The Theory and Practice of Group Psychotherapy (84 page)

The major task for the group therapist working with all of these problematic clients is neither precise diagnosis nor a formulation of early causative dynamics. Whether the diagnosis is schizoid, borderline, or narcissistic personality disorder, the primary issue is the same: the therapeutic management of the highly vulnerable individual in the therapy group.

Chapter 14

THE THERAPIST: SPECIALIZED FORMATS AND PROCEDURAL AIDS

T
he standard group therapy format in which one therapist meets with six to eight members is often complicated by other factors: the client may concurrently be in individual therapy; there may be a co-therapist in the group; the client may be involved in a twelve-step group; occasionally the group may meet without the therapist. I shall discuss these variations in this chapter and describe, in addition, some specialized techniques and approaches that, although not essential, may at times facilitate the course of therapy.

CONCURRENT INDIVIDUAL AND GROUP THERAPY

First, some definitions.
Conjoint therapy
refers to a treatment format in which the client is seen by one therapist in individual therapy and a different therapist (or two, if co-therapists) in group therapy. In
combined therapy
, the client is treated by the
same
therapist simultaneously in individual and group therapy. No systematic data exists about the comparative effectiveness of these variations. Consequently, guidelines and principles must be formulated from clinical judgment and from reasoning based on the posited therapeutic factors.

Whenever we integrate two treatment modalities, we must first consider their compatibility. More is not always better! Are the different treatments working at cross-purposes, or do they enhance one another? If compatible, are they complementary, working together by addressing different aspects of the client’s therapy needs, or are they facilitative, each supporting and enhancing the work of the other?
¹

The relative frequencies of the two types of concurrent therapy are unknown, although it is likely that in private practice
combined
therapy is more commonly employed than
conjoint
therapy.
²
The opposite appears to be true in institutional and mental health treatment settings.
³
By no means should one consider conjoint and combined therapy equivalent. They have exceedingly different features and clinical indications, and I shall discuss them separately.

Conjoint Therapy

I believe that, with some exceptions, conjoint individual therapy is not
essential
to the practice of group therapy. If members are selected with a moderate degree of care, a therapy group meeting once or (preferably) twice a week is ample therapy and should benefit the great majority of clients. But there are exceptions. The characterologically difficult client, as I discussed in chapter 13, frequently needs to be in concurrent therapy—either combined or conjoint. In fact, the earliest models of concurrent group and individual therapy developed in response to the needs of these challenging clients.
⁴
Clients with a history of childhood sexual abuse or for whom issues around shame are significant also often require concurrent therapy.
⁵

Not infrequently, group members may go through a severe life crisis (for example, bereavement or a divorce) that requires temporary individual therapy support. Some clients are so fragile or blocked by anxiety or fearful of aggression that individual therapy is required to enable them to participate in the group. From time to time, individual therapy is required to prevent a client from dropping out of the group or to monitor more closely a suicidal or impulsive client.

• Joan, a young woman with borderline personality disorder participating in her first group, was considerably threatened by the first few meetings. She had felt increasingly alienated because her bizarre fantasy and dream world seemed so far from the experience of the other members. In the fourth meeting, she verbally attacked one of the members and was, in turn, attacked. For several nights thereafter, she had terrifying nightmares. In one, her mouth turned to blood, which appeared related to her fear of being verbally aggressive because of her world-destructive fantasies. In another, she was walking along the beach when a huge wave engulfed her—this related to her fear of losing her boundaries and identity in the group. In a third dream, Joan was held down by several men who guided the therapist’s hands as he performed an operation on her brain—obviously related to her fears of therapy and of the therapist being overpowered by the male members.

Her hold on reality grew more tenuous, and it seemed unlikely that she could continue in the group without added support. Concurrent individual therapy with another therapist was arranged; it helped her to contain her anxiety and enabled her to remain in the group.

• Jim was referred to a group by his psychoanalyst, who had treated him for six years and was now terminating analysis.
⁶
Despite considerable improvement, Jim still had not mastered the symptom for which he had originally sought treatment: fear of women. He found it difficult even to dictate to his secretary. In one of his first group meetings, he was made extremely uncomfortable by a woman in the group who complimented him. He stared at the floor for the rest of the session, and afterward called his analyst to say that he wanted to drop out of the group and reenter analysis. His analyst discussed the situation with the group therapist and agreed to resume individual treatment on the condition the client return to the group as well. For the next few months, they had an individual hour after each group session. The two therapists had frequent consultations, and the group therapist was able to modulate the noxious stimuli in the group sufficiently to allow the client to continue in therapy. Within a few months, he was able to reach out emotionally to women for the first time, and he gradually grew more at ease with women in the real world.

Thus far, we have considered how individual therapy may facilitate the client’s course in group therapy. The reverse is also true: group therapy may be used to augment or facilitate the course of individual therapy.†
⁷
In fact, the majority of clients in conjoint therapy enter the group through referral by their individual therapist. The individual therapist might find a client exceptionally restricted and arid and unable to produce the material necessary for productive work. Often the rich, affective interpersonal interaction of the group is marvelously evocative and generates ample data for both individual and group work. At other times, clients have major blind spots that prevent them from reporting accurately or objectively what actually transpires in their life.

One older man was referred to group therapy by his individual therapist because the individual therapy was at an impasse due to an intense paternal transference. The male therapist could say nothing to this client without its being challenged and obsessively picked apart for its inaccuracy or incompleteness. Although both client and therapist were aware of the reenactment in the therapy of the relationship between oppressed son and bullying father, no real progress was made until the client entered the more democratic, leveled group environment and was able to hear feedback that was disentangled from paternal authority.

