The Theory and Practice of Group Psychotherapy (81 page)

Most characterologically difficult clients have in common problems in regulation of affect, in interpersonal engagement, and in sense of self. Their pathology is thought to be based on serious problems in the first few years of life. They lack internal soothing or comforting parental representations, and instead their internal world is peopled by abandoning, withholding, and disappointing parental representations. They often lack the ability to integrate ambivalent feelings and interpersonal reactions, splitting the world into black and white, good and bad, loving and hating, idealizing and devaluing. At any moment they have little recall of feelings other than the powerful ones felt at that moment. Prominent difficulties include rage, vulnerability to abandonment and to narcissistic injury, and a tendency toward projective identification. Such clients also often lack a sense of their role in their difficulties or of their impact on others.
³¹

Because these difficulties generally manifest in troubled and troubling interpersonal relationships, group therapy has a prominent role in both ambulatory and partial hospitalization settings. Group therapy is promising but challenging with these clients, but the psychological and health care cost-benefit ratios are very encouraging, particularly when adequate time in treatment is provided.
³²

Often the characterologically difficult client has experienced traumatic abuse early in life as well, which further amplifies the challenge in treatment. In some samples the comorbidity of posttraumatic stress disorder (PTSD) and borderline personality disorder exceeds 50 percent. When the traumatic experiences and consequent symptoms—chiefly intrusive reexperiencing of the trauma, avoidance of any reminder of the trauma, and general hyperarousal—have a profound combined impact on the individual, the term “complex PTSD” is often applied. This term captures the way in which the traumatic events and psychological reactions to these events shape the individual’s personality.
³³

Characterologically difficult clients are prevalent in most clinical settings. They are often referred to groups by an individual therapist when (1) the transference has grown too intense for dyadic therapy; (2) the client has become so defensively isolated that group interaction is required to engage the client; (3) therapy has proceeded well but a plateau has been reached and interactive experience is necessary to produce further gains.

The Schizoid Client

Many years ago, in a previous edition of this book, I began this section with the following sentence: “The schizoid condition, the malady of our times, perhaps accounts for more patients entering therapy than does any other psychopathological configuration.” This no longer rings true. The fashions of mental illness change: Today, clients more commonly enter treatment because of substance abuse, eating disorders, and sequelae of sexual and physical abuse. Even though the schizoid condition is no longer the malady of our times, schizoid individuals are still common visitors to therapy groups. They are emotionally blocked, isolated, and distant and often seek group therapy out of a vague sense that something is missing: they cannot feel, cannot love, cannot play, cannot cry. They are spectators of themselves; they do not inhabit their own bodies; they do not experience their own experience. Superficially, the schizoid client and the avoidant client resemble each other. There are, however, clear differences. The avoidant individual is anxiously inhibited, self-aware, and able to engage when sufficiently reassured that rejection will not ensue. In contrast, the schizoid client suffers a deficit in key emotional and reflective capacities.
³⁴

No one has described the experiential world of the schizoid individual more vividly than Sartre in
The Age of Reason
:

He closed the paper and began to read the special correspondent’s dispatch on the front page. Fifty dead and three hundred wounded had already been counted, but that was not the total, there were certainly corpses under the debris. There were thousands of men in France who had not been able to read their paper that morning without feeling a clot of anger rise in their throat, thousands of men who had clenched their fists and muttered: “Swine!” Mathieu clenched his fists and muttered: “Swine!” and felt himself still more guilty. If at least he had been able to discover in himself a trifling emotion that was veritably if modestly alive, conscious of its limits. But no: he was empty, he was confronted by a vast anger, a desperate anger, he saw it and could almost have touched it. But it was inert—if it were to live and find expression and suffer, he must lend it his own body. It was other people’s anger. Swine! He clenched his fists, he strode along, but nothing came, the anger remained external to himself. Something was on the threshold of existence, a timorous dawn of anger. At last! But it dwindled and collapsed, he was left in solitude, walking with the measured and decorous gait of a man in a funeral procession in Paris. He wiped his forehead with his handkerchief and he thought: One can’t force one’s deeper feelings. Yonder was a terrible and tragic state of affairs that ought to arouse one’s deepest emotions. It’s no use, the moment will not come.
³⁵

Schizoid individuals are often in a similar predicament in the therapy group. In virtually every group meeting, they have confirmatory evidence that the nature and intensity of their emotional experience differs considerably from that of the other members. Puzzled at this discrepancy, they may conclude that the other members are melodramatic, excessively labile, phony, overly concerned with trivia, or simply of a different temperament. Eventually, however, schizoid clients, like Sartre’s protagonist, Mathieu, begin to wonder about themselves, and begin to suspect that somewhere inside themselves is a vast frozen lake of feeling.

In one way or another, by what they say or do not say, schizoid clients convey this emotional isolation to the other members. In chapter 2, I described a male client who could not understand the members’ concern about the therapist’s leaving the group or a member’s obsessive fears about her boyfriend being killed. He saw people as interchangeable. He had his need for a minimum daily requirement of affection (without, it seemed, proper concern about the source of the affection). He was “bugged” by the departure of the therapist only because it would slow down his therapy, but he did not share the feeling expressed by the others: grief at the loss of the person who is the therapist. In his defense, he maintained, “There’s not much sense in having any strong feelings about the therapist leaving, since there’s nothing I can do about it.”

