rest of the group. In the next meeting, two group members asked the therapist to clarify some remark he had made to them at a previous meeting. The remarks had been so supportive in nature and so straightforwardly phrased that the therapist was puzzled at the request for clarification. Deeper investigation revealed that the two members and later others, too, were requesting grades from the therapist.

• In another experiential group of mental health professionals at several levels of training, the leader was much impressed by the group skills of Stewart, one of the youngest, most inexperienced members. The leader expressed his fantasy that Stewart was a plant, that he could not possibly be just beginning his training, since he conducted himself like a veteran with ten years’ group experience. The comment evoked a flood of tensions. It was not easily forgotten by the group and, for sessions to come, was periodically revived and angrily discussed. With his comment, the therapist placed the kiss of death on Stewart’s brow, since thereafter the group systematically challenged and deskilled him. It is to be expected that the therapist’s positive evaluation of one member will evoke feelings of sibling rivalry among the others.

The struggle for dominance, as I will discuss in chapter 11, fluctuates in intensity throughout the group. It is much in evidence at the beginning of the group as members jockey for position in the pecking order. Once the hierarchy is established, the issue may become quiescent, with periodic flare-ups, for example, when some member, as part of his or her therapeutic work, begins to grow in assertiveness and to challenge the established order.

When new members enter the group, especially aggressive members who do not know their place, who do not respectfully search out and honor the rules of the group, you may be certain that the struggle for dominance will rise to the surface.

• In one group a veteran member, Betty, was much threatened by the entrance of a new, aggressive woman, Rena. A few meetings later, when Betty discussed some important material concerning her inability to assert herself, Rena attempted to help by commenting that she, herself, used to be like that, and then she presented various methods she had used to overcome it. Rena reassured Betty that if she continued to talk about it openly in the group she, too, would gain considerable confidence. Betty’s response was silent fury of such magnitude that several meetings passed before she could discuss and work through her feelings. To the uninformed observer, Betty’s response would appear puzzling; but in the light of Betty’s seniority in the group and Rena’s vigorous challenge to that seniority, her response was entirely predictable. She responded not to Rena’s manifest offer of help but instead to Rena’s implicit communication: “I’m more advanced than you, more mature, more knowledgeable about the process of psychotherapy, and more powerful in this group despite your longer presence here.”