The Theory and Practice of Group Psychotherapy (65 page)

Despite the initial, raucous reaction of the group, it was soon clear that the therapists had made the proper intervention. One of the co-therapists phoned Dan and saw him individually for two sessions, then referred him to an appropriate therapist for individual therapy. Dan soon appreciated that the therapists were acting not punitively but in his best interests: irregularly attending a therapy group would not have been effective therapy for him. The group was immediately affected: attendance abruptly improved and remained near perfect over the next several months. The members, once they had recovered from their fear of similar banishment, gradually disclosed their approval of the therapists’ act and their great resentment toward Dan and, to a lesser extent, toward some of the other members for having treated the group in such a cavalier fashion.

Some therapists attempt to improve attendance by harnessing group pressure—for example, by refusing to hold a meeting until a predetermined number of members (usually three or four) are present. Even without formalization of this sort, the pressure exerted by the rest of the group is an effective lever to bring to bear on errant members. The group is often frustrated and angered by the repetitions and false starts necessitated by irregular attendance. The therapist should encourage the members to express their reactions to late or absent members. Be mindful, though, that the therapist’s concern about attendance is not always shared by the members: a young or immature group often welcomes the small meeting, regarding it as an opportunity for more individual attention from the leader. Similarly, be cautious not to punish the regular participants by withholding treatment in the process of applying group pressure on the absent members.

Like any event in the group, absenteeism or tardiness is a form of behavior that reflects an individual’s characteristic patterns of relating to others. Be sure to examine the personal meaning of the client’s action. If Mary arrives late, does she apologize? Does Joe enter in a thoughtless, exhibitionistic manner? Does Sally arrive late because she experiences herself as nonentity who makes no contribution to the group’s life in any event? Does Ralph come as he chooses because he believes nothing of substance happens without him anyway? Does Peg ask for a recap of the events of the meeting? Is her relation with the group such that the members provide her with a recap? If Stan is absent, does he phone in advance to let the group know? Does he offer complex, overelaborate excuses, as though convinced he will not be believed? Not infrequently, a client’s psychopathology is responsible for poor attendance. For example, one man who sought therapy because of a crippling fear of authority figures and a pervasive inability to assert himself in interpersonal situations was frequently late because he was unable to muster the courage to interrupt a conversation or a conference with a business associate. An obsessive-compulsive client was late because he felt compelled to clean his desk over and over before leaving his office.

Thus, absenteeism and lateness are part of the individual’s social microcosm and, if handled properly, may be harnessed in the service of self-understanding. For both the group’s and the individual’s sake, however, they must be corrected before being analyzed. No interpretation can be heard by an absent group member. In fact, the therapist must attend to the timing of his comments to the returning member. Clients who have been absent or are late often enter the meeting with some defensive guilt or shame and are not in an optimal state of receptiveness for observations about their behavior. The therapist does well to attend first to group maintenance and norm-setting tasks and then, later, when the timing seems right and defensiveness diminished, attempt to help the individual explore the meaning of his or her behavior. The timing of feedback is particularly important for members who have greater psychological vulnerability and less mature relationships.
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Group members who must miss a meeting or arrive late should, as they were advised in pregroup preparation, phone the therapist in advance in order to spare the group from wasting time expressing curiosity or concern about their absence. Often, in advanced groups, the fantasies of group members about why someone is absent provide valuable material for the therapeutic process; in early groups, however, such speculations tend to be superficial and unfruitful.

An important adage of interactional group therapy, which I emphasize many times throughout this book, is that any event in the group can serve as grist for the interpersonal mill. Even the absence of a member can generate important, previously unexplored material.

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A group composed of four women and three men held its eighth meeting in the absence of two of the men. Albert, the only male present, had previously been withdrawn and submissive in the group, but in this meeting a dramatic transformation occurred. He erupted into activity, talked about himself, questioned the other members, spoke loudly and forcefully, and, on a couple of occasions, challenged the therapist. His nonverbal behavior was saturated with quasi-courtship bids directed at the women members: for example, frequent adjustment of his shirt collar and preening of the hair at his temples. Later in the meeting, the group focused on Albert’s change, and he realized and expressed his fear and envy of the two missing males, both of whom were aggressive and assertive. He had long experienced a pervasive sense of social and sexual impotence, which had been reinforced by his feeling that he had never made a significant impact on any group of people and especially any group of women. In subsequent weeks, Albert did much valuable work on these issues—issues that might not have become accessible for many months without the adventitious absence of the two other members.

My clinical preference is to encourage attendance but never, regardless of how small the group is, to cancel a session. There is considerable therapeutic value in the client’s knowing that the group is always there, stable and reliable: its constancy will in time beget constancy of attendance. I have led many small group sessions, with as few as two members, that have proved to be critical for those attending. The technical problem with such meetings is that without the presence of interaction, the therapist may revert to focusing on intrapsychic processes in a manner characteristic of individual therapy and forgo group and interpersonal issues. It is far more therapeutically consistent to focus in depth on group and interpersonal processes even in the smallest of sessions. Consider the following clinical example from a ten-month-old group:

• For various reasons—vacations, illnesses, resistance—only two members attended: Wanda, a thirty-eight-year-old depressed woman with borderline personality disorder who had twice required hospitalization, and Martin, a twenty-three-year-old man with schizoid personality disorder who was psychosexually immature and suffered from moderately severe ulcerative colitis.

