The Theory and Practice of Group Psychotherapy (48 page)

However, one-third of the dropouts in my study deviated significantly from the rest of the group
in areas crucial to their group participation,
and this deviancy and its repercussions were considered the primary reason for their premature termination. The clients’ behavior in the group varied from those who were silent to those who were loud, angry group disrupters, but all were isolates and were perceived by the therapists and by the other members as retarding the progress of the group.

The group and the therapists said of all these members that they “just didn’t fit in.” Indeed, often the deviants said that of themselves. This distinction is difficult to translate into objectively measurable factors. The most commonly described characteristics are lack of psychological-mindedness and lack of interpersonal sensitivity. These clients were often of lower socioeconomic status and educational level than the rest of the group. The therapists, when describing the deviants’ group behavior, emphasized that they slowed the group down. They functioned on a different level of communication from that of the rest of the group. They remained at the symptom-describing, advice-giving and -seeking, or judgmental level and avoided discussion of immediate feelings and here-and-now interaction. Similar results are reported by others.
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An important subcategory of dropouts had chronic mental illness and were making a marginal adjustment. They had sealed over and utilized much denial and suppression and were obviously different from other group members in their dress, mannerisms, and comments. Given the negative psychological impact of high expressed emotionality on clients with chronic mental illness such as schizophrenia, an intensive interactional group therapy would be contraindicated in their treatment. Structured, supportive, and psychoeducational groups are more effective.†

Two clients in the study who did
not
drop out differed vastly from the other members in their life experience. One had a history of prostitution, the other had prior problems with drug addiction and dealing. However, these clients did not differ from the others in ways that impeded the group’s progress (psychological insight, interpersonal sensitivity, and effective communication) and never became group deviants.

Group Deviancy: Empirical Research.
Considerable social-psychological data from laboratory group research
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helps us understand the fate of the deviant in the therapy group. Group members who are unable to participate in the group task and who impede group progress toward the completion of the task are much less attracted to the group and are motivated to terminate membership.
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Individuals whose contributions fail to match high group standards for interaction have a high dropout rate, and the tendency to drop out is particularly marked among individuals who have a lower level of self-esteem.
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The task of group therapy is to engage in meaningful communication with the other group members, to reveal oneself, to give valid feedback, and to examine the hidden and unconscious aspects of one’s feelings, behavior, and motivation. Individuals who fail at this task often lack the required amount of psychological-mindedness, are less introspective, less inquisitive, and more likely to use self-deceptive defense mechanisms. They also may be reluctant to accept the role of client and the accompanying implication that some personal change is necessary.

Research has shown that the individuals who are most satisfied with themselves and who are inclined to overestimate others’ opinions of them tend to profit less from the group experience.
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One study demonstrated that group members who did not highly value or desire personal changes were likely to terminate the group prematurely.
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Questionnaire studies demonstrate that therapy group members who cannot accurately perceive how others view them are more likely to remain peripheral members.
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What happens to individuals who are unable to engage in the basic group task and are perceived by the group and, at some level of awareness, by themselves as impeding the group? Schachter has demonstrated that communication toward a deviant is high initially and then drops off sharply as the group rejects the deviant member.
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Much research has demonstrated that a member’s satisfaction with the group depends on his or her position in the group communication network
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and the degree to which that member is considered valuable by the other members of the group.
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It also has been demonstrated that the ability of the group to influence an individual depends partly on the attractiveness of the group for that member and partly on the degree to which the member communicates with the others in the group.
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An individual’s status in a group is conferred by the group, not seized by the individual. Lower status diminishes personal well-being and has a negative impact on one’s emotional experience in social groups.
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This is an important finding, and we will return to it: Lower group status
diminishes
personal well-being; in other words, it is antitherapeutic.

It is also well known from the work of Sherif
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and Asch
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that an individual will often be made exceedingly uncomfortable by a deviant group role, and there is evidence that such individuals will manifest progressively more anxiety and unease if unable to speak about their position.
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Lieberman, Yalom, and Miles demonstrated that deviant group members (members considered “out of the group” by the other members or who grossly misperceived the group norms)
had virtually no chance of benefiting from the group and an increased likelihood of suffering negative consequences
.
⁴⁶

To summarize,
experimental evidence suggests that the group deviant, compared with other group members, derives less satisfaction from the group, experiences anxiety, is less valued by the group, is less likely to be influenced by or to benefit from the group, is more likely to be harmed by the group, and is far more likely to terminate membership.

These experimental findings coincide with the experience of deviants in the therapy groups I studied. Of the eleven deviants, one did not terminate prematurely—a middle-aged, isolated, rigidly defended man. This man managed to continue in the group because of the massive support he received in concurrent individual therapy. However, he not only remained an isolate in the group but, in the opinion of the therapists and the other members, he impeded the progress of the group. What happened in that group was remarkably similar to the phenomena in Schachter’s laboratory groups described above.
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At first, considerable group energy was expended on the deviant; eventually the group gave up, and the deviant was, to a great extent, excluded from the communicational network. But the group could never entirely forget the deviant, who slowed the pace of the work. If there is something important going on in the group that cannot be talked about, there will always be a degree of generalized communicative inhibition. With a disenfranchised member, the group is never really free; in a sense, it cannot move much faster than its slowest member.

