The Theory and Practice of Group Psychotherapy (5 page)

Recent group therapy literature abounds with descriptions of specialized groups for individuals who have some specific disorder or face some definitive life crisis—for example, panic disorder,
³⁰
obesity,
³¹
bulimia,
³²
adjustment after divorce,
³³
herpes,
³⁴
coronary heart disease,
³⁵
parents of sexually abused children,
³⁶
male batterers,
³⁷
bereavement,
³⁸
HIV/AIDS,
³⁹
sexual dysfunction,
⁴⁰
rape,
⁴¹
self-image adjustment after mastectomy,
⁴²
chronic pain,
⁴³
organ transplant,
⁴⁴
and prevention of depression relapse.
⁴⁵

In addition to offering mutual support, these groups generally build in a psychoeducational component approach offering explicit instruction about the nature of a client’s illness or life situation and examining clients’ misconceptions and self-defeating responses to their illness. For example, the leaders of a group for clients with panic disorder describe the physiological cause of panic attacks, explaining that heightened stress and arousal increase the flow of adrenaline, which may result in hyperventilation, shortness of breath, and dizziness; the client misinterprets the symptoms in ways that only exacerbate them (“I’m dying” or “I’m going crazy”), thus perpetuating a vicious circle. The therapists discuss the benign nature of panic attacks and offer instruction first on how to bring on a mild attack and then on how to prevent it. They provide detailed instruction on proper breathing techniques and progressive muscular relaxation.

Groups are often the setting in which new mindfulness- and meditation-based stress reduction approaches are taught. By applying disciplined focus, members learn to become clear, accepting, and nonjudgmental observers of their thoughts and feelings and to reduce stress, anxiety, and vulnerability to depression.
⁴⁶

Leaders of groups for HIV-positive clients frequently offer considerable illness-related medical information and help correct members’ irrational fears and misconceptions about infectiousness. They may also advise members about methods of informing others of their condition and fashioning a less guilt-provoking lifestyle.

Leaders of bereavement groups may provide information about the natural cycle of bereavement to help members realize that there is a sequence of pain through which they are progressing and there will be a natural, almost inevitable, lessening of their distress as they move through the stages of this sequence. Leaders may help clients anticipate, for example, the acute anguish they will feel with each significant date (holidays, anniversaries, and birthdays) during the first year of bereavement. Psychoeducational groups for women with primary breast cancer provide members with information about their illness, treatment options, and future risks as well as recommendations for a healthier lifestyle. Evaluation of the outcome of these groups shows that participants demonstrate significant and enduring psychosocial benefits.
⁴⁷

Most group therapists use some form of anticipatory guidance for clients about to enter the frightening situation of the psychotherapy group, such as a preparatory session intended to clarify important reasons for psychological dysfunction and to provide instruction in methods of self-exploration.
⁴⁸
By predicting clients’ fears, by providing them with a cognitive structure, we help them cope more effectively with the culture shock they may encounter when they enter the group therapy (see chapter 10).

Didactic instruction has thus been employed in a variety of fashions in group therapy: to transfer information, to alter sabotaging thought patterns, to structure the group, to explain the process of illness. Often such instruction functions as the initial binding force in the group, until other therapeutic factors become operative. In part, however, explanation and clarification function as effective therapeutic agents in their own right. Human beings have always abhorred uncertainty and through the ages have sought to order the universe by providing explanations, primarily religious or scientific. The explanation of a phenomenon is the first step toward its control. If a volcanic eruption is caused by a displeased god, then at least there is hope of pleasing the god.

Frieda Fromm-Reichman underscores the role of uncertainty in producing anxiety. The awareness that one is not one’s own helmsman, she points out, that one’s perceptions and behavior are controlled by irrational forces, is itself a common and fundamental source of anxiety.
⁴⁹

Our contemporary world is one in which we are forced to confront fear and anxiety often. In particular, the events of September 11, 2001, have brought these troubling emotions more clearly to the forefront of people’s lives. Confronting traumatic anxieties with active coping (for instance, engaging in life, speaking openly, and providing mutual support), as opposed to withdrawing in demoralized avoidance, is enormously helpful. These responses not only appeal to our common sense but, as contemporary neurobiological research demonstrates, these forms of active coping activate important neural circuits in the brain that help regulate the body’s stress reactions.
⁵⁰

And so it is with psychotherapy clients: fear and anxiety that stem from uncertainty of the source, meaning, and seriousness of psychiatric symptoms may so compound the total dysphoria that effective exploration becomes vastly more difficult. Didactic instruction, through its provision of structure and explanation, has intrinsic value and deserves a place in our repertoire of therapeutic instruments (see chapter 5).

Direct Advice

Unlike explicit didactic instruction from the therapist, direct advice from the members occurs without exception in every therapy group. In dynamic interactional therapy groups, it is invariably part of the early life of the group and occurs with such regularity that it can be used to estimate a group’s age. If I observe or hear a tape of a group in which the clients with some regularity say things like, “I think you ought to . . .” or “What you should do is . . .” or “Why don’t you . . . ?” then I can be reasonably certain either that the group is young or that it is an older group facing some difficulty that has impeded its development or effected temporary regression. In other words, advice-giving may reflect a resistance to more intimate engagement in which the group members attempt to manage relationships rather than to connect. Although advice-giving is common in early interactional group therapy, it is rare that specific advice will directly benefit any client. Indirectly, however, advice-giving serves a purpose; the process of giving it, rather than the content of the advice, may be beneficial, implying and conveying, as it does, mutual interest and caring.

