The Theory and Practice of Group Psychotherapy (79 page)

The underlying dynamics of the boring patient vary enormously from individual to individual. Many have a core dependent position and so dread rejection and abandonment that they are compulsively compliant, eschewing any aggressive remark that might initiate retaliation. They mistakenly confuse healthy self-assertion with aggression and by refusing to acknowledge their own vitality, desires, spontaneity, interests, and opinions, they bring to pass (by boring others) the very rejection and abandonment they had hoped to forestall.†
¹⁷

If you, as the therapist, are bored with a client, that boredom is important data. (The therapy of all difficult clients necessitates thoughtful attention to your countertransference).
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Always assume that if you are bored by the member, so are others. You must counter your boredom with curiosity. Ask yourself: “What makes the person boring? When am I most and least bored? How can I find the person—the real, the lively, spontaneous, creative, person—within this boring shell?” No urgent “breakthrough” technique is indicated. Since the boring individual is tolerated by the group much better than the abrasive, narcissistic, or monopolistic client, you have much time.

Lastly, keep in mind that the therapist must take a Socratic posture with these clients. Our task is not to put something
into
the individual but quite the opposite, to let something out that was there all the time. Thus we do not attempt to
inspirit
boring clients, or inject color, spontaneity, or richness
into
them, but instead to identify their squelched creative, vital, childlike parts and to help remove the obstacles to their free expression.

THE HELP-REJECTING COMPLAINER

The help-rejecting complainer, a variant of the monopolist, was first identified and named by J. Frank in 1952.
¹⁹
Since then the behavior pattern has been recognized by many group clinicians, and the term appears frequently in the psychiatric literature, particularly in the psychotherapy and psychosomatic areas.
²⁰
In this section, I discuss the rare fully developed help-rejecting complainer; however, this pattern of behavior is not a distinct, all-or-nothing clinical syndrome. Individuals may arrive at this style of interaction through various psychological pathways. Some may persistently manifest this behavior in an extreme degree with no external provocation, whereas others may demonstrate only a trace of this pattern. Still others may become help-rejecting complainers only at times of particular stress. Closely associated with help-rejecting complaining is the expression of emotional distress through somatic complaints. Clients with medically unexplainable symptoms constitute a large and frustrating primary care burden.
²¹

Description

Help-rejecting complainers (or HRCs) show a distinctive behavioral pattern in the group: they implicitly or explicitly
request
help from the group by presenting problems or complaints and then
reject
any help offered. HRCs continually present problems in a manner that makes them to appear insurmountable. In fact, HRCs seems to take pride in the insolubility of their problems. Often HRCs focus wholly on the therapist in a tireless campaign to elicit intervention or advice and appear oblivious to the group’s reaction to them. They seem willing to appear ludicrous so long as they are allowed to persist in the search for help. They base their relationship to the other members along the singular dimension of being more in need of aid. HRCs rarely show competitiveness in any area except when another member makes a bid for the therapist’s or group’s attention by presenting a problem. Then HRCs often attempt to belittle that person’s complaints by comparing them unfavorably with their own. They often tend to exaggerate their problems and to blame others, often authority figures on whom they depend in some fashion. HRCs seem entirely self-centered, speaking only of themselves and their problems.

When the group and the therapist do respond to the HRC’s plea, the entire bewildering, configuration takes form as the client rejects the help offered. The rejection is unmistakable, though it may assume many varied and subtle forms: sometimes the advice is rejected overtly, sometimes indirectly ; sometimes while accepted verbally, it is never acted upon; if it is acted upon, it inevitably fails to improve the member’s plight.

Effects on the Group

The effects on the group are obvious: the other members become irritated, frustrated, and confused. The HRC seems a greedy whirlpool, sucking the group’s energy. Worse yet, no deceleration of the HRC’s demands is evident. Faith in the group process suffers, as members experience a sense of impotence and despair of making their own needs appreciated by the group. Cohesiveness is undermined as absenteeism occurs or as clients subgroup in an effort to exclude the HRC.

Dynamics

The behavioral pattern of the HRC appears to be an attempt to resolve highly conflicted feelings about dependency. On the one hand, the HRC feels helpless, insignificant, and totally dependent on others, especially the therapist, for a sense of personal worth. Any notice and attention from the therapist temporarily enhance the HRC’s self-esteem. On the other hand, the HRC’s dependent position is vastly confounded by a pervasive distrust and enmity toward authority figures. Consumed with need, the HRC turns for help to a figure he or she anticipates will be unwilling or unable to help. The anticipation of refusal so colors the style of requesting help that the prophecy is fulfilled, and further evidence is accumulated for the belief in the malfeasance of the potential caregiver.
²²
A vicious circle results, one that has been spinning for much of the client’s life.

Guidelines for Management

A severe HRC is an exceedingly difficult clinical challenge, and many such clients have won a Pyrrhic victory over therapist and group by failing in therapy. It would thus be presumptuous and misleading to attempt to prescribe a careful therapeutic plan; however, certain generalizations may be posited. Surely it is a blunder for the therapist to confuse the help requested for the help required.†
²³
The HRC solicits advice not for its potential value but in order to spurn it. Ultimately, the therapist’s advice, guidance, and treatment will be rejected or, if used, will prove ineffective or, if effective, will be kept secret. It is also a blunder for the therapist to express any frustration and resentment. Retaliation merely completes the vicious circle: the clients’ anticipation of ill treatment and abandonment is once again realized: They feel justified in their hostile mistrust and are able to affirm once again that no one can ever really understand them.

