The Theory and Practice of Group Psychotherapy (28 page)

What stance should the therapist take when someone reveals the big secret? To answer that question, I must first make an important distinction. I believe that when an individual reveals the big secret, the therapist must help him or her disclose even more about the secret but in a
horizontal
rather than a
vertical mode
. By
vertical disclosure
I refer to content, to greater in-depth disclosure about the secret itself. For example, when John disclosed his transvestism to the group, the members’ natural inclination was to explore the secret vertically. They asked about details of his crossdressing: “How old were you when you started?” “Whose underclothes did you begin to wear?” “What sexual fantasies do you have when you cross-dress?” “How do you publicly pass as a woman with that mustache?” But John had already disclosed a great deal vertically about his secret, and it was more important for him now to reveal horizontally:
that is, disclosure about the disclosure (metadisclosure)—especially about the interactional aspects of disclosure.
²⁰

Accordingly, when John first divulged his transvestism in the group I asked such questions as: “John, you’ve been coming to the group for approximately twelve meetings and not been able to share this with us. I wonder what it’s been like for you to come each week and remain silent about your secret?” “How uncomfortable have you been about the prospect of sharing this with us?” “It hasn’t felt safe for you to share this before now. Today you chose to do so. What’s happened in the group or in your feelings toward the group today that’s allowed you to do this?” “What were your fears in the past about revealing this to us? What did you think would happen? Whom did you feel would respond in which ways?”

John responded that he feared he would be ridiculed or laughed at or thought weird. In keeping with the here-and-now inquiry, I guided him deeper into the interpersonal process by inquiring, “
Who
in the group would ridicule you?” “
Who
would think you were weird?” And then, after John selected certain members, I invited him to check out those assumptions with them. By welcoming the belated disclosure, rather than criticizing the delay, the therapist supports the client and strengthens the therapeutic collaboration. As a general rule, it is always helpful to move from general statements about the “group” to more personal statements: in other words, ask members to differentiate between the members of the group.

Self-disclosure is always an interpersonal act. What is important is not that one discloses oneself but that one discloses something important in the context of a relationship to others. The act of self-disclosure takes on real importance because of its implications for the nature of ongoing relationships; even more important than the actual unburdening of oneself is the fact that disclosure results in a deeper, richer, and more complex relationship with others. (This is the reason why I do not, in contrast to other researchers,† consider self-disclosure as a separate therapeutic factor but instead subsume it under interpersonal learning.)

The disclosure of sexual abuse or incest is particularly charged in this way. Often victims of such abuse have been traumatized not only by the abuse itself but also by the way others have responded in the past to their disclosure of the abuse. Not uncommonly the initial disclosure within the victim’s family is met with denial, blame, and rejection. As a result, the thought of disclosing oneself in the therapy group evokes fear of further mistreatment and even retraumatization rather than hope of working through the abuse.
²¹

If undue pressure is placed on a member to disclose, I will, depending on the problems of the particular client and his or her stage of therapy, respond in one of several ways. For example, I may relieve the pressure by commenting: “There are obviously some things that John doesn’t yet feel like sharing. The group seems eager, even impatient, to bring John aboard, while John doesn’t yet feel safe or comfortable enough.” (The word “yet” is important, since it conveys the appropriate expectational set.) I might proceed by suggesting that we examine the unsafe aspects of the group, not only from John’s perspective but from other members’ perspectives as well. Thus I shift the emphasis of the group from wringing out disclosures to exploring the obstacles to disclosure. What generates the fear? What are the anticipated dreaded consequences? From whom in the group do members anticipate disapprobation?

No one should ever be punished for self-disclosure
. One of the most destructive events that can occur in a group is for members to use personal, sensitive material, which has been trustingly disclosed in the group, against one another in times of conflict. The therapist should intervene vigorously if this occurs; not only is it dirty fighting, but it undermines important group norms. This vigorous intervention can take many forms. In one way or another, the therapist must call attention to the violation of trust. Often I will simply stop the action, interrupt the conflict, and point out that something very important has just happened in the group. I ask the offended member for his or her feelings about the incident, ask others for theirs, wonder whether others have had similar experiences, point out how this will make it difficult for others to reveal themselves, and so on. Any other work in the group is temporarily postponed. The important point is that the incident be underscored to reinforce the norm that self-disclosure is not only important but safe. Only after the norm has been established should we turn to examine other aspects of the incident.

Procedural Norms

The optimal procedural format in therapy is that the group be unstructured, spontaneous, and freely interacting.
But such a format never evolves naturally: much active culture shaping is required on the part of the therapist
. There are many trends the therapist must counter. The natural tendency of a new group is to devote an entire meeting to each of the members in rotation. Often the first person to speak or the one who presents the most pressing life crisis that week obtains the group floor for the meeting. Some groups have enormous difficulty changing the focus from one member to another, because a procedural norm has somehow evolved whereby a change of topic is considered bad form, rude, or rejecting. Members may lapse into silence: they feel they dare not interrupt and ask for time for themselves, yet they refuse to keep the other member supplied with questions because they hope, silently, that he or she will soon stop talking.

These patterns hamper the development of a potent group and ultimately result in group frustration and discouragement. I prefer to deal with these antitherapeutic norms by calling attention to them and indicating that since the group has constructed them, it has the power to change them.

For example, I might say, “I’ve been noticing that over the past few sessions the entire meeting has been devoted to only one person, often the first one who speaks that day, and also that others seem unwilling to interrupt and are, I believe, sitting silently on many important feelings. I wonder how this practice ever got started and whether or not we want to change it.” A comment of this nature may be liberating to the group. The therapist has not only given voice to something that everyone knows to be true but has also raised the possibility of other procedural options.

