The Theory and Practice of Group Psychotherapy (85 page)

He might then continue, I suggested, by saying, “For example, you, John (one of the other members): I have tremendous admiration toward you in so many ways, your intelligence, your devotion to the right causes, but nonetheless last week I noted a wave of irritation when you were speaking toward the end of the meeting about your attitude toward the women you date—was that all me or did others feel that way?” My client took notes during our session and followed my lead, and within a few weeks one of the group therapists told me that not only was this client doing good work, but he had turned the whole group around and that meetings had become more lively and interactional for everyone in the group.

The individual therapist also can with great profit focus on transfer of learning, on helping the client apply what he or she has learned in the group to new situations—for example, to the relationship with the individual therapist and to other important figures in the client’s social world.

Although it is more common for group therapy to be added to an ongoing individual therapy, the opposite may also occur. It may be that the group work catalyzes changes or evokes memories that evoke great distress warranting time and attention that the group may not be able to provide.
¹¹
In general, it is best to launch one treatment first and then add the second if required, rather than start both at once, to avoid confusing or overwhelming the client.

Combined Therapy

Earlier I said that concurrent therapy is not
essential
to group therapy. I feel the same way about combined therapy. Yet I also agree with the many clinicians who find that combined therapy is an exceptionally productive and powerful therapeutic format. I continue to be impressed by the results of placing my individual clients into a group: almost invariably, therapy is accelerated and enriched.

Generally, in clinical practice, combined therapy begins with individual therapy. After several weeks or months of individual therapy, therapists place a client into one of their therapy groups—one generally composed entirely of clients who are also in individual therapy with the leader. Homogeneity in this regard is helpful—that is, that all the members of the group also be in individual therapy with the group leader—but it is not essential. The pressures of everyday practice sometimes result in some clients being in individual therapy with the group leader while one or two are not. Not infrequently issues of envy may arise in members who do not meet with the group leader individually.

Typically, the client attends one group session and one individual session weekly. Other, more cost-effective variants have been described, for example, a format in which each group member meets for one individual session every few weeks.
¹²
Although such a format has much to offer, it has a different rationale from combined therapy, in that the occasional meeting is an adjunct to the group: it is designed to facilitate norm formation and to optimize the members’ use of the group.

In combined therapy, the group is usually open-ended, with clients remaining in both therapies for months, even years. But combined therapy may also involve a time-limited group format. I have, on many occasions, formed a six-month group of my long-term individual clients. After the group terminates, the clients continue individual therapy, which has been richly fertilized by group-spawned data.

Advantages.
There is no doubt that combined therapy (as well as conjoint therapy) decreases dropouts.†
¹³
My own informal survey of combined therapy groups—my own and those of supervisees and colleagues—over a period of several years reveals that early dropouts are exceedingly rare. In fact, of clients who were already established in individual therapy before entering a group led by their individual therapist,
not a single one
dropped out in the first twelve sessions. This, of course, contrasts starkly with the high dropout rates for group therapy without concurrent individual therapy (see
table 8.1
). The reasons are obvious. First, therapists know their individual therapy clients very well and can be more accurate in the selection process. Second, the therapists in their individual therapy sessions are able to prevent impending dropouts by addressing and resolving issues that preclude the client’s work in the group.

• After seven meetings, David, a somewhat prissy, fifty-year-old confirmed bachelor, was on the verge of dropping out. The group had given him considerable feedback about several annoying characteristics: his frequent use of euphemisms, his concealment behind long, boring repetitious anecdotes, and his persistence in asking distracting cocktail-party questions. Because David seemed uninfluenced by the feedback, the group ultimately backed away and began to mascot him (to tolerate him in a good-natured fashion, but not to take him seriously).

In an individual session, he lamented about being “out of the loop” in the group and questioned whether he should continue. He also mentioned that he had not been wearing his hearing aid to the group (which I had not noticed) because of his fear of being ridiculed or stereotyped. Under ordinary circumstances, David would have dropped out of the group, but, in his individual therapy, I could capitalize on the group events and explore the meaning of his being “out of the loop.” It turned out to be a core issue for David. Throughout his childhood and adolescence, he had felt socially shunned and ultimately resigned himself to it. He became a loner and entered a profession (freelance computer consultation) that permitted a “lone-eagle” lifestyle.

At my urging, he reconnected his hearing aid in the group and expressed his feelings of being out of the loop. His self-disclosure and, even more important, his examination of his role in putting himself out of the loop were sufficient to reverse the process and bring him into the group. He remained in combined therapy with much profit for a year.

This example highlights another advantage of concurrent treatment: the rich and unpredictable interaction in the group commonly opens up areas in therapy that might otherwise never have surfaced in the more insular individual format. David never felt “out of the loop” in his individual therapy—after all, I listened to his every word and strove to be present with him continually.

• Another example involves Steven, a man who, for years, had many extramarital encounters but refused to take safer-sex precautions. In individual therapy I discussed this with him for months from every possible vantage point: his grandiosity and sense of immunity from biological law, his selfishness, his concerns about impotence with a condom. I communicated my concern for him, for his wife, and for his sex partners. I experienced and expressed paternal feelings: outrage at his selfish behavior, sadness at his self-destructiveness. All to no avail. When I placed Steven in a therapy group, he did not discuss his sexual risk-taking behavior, but some relevant experiences occurred.

