The Theory and Practice of Group Psychotherapy (35 page)

• In another group, Bea, an assertive, articulate woman, had for months been the most active and influential member. A new member, Bob, a psychiatric social worker (who did not reveal that fact to the group), was introduced. He was exceedingly assertive and articulate and in his first meeting, described his life situation with such candor and clarity that the other members were impressed and touched. Bea’s response, however, was: “Where did you get your group therapy training?” (Not “Did you ever have therapy training?” or, “You sound like you’ve had some experience in examining yourself.”) The wording of Bea’s comment clearly revealed the struggle for dominance, for she was implicitly saying: “I’ve found you out. Don’t think you can fool me with that jargon. You’ve got a long way to go to catch up with me!”

Primary Task and Secondary Gratification

The concepts of
primary task
and
secondary gratification
, and the dynamic tension between the two, provide the therapist with a useful guide to the recognition of process (and, as I will discuss later, a guide to the factors underlying a client’s resistance to process commentary).

First some definitions. The
primary task
of the client is, quite simply, to achieve his or her original goals: relief of suffering, better relationships with others, or living more productively and fully. Yet, as we examine it more closely, the task often becomes much more complicated. Generally one’s view of the primary task changes considerably as one progresses in therapy. Sometimes the client and the therapist have widely different views of the primary task. I have, for example, known clients who stated that their goal is relief from pain (for example, from anxiety, depression, or insomnia) but who have a deeper and more problematic goal. One woman wished that through therapy she would become so well that she would be even more superior to her adversaries by “out mental-healthing” them; another client wished to learn how to manipulate others even more effectively; another wished to become a more effective seducer. These goals may be unconscious or, even if conscious, well hidden from others; they are not part of the initial contract the individual makes with the therapist, and yet they exert a pervasive influence in the therapeutic work. In fact, much therapy may have to occur before some clients can formulate an appropriate primary task.
^14
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Even though their goals may evolve through the course of therapy, clients initially have some clear conception of a primary task—generally, relief of some type of discomfort. By methods discussed in chapter 10, therapists, in pregroup preparations of clients and in the first group meetings, make clients aware of what they must do in the group to accomplish their primary tasks. And yet once the group begins, very peculiar things begin to happen: clients conscious wish for change there is a deeper commitment to
avoid
change—a clinging to old familiar modes of behavior. It is often through the recognition of this clinging (that is,
resistance
) that the first real opportunity for repair emerges.†

Some clinical vignettes illustrate this paradox:

• Cal, a young man, was interested in seducing the women of the group and shaped his behavior in an effort to appear suave and charming. He concealed his feelings of awkwardness, his desperate wish to be cool,
his fear of women, and his envy of some of the men in the group. He could never discuss his compulsive masturbation and occasional voyeurism. When another male member discussed his disdain for the women in the group, Cal (purring with pleasure at the withdrawal of competition) praised him for his honesty. When another member discussed, with much anxiety, his homosexual fantasies, Cal deliberately withheld the solace he might have offered by sharing his own, similar fantasies. He never dared to discuss the issues for which he entered therapy; nothing took precedence over being cool.

Another member devoted all her energies to achieving an image of mental agility and profundity. She, often in subtle ways, continually took issue with me. She scorned any help I offered her, and took great offense at my attempts to interpret her behavior. Finally, I reflected that working with her made me feel I had nothing of value to offer. That was her finest hour! She flashed a sunny smile as she said, “Perhaps you ought to join a therapy group to work on your problem.”

Another member enjoyed an enviable position in the group because of his girlfriend, a beautiful actress, whose picture he delighted in passing around in the group. She was his showpiece, living proof of his natural superiority. When one day she suddenly and peremptorily left him, he was too mortified to face the group and dropped out of therapy.

What do these examples have in common? In each, the client gave priority
not to the declared primary task but to some secondary gratification arising in the group:
a relationship with another member, an image a client wished to project, or a group role in which a client was the most sexually desirable, the most influential, the most wise, the most superior. In each instance, the client’s pathology obstructed his or her pursuit of the primary goal. Clients diverted their energies from the real work of therapy to the pursuit of some gratification in the group. If this here-and-now behavior were available for study—if the members could, as it were, be pulled out of the group matrix to observe their actions in a more dispassionate manner—then the entire sequence would become part of good therapeutic work. But that did not happen! In all these instances,
the gratification took precedence over the work to be done
. Group members concealed information, misrepresented themselves, rejected the therapist’s help, and refused to give help to one another.

This is a familiar phenomenon in individual therapy. Long ago, Freud spoke of the patient
whose desire to remain in therapy outweighed the desire to be cured
. The individual therapist satisfies a client’s wish to be succored, to be heard, to be cradled. Yet there is a vast, quantitative difference in this respect between individual and group therapy. The individual therapy format is relatively insular; the group situation offers a far greater range of secondary gratifications, of satisfying many social needs in an individual’s life. Moreover, the gratification offered is often compelling; our social needs to be dominant, to be admired, to be loved, to be revered are powerful indeed. For some, the psychotherapy group provides satisfying relationships rather than being a bridge to forming better relationships in their world at large. This presents a clinical challenge with certain populations, such as the elderly, who have reduced opportunities for human connection outside of the therapy group. In such instances, offering ongoing, less frequent booster sessions, perhaps monthly, after a shorter intensive phase may be the best way to respond to this reluctance to end therapy.
¹⁵

Is the tension that exists between primary task and secondary gratification nothing more than a slightly different way of referring to the familiar concept of resistance and acting out? In the sense that the pursuit of secondary gratification obstructs the therapeutic work, it may generically be labeled resistance. Yet there is an important shade of difference:
Resistance
ordinarily refers to pain avoidance. Obviously, resistance in this sense is much in evidence in group therapy, on both an individual and a group level. But what I wish to emphasize is that the
therapy group offers an abundance of secondary gratifications.
Often the therapeutic work in a group is derailed not because members are too defensively anxious to work but because they find themselves unwilling to relinquish gratification.

