The Theory and Practice of Group Psychotherapy (22 page)

The existential approach holds that the human being’s paramount struggle is with the “givens” of existence, the ultimate concerns of the human condition: death, isolation, freedom, and meaninglessness. Anxiety emerges from basic conflicts in each of these realms: (1) we wish to continue to be and yet are aware of inevitable death; (2) we crave structure and yet must confront the truth that we are the authors of our own life design and our beliefs and our neural apparatus is responsible for the form of reality: underneath us there is
Nichts,
groundlessness, the abyss; (3) we desire contact, protection, to be part of a larger whole, yet experience the unbridgeable gap between self and others; and (4) we are meaning-seeking creatures thrown into a world that has no intrinsic meaning.

The items in the Q-sort that struck meaningful chords in the study subjects reflected some of these painful truths about existence. Group members realized that there were limits to the guidance and support they could receive from others and that the ultimate responsibility for the conduct of their lives was theirs alone. They learned also that though they could be close to others, there was a point beyond which they could not be accompanied: there is a basic aloneness to existence that must be faced. Many clients learned to face their limitations and their mortality with greater candor and courage. Coming to terms with their own deaths in a deeply authentic fashion permits them to cast the troublesome concerns of everyday life in a different perspective. It permits them to trivialize life’s trivia.

We often ignore these existential givens, until life events increase our sensibilities. We may at first respond to illness, bereavement, and trauma with denial, but ultimately the impact of these life-altering events may break through to create a therapeutic opportunity that may catalyze constructive changes in oneself, one’s relationships, and one’s relationship to life in general.†
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After ten sessions of integrative group therapy, women with early-stage breast cancer not only experienced more optimism and reduced depression and anxiety but also concluded that their cancer had contributed positively to their lives by causing them to realign their life priorities.
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In addition they showed a significant reduction in levels of the stress hormone cortisol.
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Members of such support groups may benefit psychologically, emotionally, and even physically as a result of the group’s support for meaningful engagement with life challenges (see chapter 15).
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The course of therapy of Sheila, a client who at the end of treatment selected the existential Q-sort items as having been instrumental in her improvement, illustrates many of these points.

• A twenty-five-year-old perennial student, Sheila complained of depression, loneliness, purposelessness, and severe gastric distress for which no organic cause could be found. In a pregroup individual session she lamented repeatedly, “I don’t know what’s going on!”

I could not discover what precisely she meant, and since this complaint was embedded in a litany of self-accusations, I soon forgot it. However, she did not understand what happened to her in the group, either: she could not understand why others were so uninterested in her, why she developed a conversion paralysis, why she entered sexually masochistic relationships, or why she so idealized the therapist.

In the group Sheila was boring and absolutely predictable. Before every utterance she scanned the sea of faces in the group searching for clues to what others wanted and expected. She was willing to be almost anything so as to avoid offending others and possibly driving them away from her. (Of course, she did drive others away, not from anger but from boredom.) Sheila was in chronic retreat from life, and the group tried endless approaches to halt the retreat, to find Sheila within the cocoon of compliance she had spun around herself.

No progress occurred until the group stopped encouraging Sheila, stopped attempting to force her to socialize, to study, to write papers, to pay bills, to buy clothes, to groom herself, but instead urged her to consider the blessings of failure. What was there in failure that was so seductive and so rewarding? Quite a bit, it turned out! Failing kept her young, kept her protected, kept her from deciding. Idealizing the therapist served the same purpose. Help was out there. He knew the answers. Her job in therapy was to enfeeble herself to the point where the therapist could not in all good conscience withhold his royal touch.

A critical event occurred when she developed an enlarged axillary lymph node. She had a biopsy performed and later that day came to the group still fearfully awaiting the results (which ultimately proved the enlarged node benign). She had never been so near to her own death before, and we helped Sheila plunge into the terrifying loneliness she experienced. There are two kinds of loneliness: the primordial, existential loneliness that Sheila confronted in that meeting, and a social loneliness, an inability to be with others.

Social loneliness is commonly and easily worked with in a group therapeutic setting. Basic loneliness is more hidden, more obscured by the distractions of everyday life, more rarely faced. Sometimes groups confuse the two and make an effort to resolve or to heal a member’s basic loneliness. But, as Sheila learned that day, it cannot be taken away; it cannot be resolved; it can only be known and ultimately embraced as an integral part of existence.

Rather quickly, then, Sheila changed. She reintegrated far-strewn bits of herself. She began to make decisions and to take over the helm of her life. She commented, “I think I know what’s going on” (I had long forgotten her initial complaint). More than anything else, she had been trying to avoid the specter of loneliness. I think she tried to elude it by staying young, by avoiding choice and decision, by perpetuating the myth that there would always be someone who would choose for her, would accompany her, would be there for her. Choice and freedom invariably imply loneliness, and, as Fromm pointed out long ago in
Escape from Freedom
, freedom holds more terror for us than tyranny does.
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Turn back again to
table 4.1
. Let us consider item 60, which so many clients rated so highly:
Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others
. In a sense, this is a double-edged factor in group therapy. Group members learn a great deal about how to relate better, how to develop greater intimacy with others, how to give help and to ask for help from others. At the same time, they discover the limits of intimacy;
they learn what they cannot obtain from others
. It is a harsh lesson and leads to both despair and strength. One cannot stare at the sun very long, and Sheila on many occasions looked away and avoided her dread. But she was always able to return to it, and by the end of therapy had made major shifts within herself.

