The Theory and Practice of Group Psychotherapy (9 page)

The mistaken assumption that a strong emotional experience is in itself a sufficient force for change is seductive as well as venerable. Modern psychotherapy was conceived in that very error: the first description of dynamic psychotherapy (Freud and Breuer’s 1895
Studies on Hysteria
)
⁴⁰
described a method of cathartic treatment based on the conviction that hysteria is caused by a traumatic event to which the individual has never fully responded emotionally. Since illness was supposed to be caused by strangulated affect, treatment was directed toward giving a voice to the stillborn emotion. It was not long before Freud recognized the error: emotional expression, though necessary, is not a sufficient condition for change. Freud’s discarded ideas have refused to die and have been the seed for a continuous fringe of therapeutic ideologies. The Viennese fin-de-siècle cathartic treatment still lives today in the approaches of primal scream, bioenergetics, and the many group leaders who place an exaggerated emphasis on emotional catharsis.

My colleagues and I conducted an intensive investigation of the process and outcome of many of the encounter techniques popular in the 1970s (see chapter 16), and our findings provide much support for the dual emotional-intellectual components of the psychotherapeutic process.
⁴¹

We explored, in a number of ways, the relationship between each member’s experience in the group and his or her outcome. For example, we asked the members after the conclusion of the group to reflect on those aspects of the group experience they deemed most pertinent to their change. We also asked them during the course of the group, at the end of each meeting, to describe which event at that meeting had the most personal significance. When we correlated the type of event with outcome, we obtained surprising results that disconfirmed many of the contemporary stereotypes about the prime ingredients of the successful encounter group experience. Although emotional experiences (expression and experiencing of strong affect, self-disclosure, giving and receiving feedback) were considered extremely important, they did not distinguish successful from unsuccessful group members. In other words, the members who were unchanged or even had a destructive experience were as likely as successful members to value highly the emotional incidents of the group.

What types of experiences
did
differentiate the successful from the unsuccessful members? There was clear evidence that a
cognitive component
was essential; some type of cognitive map was needed, some intellectual system that framed the experience and made sense of the emotions evoked in the group. (See chapter 16 for a full discussion of this result.) That these findings occurred in groups led by leaders who did not attach much importance to the intellectual component speaks strongly for its being part of the foundation, not the facade, of the change process.
⁴²

THE GROUP AS SOCIAL MICROCOSM

A freely interactive group, with few structural restrictions, will, in time, develop into a social microcosm of the participant members. Given enough time, group members will begin to be themselves: they will interact with the group members as they interact with others in their social sphere, will create in the group the same interpersonal universe they have always inhabited. In other words, clients will, over time, automatically and inevitably begin to display their maladaptive interpersonal behavior in the therapy group. There is no need for them to describe or give a detailed history of their pathology:
they will sooner or later enact it before the other group members’ eyes
. Furthermore, their behavior serves as accurate data and lacks the unwitting but inevitable blind spots of self-report. Character pathology is often hard for the individual to report because it is so well assimilated into the fabric of the self and outside of conscious and explicit awareness. As a result, group therapy, with its emphasis on feedback, is a particularly effective treatment for individuals with character pathology.
⁴³

This concept is of paramount importance in group therapy and is a keystone of the entire approach to group therapy. Each member’s interpersonal style will eventually appear in his or her transactions in the group. Some styles result in interpersonal friction that will be manifest early in the course of the group. Individuals who are, for example, angry, vindictive, harshly judgmental, self-effacing, or grandly coquettish will generate considerable interpersonal static even in the first few meetings. Their maladaptive social patterns will quickly elicit the group’s attention. Others may require more time in therapy before their difficulties manifest themselves in the here-and-now of the group. This includes clients who may be equally or more severely troubled but whose interpersonal difficulties are more subtle, such as individuals who quietly exploit others, those who achieve intimacy to a point but then, becoming frightened, disengage themselves, or those who pseudo-engage, maintaining a subordinate, compliant position.

The initial business of a group usually consists of dealing with the members whose pathology is most interpersonally blatant. Some interpersonal styles become crystal-clear from a single transaction, some from a single group meeting, and others require many sessions of observation to understand. The development of the ability to identify and put to therapeutic advantage maladaptive interpersonal behavior as seen in the social microcosm of the small group is one of the chief tasks of a training program for group psychotherapists. Some clinical examples may make these principles more graphic.
^d

The Grand Dame

Valerie, a twenty-seven-year-old musician, sought therapy with me primarily because of severe marital discord of several years’ standing. She had had considerable, unrewarding individual and hypnotic uncovering therapy. Her husband, she reported, was an alcoholic who was reluctant to engage her socially, intellectually, or sexually. Now the group could have, as some groups do, investigated her marriage interminably. The members might have taken a complete history of the courtship, of the evolution of the discord, of her husband’s pathology, of her reasons for marrying him, of her role in the conflict. They might have followed up this collection of information with advice for changing the marital interaction or perhaps suggestions for a trial or permanent separation.

But all this historical, problem-solving activity would have been in vain: this entire line of inquiry not only disregards the unique potential of therapy groups but also is based on the highly questionable premise that a client’s account of a marriage is even reasonably accurate. Groups that function in this manner fail to help the protagonist and also suffer demoralization because of the ineffectiveness of a problem-solving, historical group therapy approach. Let us instead observe Valerie’s behavior as it unfolded in the here-and-now of the group.

