The Theory and Practice of Group Psychotherapy (80 page)

In the next few meetings, all these themes went underground. The meetings became listless, shallow, and intellectualized. Attendance dwindled, and the group seemed resigned to its own impotence. At the fourteenth meeting, the therapists announced that Sandy was improved and would return the following week. A vigorous, heated discussion ensued. The members feared that:

1.
They would upset her. An intense meeting would make her ill again and, to avoid that, the group would be forced to move slowly and superficially.

2.
Sandy would be unpredictable. At any point she might lose control and display dangerous, frightening behavior.

3.
Sandy would, because of her lack of control, be untrustworthy. Nothing in the group would remain confidential.

At the same time, the members expressed considerable anxiety and guilt for wishing to exclude Sandy from the group, and soon tension and a heavy silence prevailed. The extreme reaction of the group persuaded the therapist to delay reintroducing Sandy (who was, incidentally, in concurrent individual therapy) for a few weeks.

When she finally reentered the group, she was treated as a fragile object, and the entire group interaction was guarded and defensive. By the twentieth meeting, five of the seven members had dropped out of the group, leaving only Sandy and one other member.

The therapists reconstituted the group by adding five new members. It is of interest that, despite the fact that only two of the old members and the therapists continued in the reconstituted group, the old group culture persisted—a powerful example of the staying power of norms even in the presence of a limited number of culture bearers.
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The group dynamics had locked the group and Sandy into severely restricted roles and functions. Sandy was treated so delicately and obliquely by the new members that the group moved slowly, floundering in its own politeness and social conventionality. Only when the therapists openly confronted this issue and discussed in the group their own fears of upsetting Sandy and thrusting her into another psychological decompensation were the members able to deal with their feelings and fears about her. At that point, the group moved ahead more quickly. Sandy remained in the new group for a year and made decided improvements in her ability to relate with others and in her self-concept.

Later in the Course of a Group

An entirely different situation may arise when an individual who has been an involved, active group member for many months decompensates into a psychotic state. Other members are then primarily concerned for that member rather than for themselves or for the group. Since they have previously known and understood the now-psychotic member as a person, they often react with great concern and interest; the client is less likely to be viewed as a strange and frightening object to be avoided.
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Although perceiving similar trends in themselves may enhance the other members’ ability to continue relating to a distressed group member, it also creates a personal upheaval in some, who begin to fear that they, too, can lose control and slide into a similar abyss. Hence, the therapist does well to anticipate and express this fear to the others in the group.

When faced with a psychotic client in a group, many therapists revert to a medical model and symbolically dismiss the group by intervening forcefully in a one-to-one fashion. In effect, they say to the group, “This is too serious a problem for you to handle.” Such a maneuver, however, is often antitherapeutic: the client is frightened and the group infantilized.

It has been my experience that a mature group is perfectly able to deal with the psychiatric emergency and, although there may be false starts, to consider every contingency and take every action that the therapist might have considered. Consider the following clinical example.

• In the forty-fifth meeting, Rhoda, a forty-three-year-old divorced woman, arrived a few minutes late in a disheveled, obviously disturbed state. Over the previous few weeks, she had gradually been sliding into a depression, but now the process had suddenly accelerated. She was tearful, despondent, and exhibited psychomotor retardation. During the early part of the meeting, she wept continuously and expressed feelings of great loneliness and hopelessness as well as an inability to love, hate, or, for that matter, have any deeply felt emotion. She described her feeling of great detachment from everyone, including the group, and, when prompted, discussed suicidal ruminations.

The group members responded to Rhoda with great empathy and concern. They inquired about events during the past week and helped her discuss two important occurrences that seemed related to the depressive crisis: (1) for months she had been saving money for a summer trip to Europe; during the past week, her seventeen-year-old son had decided to decline a summer camp job and refused to search for other jobs—a turn of events that, in Rhoda’s eyes, jeopardized her trip; (2) she had, after months of hesitation, decided to attend a dance for divorced middle-aged people, which proved to be a disaster: no one had asked her to dance, and she had ended the evening consumed with feelings of total worthlessness.

The group helped her explore her relationship with her son, and for the first time, she expressed rage at him for his lack of concern for her. With the group’s assistance, she attempted to explore and express the limits of her responsibility toward him. It was difficult for Rhoda to discuss the dance because of the amount of shame and humiliation she felt. Two other women in the group, one single and one divorced, empathized deeply with her and shared their experiences and reactions to the scarcity of suitable males. Rhoda was also reminded by the group of the many times she had, during sessions, interpreted every minor slight as a total rejection and condemnation of herself. Finally, after much attention, care, and warmth had been offered her, one of the members pointed out to Rhoda that the experience of the dance was being disconfirmed right in the group: several people who knew her well were deeply concerned and involved with her. Rhoda rejected this idea by claiming that the group, unlike the dance, was an artificial situation in which people followed unnatural rules of conduct. The members quickly pointed out that quite the contrary was true: the dance—the contrived congregation of strangers, the attractions based on split-second, skin-deep impressions—was the artificial situation and the group was the real one. It was in the group that she was more completely known.