An important concept in existential therapy is that human beings may relate to the ultimate concerns of existence in one of two possible modes. On the one hand, we may suppress or ignore our situation in life and live in what Heidegger termed a state of
forgetfulness of being
.
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In this everyday mode, we live in the world of things, in everyday diversions; we are absorbed in chatter, tranquilized, lost in the “they”; we are concerned only about the way things are. On the other hand, we may exist in a state of
mindfulness of being
, a state in which we marvel not at the way things are, but
that
they are. In this state, we are aware of being; we live authentically; we embrace our possibilities and limits; we are aware of our responsibility for our lives. (I prefer Sartre’s definition of responsibility: “to be responsible is to be the “uncontested author of... ”.)
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Being aware of one’s self-creation in the authentic state of mindfulness of being provides one with the power to change and the hope that one’s actions will bear fruit.† Thus, the therapist must pay special attention to the factors that transport a person from the
everyday
to the
authentic
mode of existing. One cannot effect such a shift merely by bearing down, by gritting one’s teeth. But there are certain jolting experiences (often referred to in the philosophical literature as “boundary experiences”) that effectively transport one into the mindfulness-of-being state.
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An extreme experience—such as Sheila’s encounter with a possibly malignant tumor—is a good example of a boundary experience, an event that brings one sharply back to reality and helps one prioritize one’s concerns in their proper perspective. Extreme experience, however, occurs in its natural state only rarely during the course of a therapy group, and the adept leader finds other ways to introduce these factors. The growing emphasis on brief therapy offers an excellent opportunity: the looming end of the group (or, for that matter, individual therapy) may be used by the therapist to urge clients to consider other terminations, including death, and to reconsider how to improve the quality and satisfaction of their remaining time. It is in this domain that the existential and interpersonal intersect as clients begin to ask themselves more fundamental questions: What choices do I exercise in my relationships and in my behavior? How do I wish to be experienced by others? Am I truly present and engaged in this relationship or am I managing the relationship inauthentically to reduce my anxiety? Do I care about what this person needs from me or am I motivated by my constricted self-interest?

Other group leaders attempt to generate extreme experience by using a form of existential shock therapy. With a variety of techniques, they try to bring clients to the edge of the abyss of existence. I have seen leaders begin personal growth groups, for example, by asking clients to compose their own epitaphs. Other leaders may begin by asking members to draw their lifeline and mark their present position on it: How far from birth? How close to death? But our capacity for denial is enormous, and it is the rare group that perseveres, that does not slip back into less threatening concerns. Natural events in the course of a group—illness, death, termination, and loss—may jolt the group back, but always temporarily.

In 1974, I began to lead groups of individuals who lived continuously in the midst of extreme experience.
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All the members had a terminal illness, generally metastatic carcinoma, and all were entirely aware of the nature and implications of their illness. I learned a great deal from these groups, especially about the fundamental but concealed issues of life that are so frequently neglected in traditional psychotherapy. (See Chapter 15 for a detailed description of this group and current applications of the supportive-expressive group approach.)

Reflecting back on that initial therapy group for cancer patients, many features stand out. For one thing, the members were deeply supportive to one another, and it was extraordinarily helpful for them to be so. Offering help so as to receive it in reciprocal fashion was only one, and not the most important, benefit of this supportiveness. Being useful to someone else drew them out of morbid self-absorption and provided them with a sense of purpose and meaning. Almost every terminally ill person I have spoken to has expressed deep fear of a helpless immobility—not only of being a burden to others and being unable to care for themselves but of being useless and without value to others. Living, then, becomes reduced to pointless survival, and the individual searches within, ever more deeply, for meaning. The group offered these women the opportunity to find meaning outside themselves: by extending help to another person, by caring for others, they found the sense of purpose that so often eludes sheer introspective reflection.
^k

These approaches, these avenues to self-transcendence, if well traveled, can increase one’s sense of meaning and purpose as well as one’s ability to bear what cannot be changed. Finding meaning in the face of adversity can be transformative.
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Long ago, Nietzsche wrote: “He who has a why to live can bear with almost any how.”
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It was clear to me (and demonstrated by empirical research) that the members of this group who plunged most deeply into themselves, who confronted their fate most openly and resolutely, passed into a richer mode of existence.
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Their life perspective was radically altered; the trivial, inconsequential diversions of life were seen for what they were. Their neurotic phobias diminished. They appreciated more fully the elemental features of living: the changing seasons, the previous spring, the falling leaves, the loving of others. Rather than resignation, powerlessness, and restriction, some members have experienced a great sense of liberation and autonomy.

Some even spoke of the gift of cancer. What some considered tragic, was not their death per se, but that they learned how to live life fully only after being threatened by serious illness. They wondered if it was possible to teach their loved ones this important lesson earlier in life or if it could be learned only
in extremis
? It may be that through the act of death ending life, the idea of death revitalizes life: death becomes a co-therapist pushing the work of psychotherapy ahead.

What can you as therapist do in the face of the inevitable? I think the answer lies in the verb
to be
. You do by being, by being there with the client. Presence is the hidden agent of help in all forms of therapy. Clients looking back on their therapy rarely remember a single interpretation you made, but they always remember your presence, that you were there with them. It is asking a great deal of the therapist to join this group, yet it would be hypocrisy not to join. The group does not consist of you (the therapist), and they (the dying); it is
we
who are dying,
we
who are banding together in the face of our common condition. In my book
The Gift of Therapy,
I propose that the most accurate or felicitous term for the therapeutic relationship might be “fellow traveler.” Two hundred years ago, Schopenhauer suggested we should address one another as “fellow sufferers.”
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