The Theory and Practice of Group Psychotherapy (26 page)

Once I observed a group led by a British group analyst in which a member who had been absent the six previous meetings entered the meeting a few minutes late. The therapist in no way acknowledged the arrival of the member; after the session, he explained to the student observers that he chose not to influence the group since he preferred that they make their own rules about welcoming tardy or prodigal members. It appeared clear to me, however, that the therapist’s non-welcome was an influential act and very much of a norm-setting message. His group had evolved, no doubt as a result of many similar previous actions, into a uncaring, insecure one, whose members sought methods of currying the leader’s favor.

Norms are created relatively early in the life of a group and, once established, are difficult to change. Consider, for example, the small group in an industrial setting that forms norms regulating individual member output, or a delinquent gang that establishes codes of behavior, or a psychiatric ward that forms norms of expected staff and patient role behavior. To change entrenched standards is notoriously difficult and requires considerable time and often large group membership turnover.

To summarize: every group evolves a set of unwritten rules or norms that determine the procedure of the group. The ideal therapy group has norms that permit the therapeutic factors to operate with maximum effectiveness. Norms are shaped both by the expectations of the group members and by the behavior of the therapist. The therapist is enormously influential in norm setting—in fact, it is a function that the leader cannot avoid. Norms constructed early in the group have considerable perseverance. The therapist is thus well advised to go about this important function in an informed, deliberate manner.

HOW DOES THE LEADER SHAPE NORMS?

There are two basic roles the therapist may assume in a group: technical expert and model-setting participant. In each of these roles, the therapist helps to shape the norms of the group.

The Technical Expert

When assuming the role of technical expert, therapists deliberately slip into the traditional garb of expert and employ a variety of techniques to move the group in a direction they consider desirable. They explicitly attempt to shape norms during their early preparation of clients for group therapy. In this procedure, described fully in chapter 10, therapists carefully instruct clients about the rules of the group, and they reinforce the instruction in two ways: first, by backing it with the weight of authority and experience and, second, by presenting the rationale behind the suggested mode of procedure in order to enlist the clients’ support.

At the beginning of a group, therapists have at their disposal a wide choice of techniques to shape the group culture. These range from explicit instructions and suggestions to subtle reinforcing techniques. For example, as I described earlier, the leader must attempt to create an interactional network in which the members freely interact rather than direct all their comments to or through the therapist. To this end, therapists may implicitly instruct members in their pregroup interviews or in the first group sessions; they may, repeatedly during the meetings, ask for all members’ reactions to another member or toward a group issue; they may ask why conversation is invariably directed toward the therapist; they may refuse to answer questions when addressed; they may ask the group to engage in exercises that teach clients to interact—for example, asking each member of the group in turn to give his or her first impressions of every other member; or therapists may, in a much less obtrusive manner, shape behavior by rewarding members who address one another—therapists may nod or smile at them, address them warmly, or shift their posture into a more receptive position. Exactly the same approaches may be applied to the myriad of other norms the therapist wishes to inculcate: self-disclosure, open expression of emotions, promptness, self-exploration, and so on.

Therapists vary considerably in style. Although many prefer to shape norms explicitly, all therapists, to a degree often greater than they suppose, perform their tasks through the subtle technique of social reinforcement. Human behavior is continuously influenced by a series of environmental events (reinforcers), which may have a positive or negative valence and which exert their influence on a conscious or a subliminal level.

Advertising and political propaganda techniques are but two examples of a systematic harnessing of reinforcing agents. Psychotherapy, no less, relies on the use of subtle, often nondeliberate social reinforcers. Although few self-respecting therapists like to consider themselves social reinforcing agents, nevertheless therapists continuously exert influence in this manner, unconsciously or deliberately. They may positively reinforce behavior by numerous verbal and nonverbal acts, including nodding, smiling, leaning forward, or offering an interested “mmm” or a direct inquiry for more information. On the other hand, therapists attempt to extinguish behavior not deemed salubrious by not commenting, not nodding, ignoring the behavior, turning their attention to another client, looking skeptical, raising their eyebrows, and so on. In fact research suggests that therapists who reinforce members’ pro-group behavior indirectly are often more effective than those who prompt such behavior explicitly.
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Any obvious verbal directive from therapists then becomes especially effective because of the paucity of such interventions.

Every form of psychotherapy is a learning process, relying in part on operant conditioning. Therapy, even psychoanalysis, without some form of therapist reinforcement or manipulation is a mirage that disappears on close scrutiny.
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Considerable research demonstrates the efficacy of operant techniques in the shaping of group behavior.
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Using these techniques deliberately, one can reduce silences
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or increase personal and group comments, expressions of hostility to the leader, or intermember acceptance.
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Though there is evidence that they owe much of their effectiveness to these learning principles, psychotherapists often eschew this evidence because of their unfounded fear that such a mechanistic view will undermine the essential human component of the therapy experience. The facts are compelling, however, and an understanding of their own behavior does not strip therapists of their spontaneity. After all, the objective of using operant techniques is to foster authentic and meaningful engagement. Therapists who recognize that they exert great influence through social reinforcement and who have formulated a central organizing principle of therapy will be more effective and consistent in making therapeutic interventions.

The Model-Setting Participant

Leaders shape group norms not only through explicit or implicit social engineering but also through the example they set in their own group behavior.
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The therapy group culture represents a radical departure from the social rules to which clients are accustomed. Clients are asked to discard familiar social conventions, to try out new behavior, and to take many risks. How can therapists best demonstrate to their clients that new behavior will not have the anticipated adverse consequences?

