The Theory and Practice of Group Psychotherapy (29 page)

Thus, the therapist must build a group with norms that permit conflict but only after firm foundations of safety and support have been established. It is often necessary to intervene to prevent the proliferation of too much conflict too early in the group, as the following incident illustrates.

• In a new therapy group, there were two particularly hostile members, and by the third meeting there was considerable open carping, sarcasm, and conflict. The fourth meeting was opened by Estelle (one of these two members), emphasizing how unhelpful the group had been to her thus far. Estelle had a way of turning every positive comment made to her into a negative, combative one. She complained, for example, that she could not express herself well and that there were many things she wanted to say but she was so inarticulate she couldn’t get them across.

When another member of the group disagreed and stated that she found Estelle to be extremely articulate, Estelle challenged the other member for doubting her judgment about herself. Later in the group, she complimented another member by stating, “Ilene, you’re the only one here who’s ever asked me an intelligent question.” Obviously, Ilene was made quite uncomfortable by this hexed compliment.

At this point I felt it was imperative to challenge the norms of hostility and criticism that had developed in the group, and intervened forcefully. I asked Estelle: “What are your guesses about how your statement to Ilene makes others in the group feel?”

Estelle hemmed and hawed but finally offered that they might possibly feel insulted. I suggested that she check that out with the other members of the group. She did so and learned that her assumption was correct. Not only did every member of the group feel insulted, but Ilene also felt irritated and put off by the statement. I then inquired, “Estelle, it looks as though you’re correct. You did insult the group. Also it seems that you knew that this was likely to occur. But what’s puzzling is the payoff for you. What do you get out of it?”

Estelle suggested two possibilities. First she said, “I’d rather be rejected for insulting people than for being nice to them.” That seemed a piece of twisted logic but nonetheless comprehensible. Her second statement was: “At least this way I get to be the center of attention.” “Like now?” I asked. She nodded. “How does it feel right now?” I wondered. Estelle said, “It feels good.” “How about the rest of your life?” I asked. She responded ingenuously, “It’s lonely. In fact, this is it. This hour and a half is the people in my life.” I ventured, “Then this group is a really important place for you?” Estelle nodded. I commented, “Estelle, you’ve always stated that one of the reasons you’re critical of others in the group is that there’s nothing more important than total honesty. If you want to be absolutely honest with us, however, I think you’ve got to tell us also how important we are to you and how much you like being here. That you never do, and I wonder if you can begin to investigate why it is so painful or dangerous for you to show others here how important they are to you.”

By this time Estelle had become much more conciliatory and I was able to obtain more leverage by enlisting her agreement that her hostility and insults did constitute a problem for her and that it would help her if we called her on it—that is, if we instantaneously labeled any insulting behavior on her part. It is always helpful to obtain this type of contract from a member: in future meetings, the therapist can confront members with some particular aspect of their behavior that they have asked to be called to their attention. Since they experience themselves as allies in this spotting and confrontative process, they are far less likely to feel defensive about the intervention.

Many of these examples of therapist behavior may seem deliberate, pedantic, even pontifical. They are not the nonjudgmental, nondirective, mirroring, or clarifying comments typical of a therapist’s behavior in other aspects of the therapeutic process. It is vital, however, that the therapist attend deliberately to the tasks of group creation and culture building. These tasks underlie and, to a great extent, precede much of the other work of the therapist.

It is time now to turn to the third basic task of the therapist: the activation and illumination of the here-and-now.

Chapter 6

THE THERAPIST: WORKING IN THE HERE - AND - NOW

T
he major difference between a psychotherapy group that hopes to effect extensive and enduring behavioral and characterological change and such groups as AA, psychoeducational groups, cognitive-behavioral groups, and cancer support groups is that the psychotherapy group strongly emphasizes the importance of the here-and-now experience. Yet
all
group therapies, including highly structured groups, benefit from the group therapist’s capacity to recognize and understand the here-and-now. Therapists who are aware of the nuances of the relationships between all the members of the group are more adept at working on the group task even when deeper group and interpersonal exploration or interpretation is not the therapy focus.
¹

In chapter 2, I presented some of the theoretical underpinnings of the use of the here-and-now. Now it is time to focus on the clinical application of the here-and-now in group therapy. First, keep in mind this important principle—perhaps the single most important point I make in this entire book:
the here-and-now focus, to be effective, consists of two symbiotic tiers, neither of which has therapeutic power without the other.

The
first
tier is an experiencing one: the members live in the here-and-now; they develop strong feelings toward the other group members, the therapist, and the group. These here-and-now feelings become the major discourse of the group. The thrust is ahistorical:
the immediate events of the meeting take precedence over events both in the current outside life and in the distant past of the members
. This focus greatly facilitates the development and emergence of each member’s social microcosm. It facilitates feedback, catharsis, meaningful self-disclosure, and acquisition of socializing techniques. The group becomes more vital, and
all
of the members (not only the ones directly working in that session) become intensely involved in the meeting.

But the here-and-now focus rapidly reaches the limits of its usefulness without the
second
tier,
which is the illumination of process
. If the powerful therapeutic factor of interpersonal learning is to be set in motion, the group must recognize, examine, and understand process.
It must examine itself; it must study its own transactions; it must transcend pure experience and apply itself to the integration of that experience.

