The Theory and Practice of Group Psychotherapy (45 page)

In debriefing sessions after termination I have often discussed therapist disclosure with clients. The great majority have expressed the wish that the therapist had been more open, more personally engaged in the group. Very few would have wanted therapists to have discussed more of their private life or personal problems with them. A study of individual therapy had the same findings—clients prefer and in fact thrive on therapist engagement and prefer therapists who are “not too quiet.”
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No one expressed a preference for full therapist disclosure.

Furthermore, there is evidence that leaders are more transparent than they know. The issue is not that we reveal ourselves—that is unavoidable
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—rather, it is what use we make of our transparency and our clinical honesty. Some self-revelation is inadvertent or unavoidable—for example, pregnancy, bereavement, and professional accomplishments.
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In some groups, particularly homogeneous groups with a focus such as substance abuse, sexual orientation, or specific medical illness (see chapter 15), leaders will likely be asked about their personal relationship to the common group focus: Have they had personal experience with substance abuse? Are they gay? Have they personally had the medical disease that is the focus of the group? Therapists need to reveal the relevant material about themselves that helps group members realize that the therapist can understand and empathize with the clients’ experiences. That does not mean, however, that the therapist must provide extensive personal historical details. Such revelations are usually unhelpful to the therapy because they blur the difference in role and function between the therapist and the group members.

Though members rarely press a therapist for inappropriate disclosure, occasionally one particular personal question arises that group therapists dread. It is illustrated in a dream of a group member (the same member who likened the therapist to a Jewish slumlord): “The whole group is sitting around a long table with you (the therapist) at the head. You had in your hand a slip of paper with something written on it. I tried to snatch it away from you but you were too far away.” Months later, after this woman had made some significant personal changes, she recalled the dream and added that she knew all along what I had written on the paper but hadn’t wanted to say it in front of the group. It was my answer to the question, “Do you love me?” This is a threatening question for the group therapist. And there is a related and even more alarming follow-up question: “How much do you love each of us?” or, “Whom do you love best?”

These questions threaten the very essence of the psychotherapeutic contract. They challenge tenets that both parties have agreed to keep invisible. They are but a step away from a commentary on the “purchase of friendship” model: “If you really care for us, would you see us if we had no money?” They come perilously close to the ultimate, terrible secret of the psychotherapist, which is that the intense drama in the group room plays a smaller, compartmentalized role in his or her life. As in Tom Stoppard’s play
Rosencrantz and Guildenstern Are Dead
, key figures in one drama rapidly become shadows in the wings as the therapist moves immediately onto the stage of another drama.

Only once have I been blasphemous enough to lay this bare before a group. A therapy group of psychiatry residents was dealing with my departure (for a year’s sabbatical leave). My personal experience during that time was one of saying good-bye to a number of clients and to several groups, some of which were more emotionally involving for me than the resident group. Termination work was difficult, and the group members attributed much of the difficulty to the fact that I had been so involved in the group that I was finding it hard to say good-bye. I acknowledged my involvement in the group but presented to them the fact that they knew but refused to know: I was vastly more important to them than they were to me. After all, I had many clients; they had only one therapist. They were clearly aware of this imbalance in their psychotherapeutic work with their own clients, and yet had never applied it to themselves. There was a gasp in the group as this truth, this denial of specialness, this inherent cruelty of psychotherapy, hit home.

The issue of therapist transparency is vastly complicated by widely publicized instances of therapist-client sexual abuse. Unfortunately, the irresponsible or impulse-ridden therapists who, to satisfy their own needs, betray their professional and moral covenant have not only damaged their own clients but caused a backlash that has damaged the trust in the client-therapist relationship everywhere.

Many professional associations have taken a highly reactionary stance toward the professional relationship. Feeling threatened by legal action, they advise therapists to practice defensively and always keep potential litigation in mind. The lawyers and juries, they say, will reason that “where there is smoke, there is fire” and that since every therapist-client encounter started down the slippery slope of slight boundary crossings, human interactions between client and therapist are in themselves evidence of wrongdoing. Consequently, professional organizations warn therapists to veer away from the very humanness that is the core of the therapeutic relationship. An article with a high Victorian tone in a 1993 issue of the
American Journal of Psychiatry
,
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for example, advocated a stifling formality and warned psychiatrists not to offer their clients coffee or tea, not to address them by their first names, not to use their own first names, never to run over the fifty-minute time period, never to see any client during the last working hour of the day (since that is when transgressions most often occur), never to touch a client—even an act such as squeezing the arm or patting the back of an AIDS patient who needs therapeutic touch should be scrutinized and documented.
^q
Obviously, these instructions and the sentiment behind them are deeply corrosive to the therapeutic relationship. To their credit, the authors of the 1993 article recognized the antitherapeutic impact of their first article and wrote a second paper five years later aimed at correcting the overreaction generated by the first article. The second article makes a plea for common sense and for recognition of the importance of the clinical context in understanding or judging boundary issues in therapy. They encourage therapists to obtain consultation or supervision whenever they are uncertain about their therapeutic posture or interventions.
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But moderation in all things. There is a proper place for therapist concealment, and the most helpful therapist is by no means the one who is most fully and most consistently self-disclosing. Let us turn our attention to the perils of transparency.

Pitfalls of Therapist Transparency

Some time ago I observed a group led by two neophyte therapists who were at that time much dedicated to the ideal of therapist transparency. They formed an outpatient group and conducted themselves in an unflinchingly honest fashion, expressing openly in the first meetings their uncertainty about group therapy, their inexperience, their self-doubts, and their personal anxiety. One might admire their courage, but not their results. In their overzealous obeisance to transparency, they neglected their function of group maintenance, and the majority of the members dropped out of the group within the first six sessions.

