The Theory and Practice of Group Psychotherapy (20 page)

When we interviewed the subjects in our study to learn more about the meaning of their choices, we found that the most popular item—48,
Discovering and accepting previously unknown or unacceptable parts of myself
—had a very specific implication to group members. More often than not, they discovered
positive
areas of themselves: the ability to care for another, to relate closely to others, to experience compassion.

There is an important lesson to be learned here. Too often psychotherapy, especially in naive, popularized, or early conceptualizations, is viewed as a detective search, as a digging or a stripping away. Rogers, Horney, Maslow, and our clients as well remind us that therapy is also horizontal and upward exploration; digging or excavation may uncover our riches and treasures as well as shameful, fearful, or primitive aspects of ourselves.
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Our clients want to be liberated from pathogenic beliefs; they seek personal growth and control over their lives. As they gain fuller access to themselves, they become emboldened and increase their sense of ownership of their personhood. Psychotherapy has grown beyond its emphasis on eradicating the “pathological” and now aims at increasing clients’ breadth of positive emotions and cognitions. A group therapy approach that encourages members to create and inhabit a powerful and caring environment is a potent approach to these contemporary goals.†
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Thus, one way that self-understanding promotes change is by encouraging individuals to recognize, integrate, and give free expression to previously obscured parts of themselves. When we deny or stifle parts of ourselves, we pay a heavy price: we feel a deep, amorphous sense of restriction; we are constantly on guard; we are often troubled and puzzled by internal but seemingly alien impulses that demand expression. When we are able to reclaim these disavowed parts, we experience a wholeness, and a sense of liberation.

So far, so good. But what of the other components of the intellectual task? For example, how does the highly ranked item
Learning why I think and feel the way I do
(item 47) result in therapeutic change?

First, we must recognize that there is an urgent need for intellectual understanding in the psychotherapeutic enterprise, a need that comes from both client and therapist. Our search for understanding is deeply rooted. Maslow, in a treatise on motivation, suggested that the human being has cognitive needs that are as basic as the needs for safety, love, and self-esteem.
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Most children are exceedingly curious; in fact, we grow concerned if a child lacks curiosity about the environment. Researchers studying primates also see high levels of curiosity: monkeys in a solid enclosure will do considerable work for the privilege of being able to look through a window to see outside; they will also work hard and persistently to solve puzzles without any reward except the satisfactions inherent in the puzzle solving.

In an analogous fashion our clients automatically search for understanding, and therapists who prize the intellectual pursuit join them. Often, it all seems so natural that we lose sight of the raison d’être of therapy. After all, the object of therapy is change, not self-understanding. Or is it? Are the two synonymous? Does any and every type of self-understanding lead automatically to change? Or is the quest for self-understanding simply an interesting, appealing, reasonable exercise for clients and therapists, serving, like mortar, to keep the two joined together while something else—“relationship”—develops. Perhaps it is relationship that is the real mutative force in therapy. In fact, there is considerable evidence that a supportive psychotherapy relationship in a noninterpretive therapy can produce substantial change in interpersonal behavior.
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It is far easier to pose these questions than to answer them. I will present some preliminary points here, and in chapter 6, after developing some material on the interpretative task and techniques of the therapist, I will attempt to present a coherent thesis.

If we examine the motives behind our curiosity and our proclivity to explore our environment, we shed some light on the process of change. These motives include
effectance
(our desire for mastery and power),
safety
(our desire to render the unexplained harmless through understanding), and
pure cognizance
(our desire for knowledge and exploration for its own sake).
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The worried householder who explores a mysterious and frightening noise in his home; the young student who, for the first time, looks through a microscope and experiences the exhilaration of understanding the structure of an insect wing; the medieval alchemist or the New World explorer probing uncharted and proscribed regions—all receive their respective rewards: safety, a sense of personal keenness and satisfaction, and mastery in the guise of knowledge or wealth.

Of these motives, the one least relevant for the change process is pure cognizance. There is little question that knowledge for its own sake has always propelled the human being. The lure of the forbidden is an extraordinarily popular and ubiquitous motif in folk literature, from the story of Adam and Eve to the saga of Peeping Tom. It is no surprise, then, that the desire to know enters the psychotherapeutic arena. Yet there is little evidence that understanding for its own sake results in change.

But the desires for safety and for mastery play an important and obvious role in psychotherapy. They are, of course, as White has ably discussed, closely intertwined.
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The unexplained—especially the frightening unexplained—cannot be tolerated for long. All cultures, through either a scientific or a religious explanation, attempt to make sense of chaotic and threatening situations in the physical and social environment as well as in the nature of existence itself. One of our chief methods of control is through language. Giving a name to chaotic, unruly forces provides us with a sense of mastery or control. In the psychotherapeutic situation, information decreases anxiety by removing ambiguity. There is considerable research evidence supporting this observation.
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The converse is, incidentally, also true: anxiety increases ambiguity by distorting perceptual acuteness. Anxious subjects show disturbed organization of visual perception; they are less capable of perceiving and organizing rapid visual cues and are distinctly slower in completing and recognizing incomplete pictures in a controlled experimental setting.
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Unless one is able to order the world cognitively, one may experience anxiety, which, if severe, interferes with the perceptual apparatus. Thus, anxiety begets anxiety: the ensuing perplexity and overt or subliminal awareness of perceptual distortion become a potent secondary source of anxiety.
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In psychotherapy, clients are enormously reassured by the belief that their chaotic inner world, their suffering, and their tortuous interpersonal relationships are all explicable and thereby governable. Maslow, in fact, views the increase of knowledge as having transformative effects far beyond the realms of safety, anxiety reduction, and mastery. He views psychiatric illness as a disease caused by knowledge deficiency.
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In this way he would support the moral philosophic contention that if we know the good, we will always act for the good. Presumably it follows that if we know what is ultimately good for us we will act in our own best interests.
^41
j