Wanda spent much of the early part of the meeting describing the depth of her despair, which during the past week had reached such proportions that she had been preoccupied with suicide and, since the group therapist was out of town, had visited the emergency room at the hospital. While there, she had surreptitiously read her medical chart and seen a consultation note written a year earlier by the group therapist in which he had diagnosed her as borderline. She said that she had been anticipating this diagnosis and now wanted the therapist to hospitalize her.

Martin then recalled a fragment of a dream he had several weeks before but had not discussed: the therapist was sitting at a large desk interviewing Martin, who stood up and looked at the paper on which the therapist is writing. There he saw in huge letters one word covering the entire page: IMPOTENT. The therapist helped both Wanda and Martin discuss their feelings of awe, helpless dependence, and resentment toward him as well as their inclination to shift responsibility and project onto him their bad feelings about themselves.

Wanda proceeded to underscore her helplessness by describing her inability to cook for herself and her delinquency in paying her bills, which was so extreme that she now feared police action against her. The therapist and Martin both discussed her persistent reluctance to comment on her positive accomplishments—for example, her continued excellence as a teacher. The therapist wondered whether her presentation of herself as helpless was not designed to elicit responses of caring and concern from the other members and the therapist—responses that she felt would be forthcoming in no other way.

Martin then mentioned that he had gone to the medical library the previous day to read some of the therapist’s professional articles. In response to the therapist’s question about what he really wanted to find out, Martin answered that he guessed he really wanted to know how the therapist felt about him and proceeded to describe, for the first time, his longing for the therapist’s sole attention and love.

Later, the therapist expressed his concern at Wanda’s reading his note in her medical record. Since there is a realistic component to a client’s anxiety on learning that her therapist has diagnosed her as borderline, the therapist candidly discussed both his own discomfort at having to use diagnostic labels for hospital records and the confusion surrounding psychiatric nosological terminology; he recalled as best he could his reasons for using that particular label and its implications.

Wanda then commented on the absent members and wondered whether she had driven them from the group (a common reaction). She dwelled on her unworthiness and, at the therapist’s suggestion, made an inventory of her baleful characteristics, citing her slovenliness, selfishness, greed, envy, and hostile feelings toward all those in her social environment. Martin both supported Wanda and identified with her, since he recognized many of these feelings in himself. He discussed how difficult it was for him to reveal himself in the group (Martin had disclosed very little of himself previously in the group). Later, he discussed his fear of getting drunk or losing control in other ways: for one thing, he might become indiscreet sexually. He then discussed, for the first time, his fear of sex, his impotence, his inability to maintain an erection, and his last-minute refusals to take advantage of sexual opportunities. Wanda empathized deeply with Martin and, although she had for some time regarded sex as abhorrent, expressed the strong wish (a wish, not an intention) to help him by offering herself to him sexually. Martin then described his strong sexual attraction to her, and later both he and Wanda discussed their sexual feelings toward the other members of the group. The therapist made the observation, one that proved subsequently to be of great therapeutic importance to Wanda, that her interest in Martin and her desire to offer herself to him sexually belied many of the items in her inventory: her selfishness, greed, and ubiquitous hostility to others.

Although only two members were present at this meeting, they met as a group and not as two individual clients. The other members were discussed in absentia, and previously undisclosed interpersonal feelings between the two clients and toward the therapist were expressed and analyzed. It was a valuable session, deeply meaningful to both participants. It is worth noting here that talking about group members in their absence is not “talking behind people’s backs.” A member’s absence cannot dictate what gets addressed by those in attendance, although it is essential that absent members be brought back into the loop upon their return. Mailing out a group summary (see chapter 14) is a good way to accomplish this.

Dropouts

There is no more threatening problem for the neophyte group therapist (and for many experienced therapists as well) than the dropout from group therapy. Dropouts concerned me greatly when I first started to lead groups, and my first group therapy research was a study of all the group participants who had dropped out of the therapy groups in a large psychiatric clinic.
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It is no minor problem. As I discussed earlier, the group therapy demographic research demonstrates that a substantial number of clients will leave a group prematurely regardless of what the therapist does. In fact, some clinicians suggest that dropouts are not only inevitable but necessary in the sifting process involved in achieving a cohesive group.
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Consider, too, that the existence of an escape hatch may be essential to allow some members to make their first tentative commitments to the group. The group must have some decompression mechanism: mistakes in the selection process are inevitable, unexpected events occur in the lives of new members, and group incompatibilities develop. Some intensive weeklong human relations laboratories or encounter groups that meet at a geographically isolated place lack a way of escape; on several occasions, I have seen psychotic reactions in participants forced to continue in an incompatible group.

There are various reasons for premature termination (see chapter 8). It is often productive to think about the dropout phenomenon from the perspective of the interaction of three factors: the client, the group, and the therapist.
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In general, client contributions stem from problems caused by deviancy, conflicts in intimacy and disclosure, the role of the early provocateur, external stress, complications of concurrent individual and group therapy, inability to share the leader, and fear of emotional contagion. Underlying all these reasons is the potential stress early in the group. Individuals who have maladaptive interpersonal patterns are exposed to unaccustomed demands for candor and intimacy; they are often confused about procedure; they suspect that the group activities bear little relevance to their problem; and, finally, they feel too little support in the early meetings to sustain their hope.