Other clients are referred to a therapy group because they have improved in the safe setting of the one-to-one therapy hour, yet are unable to transfer the learning to outside life. The group setting may serve as a valuable way station for the next stage of therapy: experimentation with behavior in a low-risk environment, which may effectively disconfirm the client’s fantasies of the calamitous consequences of new behavior.

Sometimes in the individual therapy of characterologically difficult clients, severe, irreconcilable problems in the transference arise, and the therapy group may be particularly helpful in diluting transference and facilitating reality testing (see chapter 13). The individual therapist may also benefit from a deintensification of the countertransference. The group and the individual therapist may function effectively as peer consultants and supports in the treatment of particularly taxing clients who use splitting and projective identification in ways that may be quite overwhelming to the therapist. In essence, conjoint therapy capitalizes on the presence in treatment of multiple settings, multiple transferences, multiple observers, multiple interpreters, and multiple maturational agents.
⁸

Complications.
Along with these advantages of conjoint therapy come a number of complications. When there is a marked difference in the basic approach of the individual therapist and the group therapist, the two therapies may work at cross-purposes.

If, for example, the individual approach is oriented toward understanding genetic causality and delves deeply into past experiences while the group focuses primarily on here-and-now material, the client is likely to become confused and to judge one approach on the basis of the other. An overarching sense of a synthesis of the group and individual work is necessary for success.

Not infrequently, clients beginning group therapy are discouraged and frustrated by the initial group meetings that offer less support and attention than their individual therapy hours. Sometimes such clients, when attacked or stressed by the group, may defend themselves by unfavorably comparing their group to their individual therapy experience. Such an attack on the group invariably results in further deterioration of the situation. It is not uncommon, however, for clients later in therapy to appreciate the unique offerings of the group and to reverse their comparative evaluations of the two modes.

Another complication of conjoint therapy arises when clients use individual therapy to drain off affect from the group. The client may interact like a sponge in the group, taking in feedback and carrying it away to gnaw on like a bone in the safe respite of the individual therapy hour. Clients may resist working in the group through the pseudo-altruistic rationalization, “I will allow the others to have the group time since I have my own hour.” Another form of resistance is to deal with important material in the opposite venue—to use the group to address the transference to the individual therapist and to use the individual therapy to address reactions to group members. When these patterns are particularly pronounced and resist all other interventions, the group therapist, in collaboration with the individual therapist, may insist that either the group or the individual therapy be terminated. I have known several clients whose involvement in the group dramatically accelerated when their concurrent individual therapy was stopped.

In my experience, the individual and the group therapeutic approaches complement each other particularly well if two conditions are met. First, there must be a good working collaboration between the individual and group therapists. They must have the client’s permission to share all information with each other. It is important that both therapists be equally committed to the idea of conjoint therapy and in agreement about the rationale for the referral to group therapy. A referral to a group for conjoint treatment should not be a cover for the sloughing of clinical responsibility because the individual therapist is paving the way to terminate the treatment.
⁹
Furthermore, it is essential that the therapists are mutually respectful—both of the competence and therapeutic approach of the other.

A solid relationship between the individual and group therapists may prove essential in addressing the inevitable tensions as clients compare their group and individual therapists, at times idealizing one and devaluing the other. This is a particularly uncomfortable issue for less experienced group therapists working conjointly with more senior individual therapists whose invisible glowering presence in the group may inhibit the group therapist and undermine confidence, stimulating the group therapist’s concern about how they are being portrayed by the client to the individual therapist.
¹⁰
These considerations are especially evident in the treatment of more difficult clients who employ defenses of splitting. It is exceedingly tough to be the vilified therapist in a conjoint treatment. The position of the idealized therapist may be easier to bear, but it is only somewhat less precarious and no less ineffective.

Thus, the first condition for an effective conjoint therapy experience is that the individual and group therapists have an open, solid, mutually respectful working relationship. The second condition is that the individual therapy must complement the group approach—it must be here-and-now oriented and must devote time to an exploration of the client’s feelings toward the group members and toward incidents and themes of current meetings. Such an exploration can serve as rehearsal for deeper involvement in the life of the group.

Individual therapists who are experienced in group methods may significantly help their client (and the rest of the group) by coaching the client on how to work in the group. I recently referred a young man I was seeing in individual therapy to a therapy group. He was characteristically suffused with rage, which he usually expressed in explosions toward his wife or as road rage (which had gotten him into several dangerous situations).

After a few weeks of group therapy, he reported in his individual hours that he had varying degrees of anger toward many of the group members. When I raised the question of his expressing this in the group, he paled: “No one ever confronts anyone directly in this group—that’s not the way this group works . . . I would feel awful . . . I’d devastate the others . . . I couldn’t face them again . . . I’d be drummed out of the group.” We rehearsed how he might confront his anger in the group. Sometimes I roleplayed how I might talk about it in the group if I were him. I gave him examples of how to give feedback that would be unlikely to evoke retaliation. For example, “I’ve a problem I haven’t been able to discuss here before. I got a lot of anger. I blow up to my wife and kids and have serious road rage. I’d like help with it here and I’m not sure how to work on it, I wonder if I could start to tackle it by talking about some flashes of anger I feel sometimes in the group meeting.” At this point, any group therapist I have ever known would purr with pleasure and encourage him to try.