Now, let’s apply these research findings and clinical observations to the selection process. The clients who will assume a deviant role in therapy groups are not difficult to identify in screening interviews. Their denial, their de-emphasis of intrapsychic and interpersonal factors, their unwillingness to be influenced by interpersonal interaction, and their tendency to attribute dysphoria to somatic and external environmental factors will be evident in a carefully conducted interview. Some of these individuals stand out by virtue of significantly greater impairment in function. They are often referred to group therapy by their individual therapists, who feel discouraged or frustrated by the lack of progress. Occasionally, postponing entry into group therapy to provide more time for some clients to benefit from pharmacotherapy and to consolidate some stability make may group therapy possible at a later time, but in conjunction with individual treatment and management, not in place of it.

Thus, it is not difficult to identify these clients
. Clinicians often err in assuming that even if certain clients will not click with the rest of the group, they will nevertheless benefit from the overall group support and the opportunity to improve their socializing techniques. In my experience, this expectation is not realized. The referral is a poor one, with neither the client nor the group profiting. Eventually the group will extrude the deviant. Therapists also tend to divest overtly and covertly from such clients, putting their therapautic energies into those clients who reward the effort.
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Rigid attitudes coupled with proselytizing desires may rapidly propel an individual into a deviant position. A very difficult client to work with in long-term groups is the individual who employs fundamentalist religious views in the service of denial. The defenses of this client are often impervious to ordinarily potent group pressures because they are bolstered by the norms of another anchor group—the particular religious sect. To tell the client that he or she is applying certain basic tenets with unrealistic literalness is often ineffective, and a frontal assault on these defenses merely rigidifies them.

To summarize,
it is important that the therapist screen out clients who are likely to become marked deviants in the group for which they are being considered.
Clients become deviants because of their interpersonal behavior in the group sessions, not because of a deviant lifestyle or history. There is no type of past behavior too deviant for a group to accept once therapeutic group norms have been established. I have seen individuals who have been involved with prostitution, exhibitionism, incest, voyeurism, kleptomania, infanticide, robbery, and drug dealing accepted by middle-class straight groups.

Problems of Intimacy.
Several clients dropped out of group therapy because of conflicts associated with intimacy, manifested in various ways: (1) schizoid withdrawal, (2) maladaptive self-disclosure (promiscuous self-disclosures or pervasive dread of self-disclosure), and (3) unrealistic demands for instant intimacy.
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Several clients who were diagnosed as having schizoid personality disorder (reflecting their social withdrawal, interpersonal coldness, aloofness, introversion, and tendency toward autistic preoccupation) experienced considerable difficulty relating and communicating in the group. Each had begun the group with a resolution to express feelings and to correct previous maladaptive patterns of relating. They failed to accomplish this aim and experienced frustration and anxiety, which in turn further blocked their efforts to speak. Their therapists described their group role as “isolate,” “silent member,” “peripheral,” and “nonrevealer.”

Most of these group members terminated treatment thoroughly discouraged about the possibility of ever obtaining help from group therapy. Early in the course of a new group, I have occasionally seen such clients leave the group having benefited much from therapeutic factors such as universality, identification, altruism, and development of socializing techniques. If they remain in the group, however, the group members, in time, often grow impatient with the schizoid member’s silence and weary of drawing them out (“playing twenty questions,” as one group put it) and turn against them.

Another intimacy-conflicted client dropped out for different reasons: his fears of his own aggression against other group members. He originally applied for treatment because of a feeling of wanting to explode: “a fear of killing someone when I explode . . . which results in my staying far away from people.” He participated intellectually in the first four meetings he attended, but was frightened by the other members’ expression of emotion. When a group member monopolized the entire fifth meeting with a repetitive, tangential discourse, he was enraged with the monopolizer and with the rest of the group members for their complacency in allowing this to happen and, with no warning, abruptly terminated therapy.

Other clients experienced a constant, pervasive dread of self-disclosure, which precluded participation in the group and ultimately resulted in their dropping out. Still others engaged in premature, promiscuous self-disclosure and abruptly terminated. Some clients made such inordinate demands on their fellow group members for immediate, prefabricated intimacy that they created a nonviable group role for themselves. One early dropout unsettled the group in her first meeting by announcing to the group that she gossiped compulsively and doubted that she would be able to maintain people’s confidentiality.

Clients with severe problems in the area of intimacy present a particular challenge to the group therapist both in selection and in therapeutic management (to be considered in chapter 13). The irony is that these individuals are the very ones for whom a successful group experience could be particularly rewarding. A study of experiential groups found that individuals with constricted emotionality, who are threatened by the expression of feelings by others, and have difficulty experiencing and expressing their own emotional reactions learn more and change more than others as a result of their group experience, even though they are significantly more uncomfortable in the group.
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Therefore, these clients, whose life histories are characterized by ungratifying interpersonal relationships, stand to profit much from successfully negotiating an intimate group experience. Yet, if their interpersonal history has been too deprived, they will find the group too threatening and will drop out of therapy more demoralized than before.
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Clients who crave social connectedness but are hampered by poor interpersonal skills are particularly prone to psychological distress.
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These individuals are frustrated and distressed being in a group bursting with opportunities for connectedness that they cannot access for themselves.
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