Thus, the effective use of the here-and-now requires two steps:
the group lives in the here-and-now, and it also doubles back on itself; it performs a self-reflective loop and examines the here-and-now behavior that has just occurred.

If the group is to be effective,
both
aspects of the here-and-now are essential. If only the first—the experiencing of the here-and-now—is present, the group experience will still be intense, members will feel deeply involved, emotional expression may be high, and members will finish the group agreeing, “Wow, that was a powerful experience!”
Yet it will also prove to be an evanescent experience
: members will have no cognitive framework that will permit them to retain the group experience, to generalize from it, to identify and alter their interpersonal behavior, and to transfer their learning from the group to situations back home. This is precisely the error made by many encounter group leaders of earlier decades.

If, on the other hand, only the
second
part of the here-and-now—the examination of process—is present, then the group loses its liveliness and meaningfulness. It degenerates into a sterile intellectual exercise. This is the error made by overly formal, aloof, rigid therapists.

Accordingly,
the therapist has two discrete functions in the here-and-now: to steer the group into the here-and-now and to facilitate the self-reflective loop (or process commentary)
. Much of the here-and-now steering function can be shared by the group members, but for reasons I will discuss later, process commentary remains to a large extent the task of the therapist.

The majority of group therapists understand that their emphasis must be on the here-and-now. A large survey of seasoned group therapists underscored activation of the here-and-now as a core skill of the contemporary group therapist.
²
A smaller but careful study codified group therapists’ interpretations and found that over 60 percent of interpretations focused on the here-and-now (either behavioral patterns or impact of behavior), while approximately 20 percent focused on historical causes and 20 percent on motivation.
³

DEFINITION OF PROCESS

The term
process,
used liberally throughout this text, has a highly specialized meaning in many fields, including law, anatomy, sociology, anthropology, psychoanalysis, and descriptive psychiatry. In interactional psychotherapy, too, process has a specific technical meaning: it refers to the
nature of the relationship between interacting individuals—members and therapists
. Moreover, as we shall see, a full understanding of process must take into account a large number of factors, including the internal psychological worlds of each member, interpersonal interactions, group-as-a-whole forces, and the clinical environment of the group.†
⁴

It is useful to contrast
process
with
content
. Imagine two individuals in a discussion. The
content
of that discussion consists of the explicit words spoken, the substantive issues, the arguments advanced. The
process
is an altogether different matter. When we ask about process, we ask, “What do these explicit words, the style of the participants, the nature of the discussion,
tell about the interpersonal relationship of the participants?”

Therapists who are process-oriented are concerned not primarily with the verbal content of a client’s utterance, but with the “how” and the “why” of that utterance, especially insofar as the how and the why illuminate aspects of the client’s relationship to other people. Thus, therapists focus on the metacommunicational
^l
aspects of the message and wonder why,
from the relationship aspect,
an individual makes a statement at a certain time in a certain manner to a certain person. Some of the message’s impact is conveyed verbally and directly; some of the message is expressed paraverbally (by nuance, inflection, pitch, and tone); and some of the message is expressed behaviorally.† Identifying the connection between the communication’s actual impact and the communicator’s intent is at the heart of the therapy process.

Consider, for example, this transaction: During a lecture, a student raised her hand and asked what year did Freud die? The lecturer replied, “1938,” only to have the student inquire, “But, sir, wasn’t it 1939?” Since the student asked a question whose answer she already knew, her motivation was obviously not a quest for information. (A question isn’t a question if you know the answer.) The process of this transaction? Most likely that the student wished to demonstrate her knowledge or wished to humiliate or defeat the lecturer!

Frequently, the understanding of process in a group is more complex than in a two-person interaction; we must search for the process not only behind a simple statement but behind a sequence of statements made by several members. The group therapist must endeavor to understand what a particular sequence reveals about the relationship between one client and the other group members, or between clusters or cliques of members, or between the members and the leader, or, finally, between the group as a whole and its primary task.†

Some clinical vignettes may further clarify the concept.

• Early in the course of a group therapy meeting, Burt, a tenacious, intense, bulldog-faced graduate student, exclaimed to the group in general and to Rose (an unsophisticated, astrologically inclined cosmetologist and mother of four) in particular, “Parenthood is degrading!” This provocative statement elicited considerable response from the group members, all of whom had parents and many of whom were parents. The free-for-all that followed consumed the remainder of the group session.

Burt’s statement can be viewed strictly in terms of
content
. In fact, this is precisely what occurred in the group; the members engaged Burt in a debate over the virtues versus the dehumanizing aspects of parenthood—a discussion that was affect-laden but intellectualized and brought none of the members closer to their goals in therapy. Subsequently, the group felt discouraged about the meeting and angry with themselves and with Burt for having dissipated a meeting.

On the other hand, the therapist might have considered the
process
of Burt’s statement from any one of a number of perspectives:

1. Why did Burt attack Rose? What was the interpersonal process between them? In fact, the two had had a smoldering conflict for many weeks, and in the previous meeting Rose had wondered why, if Burt was so brilliant, he was still, at the age of thirty-two, a student. Burt had viewed Rose as an inferior being who functioned primarily as a mammary gland; once when she was absent, he referred to her as a brood mare.

2. Why was Burt so judgmental and intolerant of nonintellectuals? Why did he always have to maintain his self-esteem by standing on the carcass of a vanquished or humiliated adversary?