One method, which has considerable research backing, is modeling: Clients are encouraged to alter their behavior by observing their therapists engaging freely and without adverse effects in the desired behavior. Bandura has demonstrated in many well-controlled studies that individuals may be influenced to engage in more adaptive behavior (for example, the overcoming of specific phobias)
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or less adaptive behavior (for example, unrestrained aggressivity)
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through observing and assuming other’s behavior.

The leader may, by offering a model of nonjudgmental acceptance and appreciation of others’ strengths as well as their problem areas, help shape a group that is health oriented. If, on the other hand, leaders conceptualize their role as that of a detective of psychopathology, the group members will follow suit. For example, one group member had actively worked on the problems of other members for months but had steadfastly declined to disclose her own problems. Finally in one meeting she confessed that one year earlier she had had a two-month stay in a state psychiatric hospital. The therapist responded reflexively, “Why haven’t you told us this before?”

This comment, perceived as punitive by the client, served only to reinforce her fear and discourage further self-disclosure. Obviously, there are questions and comments that will close people down and others that will help them open up. The therapist had “opening-up” options: for example, “I think it’s great that you now trust the group sufficiently to share these facts about yourself,” or, “How difficult it must have been for you in the group previously, wanting to share this disclosure and yet being afraid to do so.”

The leader sets a model of interpersonal honesty and spontaneity but must also keep in mind the current needs of the members and demonstrate behavior that is congruent with those needs. Do not conclude that group therapists should freely express all feelings. Total disinhibition is no more salubrious in therapy groups than in other forms of human encounter and may lead to ugly, destructive interaction. The therapist must model responsibility and appropriate restraint as well as honesty. We want to engage our clients and allow ourselves to be affected by them. In fact, “disciplined personal involvement” is an invaluable part of the group leader’s armamentarium.
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Not only is it therapeutic to our clients that we let them matter to us, we can also use our own reactions as valuable data about our clients—provided we know ourselves well enough.†

Consider the following therapeutically effective intervention:

• In the first session of a group of business executives meeting for a five-day human relations laboratory, a twenty-five-year-old, aggressive, swaggering member who had obviously been drinking heavily proceeded to dominate the meeting and make a fool of himself. He boasted of his accomplishments, belittled the group, monopolized the meeting, and interrupted, outshsituation—feedback about how angry or hurt he had made others feel, or interpretations about the meaning and cause of his behavior—failed. Then my co-leader commented sincerely, “You know what I like about you? Your fear and lack of confidence. You’re scared here, just like me. We’re all scared about what will happen to us this week.” That statement permitted the client to discard his facade and, eventually, to become a valuable group member. Furthermore, the leader, by modeling an empathic, nonjudgmental style, helped establish a gentle, accepting group culture.

This effective intervention required that the co-leader first recognize the negative impact of this member’s behavior and then supportively articulate the vulnerability that lay beneath the offensive behavior.
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Interacting as a group member requires, among other things, that group therapists accept and admit their personal fallibility. Therapists who need to appear infallible offer a perplexing and obstructing example for their clients. At times they may be so reluctant to admit error that they become withholding or devious in their relationship with the group. For example, in one group, the therapist, who needed to appear omniscient, was to be out of town for the next meeting. He suggested to the group members that they meet without him and tape-record the meeting, and he promised to listen to the tape before the next session. He forgot to listen to the tape but did not admit this to the group. Consequently, the subsequent meeting, in which the therapist bluffed by avoiding mention of the previous leaderless session, turned out to be diffuse, confusing, and discouraging.

Another example involves a neophyte therapist with similar needs. A group member accused him of making long-winded, confusing statements. Since this was the first confrontation of the therapist in this young group, the members were tense and perched on the edge of their chairs. The therapist responded by wondering whether he didn’t remind the client of someone from the past. The attacking member clutched at the suggestion and volunteered his father as a candidate; the crisis passed, and the group members settled back in their chairs. However, it so happened that previously this therapist had himself been a member of a group (of psychotherapy students) and his colleagues had repeatedly focused on his tendency to make long-winded, confusing comments. In fact, then, what had transpired was that the client had seen the therapist quite correctly but was persuaded to relinquish his perceptions. If one of the goals of therapy is to help clients test reality and clarify their interpersonal relationships, then this transaction was
antitherapeutic.
This is an instance in which the therapist’s needs were given precedence over the client’s needs in psychotherapy.†

Another consequence of the need to be perfect occurs when therapists become overly cautious. Fearing error, they weigh their words so carefully, interacting so deliberately that they sacrifice spontaneity and mold a stilted, lifeless group. Often a therapist who maintains an omnipotent, distant role is saying, in effect, “Do what you will; you can’t hurt or touch me.” This pose may have the counterproductive effect of aggravating a sense of interpersonal impotence in clients that impedes the development of an autonomous group.

• In one group a young man named Les had made little movement for months despite vigorous efforts by the leader. In virtually every meeting the leader attempted to bring Les into the discussion, but to no avail. Instead, Les became more defiant and withholding, and the therapist became more active and insistent. Finally Joan, another member, commented to the therapist that he was like a stubborn father treating Les like a stubborn son and was bound and determined to make Les change. Les, she added, was relishing the role of the rebellious son who was determined to defeat his father. Joan’s comment rang true for the therapist; it clicked with his internal experience, and he acknowledged this to the group and thanked Joan for her comments
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