Advice-giving or advice-seeking behavior is often an important clue in the elucidation of interpersonal pathology. The client who, for example, continuously pulls advice and suggestions from others, ultimately only to reject them and frustrate others, is well known to group therapists as the “help-rejecting complainer” or the “yes . . . but” client (see chapter 13).
⁵¹
Some group members may bid for attention and nurturance by asking for suggestions about a problem that either is insoluble or has already been solved. Others soak up advice with an unquenchable thirst, yet never reciprocate to others who are equally needy. Some group members are so intent on preserving a high-status role in the group or a facade of cool self-sufficiency that they never ask directly for help; some are so anxious to please that they never ask for anything for themselves; some are excessively effusive in their gratitude; others never acknowledge the gift but take it home, like a bone, to gnaw on privately.

Other types of more structured groups that do not focus on member interaction make explicit and effective use of direct suggestions and guidance. For example, behavior-shaping groups, hospital discharge planning and transition groups, life skills groups, communicational skills groups, Recovery, Inc., and Alcoholics Anonymous all proffer considerable direct advice. One communicational skills group for clients who have chronic psychiatric illnesses reports excellent results with a structured group program that includes focused feedback, videotape playback, and problem-solving projects.
⁵²
AA makes use of guidance and slogans: for example, members are asked to remain abstinent for only the next twenty-four hours—“One day at a time.” Recovery, Inc. teaches members how to spot neurotic symptoms, how to erase and retrace, how to rehearse and reverse, and how to apply willpower effectively.

Is some advice better than others? Researchers who studied a behavior-shaping group of male sex offenders noted that advice was common and was useful to different members to different extents. The least effective form of advice was a direct suggestion; most effective was a series of alternative suggestions about how to achieve a desired goal.
⁵³
Psychoeducation about the impact of depression on family relationships is much more effective when participants examine, on a direct, emotional level, the way depression is affecting their own lives and family relationships. The same information presented in an intellectualized and detached manner is far less valuable.
⁵⁴

ALTRUISM

There is an old Hasidic story of a rabbi who had a conversation with the Lord about Heaven and Hell. “I will show you Hell,” said the Lord, and led the rabbi into a room containing a group of famished, desperate people sitting around a large, circular table. In the center of the table rested an enormous pot of stew, more than enough for everyone. The smell of the stew was delicious and made the rabbi’s mouth water. Yet no one ate. Each diner at the table held a very long-handled spoon—long enough to reach the pot and scoop up a spoonful of stew, but too long to get the food into one’s mouth. The rabbi saw that their suffering was indeed terrible and bowed his head in compassion. “Now I will show you Heaven,” said the Lord, and they entered another room, identical to the first—same large, round table, same enormous pot of stew, same long-handled spoons. Yet there was gaiety in the air; everyone appeared well nourished, plump, and exuberant. The rabbi could not understand and looked to the Lord. “It is simple,” said the Lord, “but it requires a certain skill. You see, the people in this room have learned to feed each other!”
^c

In therapy groups, as well as in the story’s imagined Heaven and Hell, members gain through giving, not only in receiving help as part of the reciprocal giving-receiving sequence, but also in profiting from something intrinsic to the act of giving. Many psychiatric patients beginning therapy are demoralized and possess a deep sense of having nothing of value to offer others. They have long considered themselves as burdens, and the experience of finding that they can be of importance to others is refreshing and boosts self-esteem. Group therapy is unique in being the only therapy that offers clients the opportunity to be of benefit to others. It also encourages role versatility, requiring clients to shift between roles of help receivers and help providers.
⁵⁵

And, of course, clients are enormously helpful to one another in the group therapeutic process. They offer support, reassurance, suggestions, insight; they share similar problems with one another. Not infrequently group members will accept observations from another member far more readily than from the group therapist. For many clients, the therapist remains the paid professional; the other members represent the real world and can be counted on for spontaneous and truthful reactions and feedback. Looking back over the course of therapy, almost all group members credit other members as having been important in their improvement. Sometimes they cite their explicit support and advice, sometimes their simply having been present and allowing their fellow members to grow as a result of a facilitative, sustaining relationship. Through the experience of altruism, group members learn firsthand that they have obligations to those from whom they wish to receive care.

An interaction between two group members is illustrative. Derek, a chronically anxious and isolated man in his forties who had recently joined the group, exasperated the other members by consistently dismissing their feedback and concern. In response, Kathy, a thirty-five-year-old woman with chronic depression and substance abuse problems, shared with him a pivotal lesson in her own group experience. For months she had rebuffed the concern others offered because she felt she did not merit it. Later, after others informed her that her rebuffs were hurtful to them, she made a conscious decision to be more receptive to gifts offered her and soon observed, to her surprise, that she began to feel much better. In other words, she benefited not only from the support received but also in her ability to help others feel they had something of value to offer. She hoped that Derek could consider those possibilities for himself.

Altruism is a venerable therapeutic factor in other systems of healing. In primitive cultures, for example, a troubled person is often given the task of preparing a feast or performing some type of service for the community.
⁵⁶
Altruism plays an important part in the healing process at Catholic shrines, such as Lourdes, where the sick pray not only for themselves but also for one another. People need to feel they are needed and useful. It is commonplace for alcoholics to continue their AA contacts for years after achieving complete sobriety; many members have related their cautionary story of downfall and subsequent reclamation at least a thousand times and continually enjoy the satisfaction of offering help to others.