What course, then, is available to the therapist? One clinician suggests, perhaps in desperation, that the therapist interrupt the vicious circle by indicating that he or she “not only understands but shares the patient’s feelings of hopelessness about the situation,” thus refusing to perpetuate his or her part in a futile relationship. Two brave co-therapists who led a group composed only of help-rejecting complainers warn us against investing in a sympathetic, nurturing relationship with the client. They suggest that therapists sidestep any expression of optimism, encouragement, or advice and adopt instead a pose of irony in which they agree with the content of the client’s pessimism while maintaining a detached affect. Eric Berne, who considers the HRC pattern to be the most common of all social and psychotherapy group games, labeled it “Why don’t you—yes but.” The use of such easily accessible descriptive labels often makes the process more transparent to the group members, but great caution must be exercised when using any bantering approach: there is a fine line separating therapeutic playful caring from mockery and humiliation.
²⁴

In general, the therapist should attempt to mobilize the major therapeutic factors in the service of the client. When a cohesive group has been formed and the client—through universality, identification, and catharsis—has come to value membership in the group, then the therapist can encourage interpersonal learning by continually focusing on feedback and process in much the same manner as I have described in discussing the monopolistic client. HRCs are generally not aware of their lack of empathy to others. Helping them see their interpersonal impact on the other members is a key step in their coming to examine their characteristic pattern of relationships.

THE PSYCHOTIC OR BIPOLAR CLIENT

Many groups are designed specifically to work with clients with significant Axis I disturbance. In fact, when one considers groups on psychiatric wards, partial hospitalization units, veterans’ hospitals, and aftercare programs, the total number of therapy groups for severely impaired clients likely outnumbers those for higher-functioning clients. I will discuss groups composed for hospitalized clients in chapter 15 (for more on this topic, see my text
Inpatient Group Psychotherapy,
Basic Books, 1983) but for now consider the issue of what happens to the course of an interactive therapy group of higher-functioning individuals when one member develops a psychotic illness during treatment.

The fate of the psychotic client, the response of the other members, and the effective options available to the therapist all depend in part on
timing
, that is,
when in the course of the group the psychotic illness occurs
. In general, in a mature group in which the psychotic client has long occupied a central, valued role, the group members are more likely to be tolerant and effective during the crisis.

The Early Phases of a Group

In chapter 8, I emphasized that in the initial screening, the grossly psychotic client should be excluded from ambulatory interactional group therapy. However, it is common practice to refer clients with apparently stable bipolar disease to group therapy to address the interpersonal consequences of their illness.

At times, despite cautious screening, an individual decompensates in the early stages of therapy, perhaps because of unanticipated stress from life circumstances, or from the group, or perhaps because of poor adherence to a medication regimen. This is a major event for the group and always creates substantial problems for the newly formed group (and, of course, for the client, who is likely to slide into a deviant role in the group and eventually terminate treatment, often much the worse for the experience).

In this book I have repeatedly stressed that the early stages of the group are a time of great flux and great importance. The young group is easily influenced, and norms that are established early are often exceedingly durable. An intense sequence of events unfolds as, in a few weeks, an aggregate of frightened, distrustful strangers evolves into an intimate, mutually helpful group. Any event that consumes an inordinate amount of time early on and diverts energy from the tasks of the developmental sequence is potentially destructive to the group. Some of the relevant problems are illustrated by the following clinical example.

• Sandy was a thirty-seven-year-old housewife who had once, many years before, suffered a major and recalcitrant depression requiring hospitalization and electroconvulsive therapy. She sought group therapy at the insistence of her individual therapist, who thought that an understanding of her interpersonal relationships would help her to improve her relationship with her husband. In the early meetings of the group, she was an active member who tended to reveal far more intimate details of her history than did the other members. Occasionally, Sandy expressed anger toward another member and then engaged in excessively profuse apologies coupled with self-deprecatory remarks. By the sixth meeting, her behavior became still more inappropriate. She discoursed at great length on her son’s urinary problems, for example, describing in intricate detail the surgery that had been performed to relieve his urethral stricture. At the following meeting, she noted that the family cat had also developed a blockage of the urinary tract; she then urged the other members to describe their pets.

In the eighth meeting, Sandy became increasingly manic. She behaved in a bizarre, irrational manner, insulted members of the group, openly flirted with the male members to the point of stroking their bodies, and finally lapsed into punning, clang associations, inappropriate laughter, and tears. One of the therapists finally escorted her from the room, phoned her husband, and arranged for immediate psychiatric hospitalization. Sandy remained in the hospital in a manic, psychotic state for a month and then gradually recovered.

The members were obviously extremely uncomfortable during the meeting, their feelings ranging from bafflement and fright to annoyance. After Sandy left, some expressed their guilt for having, in some unknown manner, triggered her behavior. Others spoke of their fear, and one recalled someone he knew who had acted in a similar fashion but had also brandished a gun.

During the subsequent meeting, the members discussed many feelings related to the incident. One member expressed his conviction that no one could be trusted: even though he had known Sandy for seven weeks, her behavior proved to be totally unpredictable. Others expressed their relief that they were, in comparison, psychologically healthy; others, in response to their fears of similarly losing control, employed considerable denial and veered away from discussing these problems. Some expressed a fear of Sandy’s returning and making a shambles of the group. Others expressed their diminished faith in group therapy; one member asked for hypnosis, and another brought to the meeting an article from a scientific journal claiming that psychotherapy was ineffective. A loss of faith in the therapists and their competence was expressed in the dream of one member, in which the therapist was in the hospital and was rescued by the client.