On a number of occasions, he gave feedback to women members in a cruel, unfeeling manner. Gradually, the group confronted him on this and reflected on his uncaring, even vindictive, attitudes to women. Most of his group work centered on his lack of empathy. Gradually, he learned to enter the experiential world of others. The group was time limited (six months), and many months later in individual therapy, when we again focused in depth on Steven’s sexual behavior, he recalled, with considerable impact, the group members’ accusing him of being uncaring. Only then was he able to consider his choices in the light of his lack of loving, and only then did his behavioral pattern yield.

• A third example involves Roger, a young man who for a year in individual therapy had been continually critical of me. Roger acknowledged that he had made good gains—but, after all, that was precisely what he had hired me for, and, he never forgot to add, he was paying me big bucks for my services. Where were his positive, tender feelings? They never surfaced in individual therapy. When he entered my six-month combined therapy group, the pattern continued, and the members perceived him as cold, unfeeling, and often hostile—they called him the “grenade launcher.” Much to everyone’s surprise, it was Roger who expressed the strongest regret at the ending of the group. When pressed, he said that he would miss the group and miss his contact with some of the members. “Which of us in particular?” the group inquired. Before he could respond, I intervened and asked if the group could guess. No one had the vaguest idea. When Roger singled out two members, they were astonished, having had no hint that Roger cared for them.

The two therapies worked together. My experience with Roger in individual therapy cued me to pursue Roger’s affective block but it was the group members’ reaction—their inability to read him or to know of his feelings for them—that had a far more powerful impact on Roger. After all, their feelings could not be rationalized away—it was not part of their job.

• Sam, a man who entered therapy because of his inhibitions and lack of joie de vivre, encountered his lack of openness and his rigidity far more powerfully in the therapy group than in the individual format. He kept from the group three particularly important secrets: that he had been trained as a therapist and practiced for a few years; that he had retired after inheriting a large fortune; and that he felt superior and held others in contempt. He rationalized keeping secrets in the group (as he did in his social life) by believing that self-revelation would result in greater distance from others: he would be stereotyped in one way or another, “used,” envied, revered, or hated.

After three months of participation in a newly formed group, he became painfully aware of how he had re-created in the group the same peripheral onlooker role that he assumed in his real life. All the members had started together, all the others had revealed themselves and participated in a personal, uninhibited manner—he alone had chosen to stay outside.

In our individual work, I urged Sam to reveal himself in the group. Individual session after session, I felt like a second in a boxing ring exhorting him to take a chance. In fact, as the group meetings went by, I told him that delay was making things much worse. If he waited much longer to tell the group he had been a therapist, he would get a lot of flak when he did. (Sam had been receiving a steady stream of compliments about his perceptivity and sensitivity.)

Finally, Sam took the plunge and revealed his three secrets. Immediately he and the other members began to relate in a more genuine fashion. He enabled other members to work on related issues. A member who was a student therapist discussed her fear of being judged for superficial comments; another wealthy member revealed his concerns about others’ envy; another revealed that she was a closet snob. Still others discussed strong, previously hidden feelings about money—including their anger at the therapist’s fees. After the group ended, Sam continued to discuss these interactions in individual therapy and to take new risks with the therapist. The members’ acceptance of him after his disclosures was a powerfully affirming experience. Previously, they had accepted him for his helpful insights, but that acceptance meant little, because it was rooted in bad faith: his false presentation of himself and his concealment of his training, wealth, and personal traits.

Sam’s case points out some of the inherent pitfalls in combined therapy. For one thing, the role of the therapist changes significantly and increases in complexity. There is something refreshingly simple in leading a group when the leader knows the same thing about each member as everyone else does. But the combined therapist knows so much that life gets complicated. A member once referred to my role as that of the Magus: I knew everything: what members felt toward one another, what they chose to say, and, above all, what they chose to withhold.

Group therapists who see none of their group clients in individual therapy can be more freewheeling: they can ask for information, take blind guesses, ask broad, general questions, call on members to describe their feelings about another member or some group incident. But the combined therapist knows too much! It becomes awkward to ask questions of members when you know the answer. Consequently, many therapists find that they are less active in groups of their own individual clients than when leading other groups.

Input of group members often opens up rich areas for exploration, areas into which the individual therapist may enter. For example, Irene, a middle-aged woman, had left her husband months earlier and was, in a state of great indecision, living in a small rented apartment. Other group members asked how she had furnished the place, and gradually it came out that she had done virtually nothing to make her surroundings comfortable or attractive. An investigation into her need to deprive herself, to wear a hair shirt, proved enormously valuable to her.

The combined therapist often struggles with the issue of boundaries. (This is also true in conjoint therapy at times when the group therapist has learned from the individual therapist about important feelings or events that their mutual client has not yet addressed in the group.) Is the content of the client’s individual therapy the property of the group? As a general rule, it is almost always important to urge clients to bring up group-relevant material in the group. If, for example, in the individual therapy hour, the client brings up angry feelings toward another member, the therapist must urge the client to bring these feelings back to the group.

Suppose the client resists? Again, most therapists will pursue the least intrusive options: first, repeated urging of the client and investigation of the resistance; then focusing on in-group conflict between the two members, even if the conflict is mild; then sending knowing glances to the client; and, the final step, asking the client for permission to introduce the material into the group. Good judgment, of course, must be exercised. No technical rationale justifies humiliating a client. As noted earlier, a promise of absolute therapist confidentiality can rarely be provided without negatively constraining the therapy. Therapists can only promise that they will use their discretion and best professional judgment. Meanwhile, they must work toward helping the client accept the responsibility of bringing forward relevant material from one venue to the other.