Rhoda, suffused with feelings of worthlessness, then berated herself for her inability to feel reciprocal warmth and involvement with the group members. One of the members quickly intercepted this maneuver by pointing out that Rhoda had a familiar and repetitive pattern of experiencing feelings toward the other members, evidenced by her facial expression and body posture, but then letting her “shoulds” take over and torture her by insisting that she should feel more warmth and more love than anyone else. The net effect was that the real feeling she did have was rapidly extinguished by the winds of her impossible selfdemands.

In essence, what then transpired was Rhoda’s gradual recognition of the discrepancy between her public and private esteem (described in chapter 3). At the end of the meeting, Rhoda responded by bursting into tears and crying for several minutes. The group was reluctant to leave but did so when the members had all convinced themselves that suicide was no longer a serious consideration. Throughout the next week, the members maintained an informal vigil, each phoning Rhoda at least once.

A number of important and far-reaching principles emerge from this illustration. Rather early in the session, the therapist realized the important dynamics operating in Rhoda’s depression and, had he chosen, might have made the appropriate interpretations to allow the client and the group to arrive much more quickly at a cognitive understanding of the problem—but that would have detracted considerably from the meaningfulness and value of the meeting to both the protagonist and the other members. For one thing, the group would have been deprived of an opportunity to experience its own potency; every success adds to the group’s cohesiveness and enhances the self-regard of each of the members. It is difficult for some therapists to refrain from interpretation, and yet it is essential to learn to sit on your wisdom. There are times when it is foolish to be wise and wise to be silent.

At times, as in this clinical episode, the group chooses and performs the appropriate action; at other times, the group may decide that the therapist must act. But there is a vast difference between a group’s hasty decision stemming from infantile dependence and unrealistic appraisal of the therapist’s powers and a decision based on the members’ thorough investigation of the situation and mature appraisal of the therapist’s expertise.

These points lead me to an important principle of group dynamics, one substantiated by considerable research.
A group that reaches an autonomous decision based on a thorough exploration of the pertinent problems will employ all of its resources in support of its decision; a group that has a decision thrust upon it is likely to resist that decision and be even less effective in making valid decisions in the future.

Let me take a slight but relevant tangent here and tell you a story about a well-known study in group dynamics. The focus of this illustration is a pajama-producing factory in which periodic changes in jobs and routine were necessitated by advances in technology. For many years, the employees resisted these changes; with each change, there was an increase in absenteeism, turnover, and aggression toward the management as well as decreased efficiency and output.

Researchers designed an experiment to test various methods of overcoming the employees’ resistance to change. The critical variable to be studied was the degree of participation of the group members (the employees) in planning the change. The employees were divided into three groups, and three variations were tested. The first variation involved no participation by the employees in planning the changes, although they were given an explanation. The second variation involved participation through elected representation of the workers in designing the changes to be made in the job. The third variation consisted of total participation by all the members of the group in designing the changes. The results showed conclusively that,
on all measures studied (aggression toward management, absenteeism, efficiency, number of employees resigning from the job), the success of the change was directly proportional to the degree of participation of the group members.
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The implications for group therapy are apparent: members who personally participate in planning a course of action will be more committed to the enactment of the plan. They will, for example, invest themselves more fully in the care of a disturbed member if they recognize that it is their problem and not the therapist’s alone.

At times, as in the previous clinical example, the entire experience is beneficial to the development of group cohesiveness. Sharing intense emotional experiences usually strengthens ties among members. The danger to the group occurs when the psychotic client consumes a massive amount of energy for a prolonged period. Then other members may drop out, and the group may deal with the disturbed individual in a cautious, concealed manner or attempt to ignore him or her. These methods never fail to aggravate the problem. In such critical situations, one important option always available to the therapist is to see the disturbed client in individual sessions for the duration of the crisis (this option will be dealt with more fully in the discussion of combined therapy). Here too, however, the group should thoroughly explore the implications and share in the decision.

One of the worst calamities that can befall a therapy group is the presence of a manic member. A client in the midst of a severe hypomanic episode is perhaps the single most disruptive problem for a group. (In contrast, a full-blown manic episode presents little problem, since the immediate course of action is clear: hospitalization.)

The client with acute, poorly contained bipolar affective disorder is best managed pharmacologically and is not a good candidate for interactionally oriented treatment. It is obviously unwise to allow the group to invest much energy and time in treatment that has such little likelihood of success. There is mounting evidence, however, for the use of specific, homogeneous group interventions for clients with bipolar illness. These groups offer psychoeducation about the illness and stress the importance of pharmacotherapy adherence and maintenance of healthy lifestyle and self-regulation routines. These groups are best employed in conjunction with pharmacotherapy in the maintenance phase of this chronic illness, after any acute disturbances have settled. Substantial benefits from therapy have been demonstrated, including improved pharmacotherapy adherence; reduced mood disturbance; fewer illness relapses; less substance abuse; and improved psychosocial functioning.
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THE CHARACTEROLOGICALLY DIFFICULT CLIENT

The final three types of problem clients in group therapy I shall discuss are the schizoid client, the borderline client, and the narcissistic client. These clients are often discussed together in the clinical literature under the rubric of characterologically difficult or Axis II clients.
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Traditional DSM diagnostic criteria do not do justice to the complexity of these clients and fail to capture adequately their inner psychological experience.
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