Another member, chided by the group because of his lack of empathy toward two highly distressed members, responded, “So, they’re hurting. There are millions of people hurting all over the world at this instant. If I let myself feel bad for everyone who is hurting, it would be a full-time occupation.” Most of us get a rush of feelings and then we sometimes try to comprehend the meaning of the feelings. In schizoid clients, feelings come later—they are awarded priority according to the dictates of rationality. Feeling must be justified pragmatically: if they serve no purpose, why have them?

The group is often keenly aware of discrepancies among a member’s words, experience, and emotional response. One member, who had been criticized for withholding information from the group about his relationship with a girlfriend, frostily asked, “Would you like to bring your camera and climb into bed with us?” When questioned, however, he denied feeling any anger and could not account for the tone of sarcasm.

At other times, the group reads the schizoid member’s emotions from postural or behavioral cues. Indeed, such individuals may relate to themselves in a similar way and join in the investigation, commenting, for example, “My heart is beating fast, so I must be frightened,” or “My fist is clenched, so I must be mad.” In this regard they share a common difficulty with the alexithymic clients described earlier.

The response of the other members is predictable; it proceeds from curiosity and puzzlement through disbelief, solicitude, irritation, and frustration. They will repeatedly inquire, “What do you feel about . . . ?” and only much later come to realize that they were demanding that this member quickly learn to speak a foreign language. At first, members become very active in helping to resolve what appears to be a minor affliction, telling schizoid clients what to feel and what
they
would feel if they were in that situation. Eventually, the group members grow weary; frustration sets in; and then they redouble their efforts—almost always with no noticeable results. They try harder yet, in an attempt to force an affective response by increasing the intensity of the stimulus. Ultimately, they resort to a sledgehammer approach.

The therapist must avoid joining in the quest for a breakthrough. I have never seen a schizoid client significantly change by virtue of a dramatic incident; change is a prosaic process of grinding labor, repetitive small steps, and almost imperceptible progress. It is tempting and often useful to employ some activating, nonverbal, or gestalt techniques to hasten a client’s movement. These approaches may speed up the client’s recognition and expression of nascent or repressed feelings, but keep in mind that if you do excessive, one-to-one directive work, the group may become less potent, less autonomous, and more dependent and leader centered. (I will discuss these issues at length in chapter 14.) Furthermore, schizoid clients not only need new skills but, more important, they need a new internalized experience of the world of relationships—and that takes time, patience, and perseverance.

In chapter 6, I described several here-and-now activating techniques that are useful in work with the schizoid client. Work energetically in the here-and-now. Encourage the client to differentiate among members; despite protestations, the client does not feel
precisely
the same way toward everyone in the group. Help such members move into feelings they pass off as inconsequential. When the client admits, “Well, I may feel slightly irritated or slightly hurt,” suggest staying with these feelings; no one ever said it was necessary to discuss only big feelings. “Hold up a magnifying glass to the hurt,” you might suggest; “describe exactly what it is like.” Invite the client to imagine what others in the group are feeling. Try to cut off the client’s customary methods of dismissal: “Somehow, you’ve gotten away from something that seemed important. Can we go back to where we were five minutes ago? When you were talking to Julie, I thought you looked near tears. Something was going on inside.”†

Encourage the client to observe his or her body. Often the client may not experience affect but will be aware of the affective autonomic equivalents: tightness in the stomach, sweating, throat constriction, flushing, and so on. Gradually the group may help the client translate those feelings into their psychological meaning. The members may, for example, note the timing of the client’s reactions in conjunction with some event in the group.

Therapists must beware of assessing events solely according to their own experiential world. As I have discussed previously, clients may experience the same event in totally different ways: An event that is seemingly trivial to the therapist or to one member may be an exceedingly important experience to another member. A slight show of irritation by a restricted schizoid individual may be a major breakthrough for that person. It may be the first time in adulthood that he or she has expressed anger and may enable further testing out of new behavior, both in and out of the group.

In the group, these individuals are high risk and high reward. Those who can manage to persevere, to continue in the group and not be discouraged by the inability to change their relationship style quickly, are almost certain to profit considerably from the group therapy experience.

The Borderline Client

For decades, psychotherapists have known about a large cluster of individuals who are unusually difficult to treat and who fall between the major diagnostic criteria of severity of impairment: more disorganized than neurotic clients but more integrated than psychotic clients. A thin veneer of integration conceals a primitive personality structure. Under stress, these borderline clients are highly unstable; some develop psychoses that may resemble schizophrenic psychosis but are circumscribed, short-lived, and episodic.

DSM-IV-TR states that borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, affects, and control over impulses requiring at least five of these nine features: frantic efforts to avoid real or imagined abandonment; unstable and intense interpersonal relationships characterized by alternation between extremes of idealization and devaluation; identity disturbance—persistent and markedly disturbed, distorted, or unstable self-image or sense of self; impulsiveness in two self-damaging areas, such as substance abuse, spending, sex, binge eating, and reckless driving; recurrent suicidal threats or behavior, or self-mutilation; affective instability due to a marked reactivity of mood; chronic feelings of emptiness; inappropriate intense anger or lack of control of anger; transient, stress-related paranoid ideation or severe dissociative symptoms.
³⁶

In recent years, a great deal more clarity about clients with borderline personality disorder has emerged, thanks especially to the work of Otto Kernberg, who emphasized the overriding instability of the borderline client—instability of mood, thought, and interpersonal involvement.
³⁷
Yet the category still lacks precision, has unsatisfactory reliability,
³⁸
and often serves as a catchall for a personality disorder that clinicians cannot otherwise diagnose. It will, in all likelihood, undergo further transformation in future classificatory systems.