Therapists, too, are less anxious if, when confronted with great suffering and voluminous, chaotic material, they can believe in a set of principles that will permit an ordered explanation. Frequently, therapists will cling tenaciously to a particular system in the face of considerable contradictory evidence—sometimes, in the case of researcher-clinicians, even evidence that has issued from their own investigations. Though such tenacity of belief may carry many disadvantages, it performs one valuable function: it enables the therapist to preserve equanimity in the face of considerable affect emerging within the transference or countertransference.

There is little in the above that is controversial. Self-knowledge permits us to integrate all parts of ourselves, decreases ambiguity, permits a sense of effectance and mastery, and allows us to act in concert with our own best interests. An explanatory scheme also permits generalization and transfer of learning from the therapy setting to new situations in the outside world.

The great controversies arise when we discuss not the process or the purpose or the effects of explanation but the
content
of explanation. As I hope to make clear in chapter 6, I think these controversies are irrelevant. When we focus on change rather than on self-understanding as our ultimate goal, we can only conclude that an explanation is correct if it leads to change. The final common result of all our intellectual efforts in therapy is change. Each clarifying, explanatory, or interpretive act of the therapist is ultimately designed to exert leverage on the client’s will to change.

Imitative Behavior (Identification)

Group therapy participants rate imitative behavior among the least helpful of the twelve therapeutic factors. However, we learned from debriefing interviews that the five items in this category seem to have tapped only a limited sector of this therapeutic mode (see
table 4.1
). They failed to distinguish between mere mimicry, which apparently has only a restricted value for clients, and the acquisition of general styles and strategies of behavior, which may have considerable value. To clients, conscious mimicry is an especially unpopular concept as a therapeutic mode since it suggests a relinquishing of individuality—a basic fear of many group participants.

On the other hand, clients may acquire from others a general strategy that may be used across a variety of personal situations. Members of groups for medically ill patients often benefit from seeing other members manage a shared problem effectively.
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This process also works at both overt and more subtle levels. Clients may begin to approach problems by considering, consciously or unconsciously, what some other member or the therapist would think or do in the same situation. If the therapist is tolerant and flexible, then clients may also adopt these traits. If the therapist is self-disclosing and accepts limitations without becoming insecure or defensive, then clients are more apt to learn to accept their personal shortcomings.
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Not only do group members adopt the traits and style of the therapist, but sometimes they may even assimilate the therapist’s complex value system.
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Initially, imitative behavior is in part an attempt to gain approval, but it does not end there. The more intact clients retain their reality testing and flexibility and soon realize that changes in their behavior result in greater acceptance by others. This increased acceptance can then act to change one’s self-concept and self-esteem in the manner described in chapter 3, and an adaptive spiral is instigated. It is also possible for an individual to identify with aspects of two or more other people, resulting in an amalgam. Although parts of others are imitated, the amalgam represents a creative synthesis, a highly innovative individualistic identity.

What of spectator therapy? Is it possible that clients may learn much from observing the solutions arrived at by others who have similar problems? I have no doubt that such learning occurs in the therapy group. Every experienced group therapist has at least one story of a member who came regularly to the group for months on end, was extremely inactive, and finally terminated therapy much improved.

I clearly remember Rod, who was so shy, isolated, and socially phobic that in his adult life he had never shared a meal with another person. When I introduced him into a rather fast-paced group, I was concerned that he would be in over his head. And in a sense he was. For months he sat and listened in silent amazement as the other members interacted intensively with one another. That was a period of high learning for Rod: simply to be exposed to the possibilities of intimate interaction enriched his life. But then things changed! The group began to demand more reciprocity and placed great pressure on him to participate more personally in the meetings. Rod grew more uncomfortable and ultimately, with my encouragement, decided to leave the group. Since he worked at the same university, I had occasion to cross paths with him several times in the ensuing years, and he never failed to inform me how important and personally useful the group had been. It had shown him what was possible and how individuals could engage one another, and it offered him an internal reference point to which he could turn for reassurance as he gradually reached out to touch others in his life.

Clients learn not only from observing the substantive work of others who are like them but also from watching the process of the work. In that sense, imitative behavior is a transitional therapeutic factor that permits clients subsequently to engage more fully in other aspects of therapy. Proof of this is to be found in the fact that one of the five imitative behavior items (item 37,
Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same
) was rated as the eighth (of sixty) most important therapeutic factor. A largescale study in the Netherlands found that clients considered identification to be more important in the early stages of therapy, when novice members looked for more senior members with whom to identify.
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