Some groups evolve a formal “check-in” format in which each member in turn gets the floor to discuss important events of the previous week or certain moments of great distress. Sometimes, especially with groups of highly dysfunctional, anxious members, such an initial structure is necessary and facilitating but, in my experience, such a formal structure in most groups generally encourages an inefficient, taking-turns, noninteractive, “then-and-there” meeting. I prefer a format in which troubled members may simply announce at the beginning, “I want some time today,” and the members and the therapist attempt, during the natural evolution of the session, to turn to each of those members.

Specialized groups, especially those with brief life spans and more deeply troubled members, often require different procedural norms. Compromises must be made for the sake of efficient time management, and the leader must build in an explicit structure. I will discuss such modifications of technique in chapter 15 but for now wish only to emphasize the general principle that the leader must attempt to structure a group in such a way as to build in the therapeutic norms I discuss in this chapter: support and confrontation, self-disclosure, self-monitoring, interaction, spontaneity, the importance of the group members as the agents of help.

The Importance of the Group to Its Members

The more important the members consider the group, the more effective it becomes. I believe that the ideal therapeutic condition is present when clients consider their therapy group meeting to be the most important event in their lives each week. The therapist is well advised to reinforce this belief in any available manner. If I am forced to miss a meeting, I inform the members well in advance and convey to them my concern about my absence. I arrive punctually for meetings. If I have been thinking about the group between sessions, I may share some of these thoughts with the members. Any self-disclosures I make are made in the service of the group. Though some therapists eschew such personal disclosure, I believe that it is important to articulate how much the group matters to you.

I reinforce members when they give testimony of the group’s usefulness or when they indicate that they have been thinking about other members during the week. If a member expresses regret that the group will not meet for two weeks over the Christmas holidays, I urge them to express their feelings about their connection to the group. What does it mean to them to cherish the group? To protest its disruption? To have a place in which to describe their concerns openly rather than submerge their longings?

The more continuity between meetings, the better. A well-functioning group continues to work through issues from one meeting to the next. The therapist does well to encourage continuity. More than anyone else, the therapist is the group historian, connecting events and fitting experiences into the temporal matrix of the group. “That sounds very much like what John was working on two weeks ago,” or, “Ruthellen, I’ve noticed that ever since you and Debbie had that run-in three weeks ago, you have become more depressed and withdrawn. What are your feelings now toward Debbie?”

I rarely start a group meeting, but when I do, it is invariably in the service of providing continuity between meetings. Thus, when it seems appropriate, I might begin a meeting: “The last meeting was very intense! I wonder what types of feelings you took home from the group and what those feelings are now?”

In chapter 14, I will describe the group summary, a technique that serves to increase the sense of continuity between meetings. I write a detailed summary of the group meeting each week (an editorialized narrative description of content and process) and mail it to the members between sessions. One of the many important functions of the summary is that it offers the client another weekly contact with the group and increases the likelihood that the themes of a particular meeting will be continued in the following one.

The group increases in importance when members come to recognize it as a rich reservoir of information and support. When members express curiosity about themselves, I, in one way or another, attempt to convey the belief that
any information members might desire about themselves is available in the group room, provided they learn how to tap it.
Thus, when Ken wonders whether he is too dominant and threatening to others, my reflex is to reply, in effect, “Ken, there are many people who know you very well in this room. Why not ask them?”

Events that strengthen bonds between members enhance the potency of the group. It bodes well when group members go out for coffee after a meeting, hold long discussions in the parking lot, or phone one another during the week in times of crisis. (Such extragroup contact is not without potential adverse effects, as I shall discuss in detail in chapter 11.)

Members as Agents of Help

The group functions best if its members appreciate the valuable help they can provide one another. If the group continues to regard the therapist as the sole source of aid, then it is most unlikely that the group will achieve an optimal level of autonomy and self-respect. To reinforce this norm, the therapist may call attention to incidents demonstrating the mutual helpfulness of members. The therapist may also teach members more effective methods of assisting one another. For example, after a client has been working with the group on some issue for a long portion of a meeting, the therapist may comment, “Reid, could you think back over the last forty-five minutes? Which comments have been the most helpful to you and which the least?” Or, “Victor, I can see you’ve been wanting to talk about that for a long time in the group and until today you’ve been unable to. Somehow Eve helped you to open up. What did she do? And what did Ben do today that seemed to close you down rather than open you up?” Behavior undermining the norm of mutual helpfulness should not be permitted to go unnoticed. If, for example, one member challenges another concerning his treatment of a third member, stating, “Fred, what right do you have to talk to Peter about that? You’re a hell of a lot worse off than he is in that regard,” I might intervene by commenting, “Phil, I think you’ve got some negative feelings about Fred today, perhaps coming from another source. Maybe we should get into them. I can’t, however, agree with you when you say that because Fred is similar to Peter, he can’t be helpful. In fact, quite the contrary has been true here in the group.”

Support and Confrontation

As I emphasized in my discussion of cohesiveness, it is essential that the members perceive their therapy group as safe and supportive. Ultimately, in the course of therapy, many uncomfortable issues must be broached and explored. Many clients have problems with rage or are arrogant or condescending or insensitive or just plain cantankerous. The therapy group cannot offer help without such traits emerging during the members’ interactions. In fact, their emergence is to be welcomed as a therapeutic opportunity. Ultimately, conflict must occur in the therapy group, and, as I will discuss in chapter 12, it is essential for the work of therapy. At the same time, however, too much conflict early in the course of a group can cripple its development. Before members feel free enough to express disagreement, they must feel safe enough and must value the group highly enough to be willing to tolerate uncomfortable meetings.