Often, when the therapist is bewildered by the course of events in the therapy group, the distinction between primary task and secondary gratification is extremely useful. It is often clarifying for therapists to ask themselves whether the client is working on his or her primary task. And when the substitution of secondary gratification for primary task is well entrenched and resists intervention, therapists have no more powerful technique than reminding the group members of the primary task—the reasons for which they seek therapy.

The same principle applies to the
entire group
. It can be said that the entire group has a primary task that consists of the development and exploration of all aspects of the relationship of each member to each of the others, to the therapist, and to the group as an aggregate. The therapist and, later, the group members can easily enough sense when the group is working, when it is involved in its primary task, and when it is avoiding that task.

At times the therapist may be unclear about what a group is doing but knows that it is not focused on either developing or exploring relationships between members. If therapists have attended to providing the group a clear statement of its primary task, then they must conclude that the group is actively evading the task—either because of some dysphoria associated with the task itself or because of some secondary gratification that is sufficiently satisfying to supplant the therapy work.

The Therapist’s Feelings

All of these guides to the therapist’s recognition and understanding of process have their usefulness. But there is an even more important clue: the therapist’s own feelings in the meeting, feelings that he or she has come to trust after living through many previous similar incidents in group therapy. Experienced therapists learn to trust their feelings; they are as useful to a therapist as a microscope or DNA mapping to a microbiologist. If therapists feel impatient, frustrated, bored, confused, discouraged—any of the panoply of feelings available to a human being—they should consider this valuable data and learn to put it to work.

Remember, this does not mean that therapists have to understand their feelings and arrange and deliver a neat interpretive corsage. The simple expression of feelings is often sufficient to help a client proceed further.

• One therapist experienced a forty-five-year-old woman in an unreal, puzzling manner because of her rapidly fluctuating method of presenting herself. He finally commented, “Sharon, I have several feelings about you that I’d like to share. As you talk, I often experience you as a competent mature woman, but sometimes I see you as a very young, almost preadolescent child, unaware of your sexuality, trying to cuddle, trying to be pleasing to everyone. I don’t think I can go any farther with this now, but I wonder whether this has meaning for you.” The observation struck deep chords in the client and helped her explore her conflicted sexual identity and her need to be loved by everyone.

It is often very helpful to the group if you share feelings of being shut out by a member. Such a comment rarely evokes defensiveness, because it always implies that you wish to get closer to that person. It models important group therapy norms: risk taking, collaboration, and taking relationships seriously.

To express feelings in the therapeutic process, the therapist must have a reasonable degree of confidence in their appropriateness. The more you respond unrealistically to the client (on the basis of countertransference or possibly because of pressing personal emotional problems), the less helpful—in fact, the more antitherapeutic—will you be in presenting these feelings as if they were the client’s problem rather than your own. You need to use the delicate instrument of your own feelings, and to do so frequently and spontaneously.
But it is of the utmost importance that this instrument be as reliable and accurate as possible
.

Countertransference refers broadly to the reactions therapists have to their clients. It is critically important to distinguish between your
objective
countertransference, reflecting on the client’s characteristic interpersonal impact on you and others, and your
subjective
countertransference—those idiosyncratic reactions that reflect more specifically on what you, personally, carry into your relationships or interactions.
¹⁶
The former is an excellent source of interpersonal data about the client. The latter, however, says a good deal more about the therapist. To discriminate between the two requires not only experience and training but also deep self-knowledge.
It is for this reason that I believe every therapist should obtain personal psychotherapy
. (More about this in chapter 17.)

HELPING CLIENTS ASSUME A PROCESS ORIENTATION

It has long been known that observations, viewpoints, and insights arrived at through one’s own efforts are valued more highly than those that are thrust upon one by another person. The mature leader resists the temptation to make brilliant virtuoso interpretations, but searches instead for methods that will permit clients to achieve self-knowledge through their own efforts. As Foulkes and Anthony put it, “There are times when the therapist must sit on his wisdom, must tolerate defective knowledge and wait for the group to arrive at solutions.”
¹⁷

The task, then, is to influence members to assume and to value the process perspective. Many of the norm-setting activities of the leader described in chapter 5 serve this end. For example, the therapist emphasizes process by periodically tugging the members out of the here-and-now and inviting them to consider more dispassionately the meaning of recent transactions. Though techniques vary depending on a therapist’s style, the intention of these interventions is to switch on a self-reflective beacon. The therapist may, for example, interrupt the group at an appropriate point to comment, in effect, “We are about halfway through our time for today, and I wonder how everyone feels about the meeting thus far?” Again, by no means do you have to understand the process to ask for members’ analyses. You might simply say, “I’m not sure what’s happening in the meeting, but I do see some unusual things. For example, Bill has been unusually silent, Jack’s moved his chair back three feet, Mary’s been shooting glances at me for the past several minutes. What ideas do you all have about what’s going on today?”