Untrained leaders who undertake to lead groups with the monolithic credo “Be yourself” as a central organizing principle for all other technique and strategy generally achieve not freedom but restriction. The paradox is that freedom and spontaneity in extreme form can result in a leadership role as narrow and restrictive as the traditional blank-screen leader. Under the banner of “Anything goes if it’s genuine,” the leader sacrifices flexibility.
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Consider the issue of timing. The fully open neophyte therapists I just mentioned overlooked the fact that leadership behavior that may be appropriate at one stage of therapy may be quite inappropriate at another. If clients need initial support and structure to remain in the group, then it is the therapist’s task to provide it.

The leader who strives only to create an atmosphere of egalitarianism between member and leader may in the long run provide no leadership at all. Effective leader role behavior is by no means unchanging; as the group develops and matures, different forms of leadership are required.
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“The honest therapist” as Parloff states, “is one who attempts to provide that which the client can assimilate, verify and utilize.”
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Ferenczi years ago underscored the necessity for proper timing. The analyst, he said, must not admit his flaws and uncertainty too early.
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First, the client must feel sufficiently secure in his own abilities before being called upon to face defects in the one on whom he leans.
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Research on group members’ attitudes toward therapist self-disclosure shows that members are sensitive to the timing and the content of disclosure.
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Therapists’ disclosures that are judged as harmful in early phases of the group are considered facilitative as a group matures. Furthermore, members who have had much group therapy experience are far more desirous of therapist self-disclosure than are inexperienced group members. Content analysis demonstrates that members prefer leaders who disclose positive ambitions (for example, personal and professional goals) and personal emotions (loneliness, sadness, anger, worries, and anxieties); they disapprove of a group leader’s expressing negative feelings about any individual member or about the group experience (for example, boredom or frustration).
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Not all emotions can be expressed by the therapist. Expressing hostility is almost invariably damaging and often irreparable, contributing to premature termination and negative therapy outcomes.†

Is full disclosure even possible in the therapy group or in the outside world? Or desirable? Some degree of personal and interpersonal concealment are an integral ingredient of any functioning social order. Eugene O’Neill illustrated this in dramatic form in the play
The Iceman Cometh
.
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A group of derelicts live, as they have for twenty years, in the back room of a bar. The group is exceedingly stable, with many well-entrenched group norms. Each man maintains himself by a set of illusions (“pipe dreams,” O’Neill calls them). One of the most deeply entrenched group norms is that no members challenge another’s pipe dreams. Then enters Hickey, the iceman, a traveling salesman, a totally enlightened therapist, a false prophet who believes he brings fulfillment and lasting peace to each man by forcing him to shed his self-deceptions and stare with unblinking honesty at the sun of his life. Hickey’s surgery is deft. He forces Jimmy Tomorrow (whose pipe dream is to get his suit out of hock, sober up, and get a job “tomorrow”) to act now. He gives him clothes and sends him, and then the other men, out of the bar to face today.

The effects on each man and on the group are calamitous. One commits suicide, others grow severely depressed, “the life goes out of the booze,” the men attack one another’s illusions, the group bonds disintegrate, and the group veers toward dissolution. In a sudden, last-minute convulsive act, the group labels Hickey psychotic, banishes him, and gradually reestablishes its old norms and cohesion. These “pipe dreams”—or “vital lies,” as Henrik Ibsen called them in
The Wild Duck
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—are often essential to personal and social integrity. They should not be taken lightly or impulsively stripped away in the service of honesty.

Commenting on the social problems of the United States, Victor Frankl once suggested that the Statue of Liberty on the East Coast be counterbalanced by a Statue of Responsibility on the West Coast.
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In the therapy group, freedom becomes possible and constructive
only
when it is coupled with responsibility. None of us is free from impulses or feelings that, if expressed, could be destructive to others. I suggest that we encourage clients and therapists to speak freely, to shed all internal censors and filters save one—the filter of responsibility to others.

I do not mean that no unpleasant sentiments are to be expressed; indeed, growth cannot occur in the absence of conflict. I do mean, however, that
responsibility
, not total disclosure, is the superordinate principle.† The therapist has a particular type of responsibility—responsibility to clients and to the task of therapy. Group members have a human responsibility toward one another. As therapy progresses, as solipsism diminishes, as empathy increases, they come to exercise that responsibility in their interactions among themselves.

Thus, your raison d’être as group therapist is not primarily to be honest or fully disclosing. You must be clear about why you reveal yourself. Do you have a clear therapeutic intent or is countertransference influencing your approach? What impact can you anticipate from your self-disclosure? In times of confusion about your behavior, you may profit from stepping back momentarily to reconsider your primary tasks in the group. Therapist self-disclosure is an aid to the group because it sets a model for the clients and permits some members to reality-test their feelings toward you. When considering a self-disclosure, ask yourself where the group is now. Is it a concealed, overly cautious group that may profit from a leader who models personal self-disclosure? Or has it already established vigorous self-disclosure norms and is in need of other kinds of assistance? Again, you must consider whether your behavior will interfere with your group-maintenance function. You must know when to recede into the background. Unlike the individual therapist, the group therapist does not have to be the axle of therapy. In part, you are midwife to the group: you must set a therapeutic process in motion and take care not to interfere with that process by insisting on your centrality.