Valerie’s group behavior was flamboyant. First, there was her grand entrance, always five or ten minutes late. Bedecked in fashionable but flashy garb, she would sweep in, sometimes throwing kisses, and immediately begin talking, oblivious to whether another member was in the middle of a sentence. Here was narcissism in the raw! Her worldview was so solipsistic that it did not take in the possibility that life could have been going on in the group before her arrival.

After very few meetings, Valerie began to give gifts: to an obese female member, a copy of a new diet book; to a woman with strabismus, the name of a good ophthalmologist; to an effeminate gay client, a subscription to
Field and Stream
magazine (intended, no doubt, to masculinize him); to a twenty-four-year-old virginal male, an introduction to a promiscuous divorced friend of hers. Gradually it became apparent that the gifts were not duty-free. For example, she pried into the relationship that developed between the young man and her divorced friend and insisted on serving as confidante and go-between, thus exerting considerable control over both individuals.

Her efforts to dominate soon colored all of her interactions in the group. I became a challenge to her, and she made various efforts to control me. By sheer chance, a few months previously I had seen her sister in consultation and referred her to a competent therapist, a clinical psychologist. In the group Valerie congratulated me for the brilliant tactic of sending her sister to a psychologist; I must have divined her deep-seated aversion to psychiatrists. Similarly, on another occasion, she responded to a comment from me, “How perceptive you were to have noticed my hands trembling.”

The trap was set! In fact, I had neither “divined” her sister’s alleged aversion to psychiatrists (I had simply referred her to the best therapist I knew) nor noted Valerie’s trembling hands. If I silently accepted her undeserved tribute, then I would enter into a dishonest collusion with Valerie; if, on the other hand, I admitted my insensitivity either to the trembling of the hands or to the sister’s aversion, then, by acknowledging my lack of perceptivity, I would have also been bested. She would control me either way! In such situations, the therapist has only one real option: to change the frame and to comment on the process—the nature and the meaning of the entrapment. (I will have a great deal more to say about relevant therapist technique in chapter 6.)

Valerie vied with me in many other ways. Intuitive and intellectually gifted, she became the group expert on dream and fantasy interpretation. On one occasion she saw me between group sessions to ask whether she could use my name to take a book out of the medical library. On one level the request was reasonable: the book (on music therapy) was related to her profession; furthermore, having no university affiliation, she was not permitted to use the library. However, in the context of the group process, the request was complex in that she was testing limits; granting her request would have signaled to the group that she had a special and unique relationship with me. I clarified these considerations to her and suggested further discussion in the next session. Following this perceived rebuttal, however, she called the three male members of the group at home and, after swearing them to secrecy, arranged to see them. She engaged in sexual relations with two; the third, a gay man, was not interested in her sexual advances but she launched a formidable seduction attempt nonetheless.

The following group meeting was horrific. Extraordinarily tense and unproductive, it demonstrated the axiom (to be discussed later) that if something important in the group is being actively avoided, then nothing else of import gets talked about either. Two days later Valerie, overcome with anxiety and guilt, asked for an individual session with me and made a full confession. It was agreed that the whole matter should be discussed in the next group meeting.

Valerie opened the next meeting with the words: “This is confession day! Go ahead, Charles!” and then later, “Your turn, Louis,” deftly manipulating the situation so that the confessed transgressions became the sole responsibilities of the men in question, and not herself. Each man performed as she bade him and, later in the meeting, received from her a critical evaluation of his sexual performance. A few weeks later, Valerie let her estranged husband know what had happened, and he sent threatening messages to all three men. That was the last straw! The members decided they could no longer trust her and, in the only such instance I have known, voted her out of the group. (She continued her therapy by joining another group.) The saga does not end here, but perhaps I have recounted enough to illustrate the concept of the group as social microcosm.

Let me summarize. The first step was that Valerie clearly displayed her interpersonal pathology in the group. Her narcissism, her need for adulation, her need to control, her sadistic relationship with men—the entire tragic behavioral scroll—unrolled in the here-and-now of therapy. The next step was reaction and feedback. The men expressed their deep humiliation and anger at having to “jump through a hoop” for her and at receiving “grades” for their sexual performance. They drew away from her. They began to reflect: “I don’t want a report card every time I have sex. It’s controlling, like sleeping with my mother! I’m beginning to understand more about your husband moving out!” and so on. The others in the group, the female members and the therapists, shared the men’s feelings about the wantonly destructive course of Valerie’s behavior—destructive for the group as well as for herself.

Most important of all, she had to deal with this fact: she had joined a group of troubled individuals who were eager to help each other and whom she grew to like and respect; yet, in the course of several weeks, she had so poisoned her own environment that, against her conscious wishes, she became a pariah, an outcast from a group that could have been very helpful to her. Facing and working through these issues in her subsequent therapy group enabled her to make substantial personal changes and to employ much of her considerable potential constructively in her later relationships and endeavors.

The Man Who Liked Robin Hood

Ron, a forty-eight-year-old attorney who was separated from his wife, entered therapy because of depression, anxiety, and intense feelings of loneliness. His relationships with both men and women were highly problematic. He yearned for a close male friend but had not had one since high school. His current relationships with men assumed one of two forms: either he and the other man related in a highly competitive, antagonistic fashion, which veered dangerously close to combativeness, or he assumed an exceedingly dominant role and soon found the relationship empty and dull.

His relationships with women had always followed a predictable sequence: instant attraction, a crescendo of passion, a rapid loss of interest. His love for his wife had withered years ago and he was currently in the midst of a painful divorce.