The Theory and Practice of Group Psychotherapy (86 page)
Read The Theory and Practice of Group Psychotherapy Online
Authors: Irvin D. Yalom,Molyn Leszcz
Tags: #Psychology, #General, #Psychotherapy, #Group
Combined group and individual therapy may present special problems for neophyte group therapists. Some find it difficult to see the same client in two formats because they customarily assume a different role in the two types of therapy: in group, therapists tend to be more informal, open, and actively engaged with the client; in individual therapy, the therapist tends to remain somewhat impersonal and distant. Often therapists in training prefer that clients have a pure treatment experience—that is, solely group therapy without any concurrent individual therapy with themselves or other therapists—in order to discover for themselves what to expect from each type of therapy.
COMBINING GROUP THERAPY AND TWELVE-STEP GROUPS
An increasingly common form of concurrent therapy is the treatment in group psychotherapy of clients who are also participating in twelve-step groups. Historically, a certain antipathy has existed between the proponents of these two modalities, with subtle and at times overt denigration of one another.
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Recently there has been a growing recognition that substance use disorders are an appropriate focus for the mental health field. The vast economic costs and psychosocial scope of addiction disorders, the high comorbidity rates with other psychological problems, and the social and relational context of addiction make group therapy particularly relevant.†
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Individuals who abuse substances also typically experience substantial interpersonal disturbance at every stage of their illness: first, they have predisposing interpersonal difficulties resulting in emotional pain that the individual attempts to abate by substance use; second, they have relational difficulties resulting from the substance abuse; third, they have interpersonal difficulties that complicate the maintenance of sobriety. There is good evidence that group therapy can play an important role in recovery by alcoholics helping them develop coping skills that sustain sobriety and enhance resilience to relapse.
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There is also strong evidence that twelve-step groups are both effective and valued by clients.
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(Alcoholics Anonymous is the most prevalent of the twelve-step groups, but there are over 100 variations, for such conditions as cocaine and other narcotics addiction, gambling, sexual addiction, and overeating.) It is inevitable that some of the many million of members of AA attending the thousands of weekly group meetings in the United States alone will also participate in group psychotherapy. Furthermore, there is emerging evidence that twelve-step groups and mainstream therapies can be effectively integrated.†
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Group therapy and AA can complement one another if certain obstacles are removed. First, group leaders must become informed about the mechanism of twelve-step group work and learn to appreciate the inherent wisdom in the twelve-step program as well as the enormous support it offers to those struggling with addiction. Second, there are several common misconceptions that must be cleared up—misconceptions held by group therapists and/or by members of AA. These include:
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1. Twelve-step groups are opposed to psychotherapy or medication.
2. Twelve-step groups encourage the abdication of personal responsibility.
3. Twelve-step groups discourage the expression of strong affects.
4. Mainstream group therapy neglects spirituality.
5. Mainstream group therapy is powerful enough to be effective without twelve-step groups.
6. Mainstream group therapy views the AA relationships and the relationship between sponsor and sponsee as regressive.
Keep in mind that it is difficult to make blanket statements about AA meetings, because AA meetings are not all the same: there is much variability from group to group. In general, however, there are two major differences between the AA approach and the group therapy approach.
AA relies heavily on the members’ relationship to a higher power, submission to that power, and understanding of the self in relation to that higher power.
Group therapy encourages member-to-member interaction, especially in the here-and-now: it is the lifeblood of the group. AA, by contrast, specifically prohibits “crosstalk”—that is, direct interaction between members during a meeting. “Crosstalk” could be any direct inquiry, suggestion, advice, feedback, or criticism. (This, too, is a generalization, however: if one searches, one can find AA groups that engage in considerable interaction.) The prohibition of “crosstalk” by no means leads to an impersonal meeting, however. AA members have pointed out to me that the knowledge that there will be no judgment or criticism is freeing to members and encourages them to self-disclose at deep levels. Since there is no designated trained group leader to modulate and process here-and-now interaction, it seems to me that AA’s decision to avoid intensive interpersonal interaction is a wise and instrumental one.
Therapy group leaders introducing an AA member into their therapy group must keep in mind that group feedback will be an unfamiliar concept and should take extra time and care in pregroup preparation sessions to explain the difference between the AA model and the therapy group model regarding the use of the here-and-now.
I recommend that group leaders attend some AA meetings and thoroughly familiarize themselves with the twelve steps. Demonstrate your respect for the steps and attempt to convey to the client that most of the twelve steps have meaning in the context of the therapy group and, if followed, will enhance the work of therapeutic change.
Table 14.1
lists the twelve steps and suggests related group therapy themes. I do not suggest a reinterpretation of the twelve steps but a loose translation of ideas in the steps into related interpersonal group concepts. With this framework, group leaders can readily employ a common language that covers both approaches and reinforces the idea that therapy and the recovery process are mutually facilitative.
TABLE 14.1
The Convergence of Twelve-Step and Interpersonal Group Therapy Approaches
| The Twelve Steps | Interpersonal Group Psychotherapy |
|---|---|
| 1. We admitted that we were powerless over alcohol and that our lives had become unmanageable | Relinquish grandiosity and counterdependence. |
| Begin the process of trusting the process and the power of the group. | |
| 2. Came to believe that a Power greater than ourselves could restore us to sanity | Self-repair through relationships and human connection. |
| Reframe “Higher Power” into a source of soothing, nurturance, and hope that may replace the reliance on substances. | |
| 3. Made a decision to turn our will and our lives over to the care of God as we understood Him | Make a leap of trust in the therapy procedure and the good will of fellow group members. |
| 4. Made a searching and fearless moral inventory of ourselves | Self-discovery. Search within. Learn as much about yourself as possible. |
| 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs | Self-disclosure. Share your inner world with others—the experiences that fill you with shame and guilt as well as your dreams and hopes. |
| 6. Were entirely ready to have God remove all these defects of character | Explore and illuminate, in the here-and- now of the treatment, all destructive interpersonal actions that invite relapses. |
| The task of the group is to help members find the resources within themselves to prepare to take action. | |
| 7. Humbly asked Him to remove our shortcomings | Acknowledge interpersonal feelings and behaviors that hinder satisfying relationships. Modify these by experimenting with new behaviors. |
| Request and accept feedback in order to broaden your interpersonal repertoire. | |
| Though the group offers the opportunity to work on issues, it is your responsibility to do the work. | |
| 8. Made a list of all persons we had harmed, and became willing to make amends to them all | Identify interpersonal injuries you have been responsible for; develop empathy for others’ feelings. Try to appreciate the impact of your actions on others and develop the willingness to repair injury. |
| 9. Made direct amends to such people wherever possible, except when to do so would injure them or others | Use the group as a testing ground for the sequence of recognition and repair. Start the ninth step work by making amends to other group members whom you have in any manner impeded or offended. |
| 10. Continued to take personal inventory and when we were wrong promptly admit it | Internalize the process of self-reflection, assumption of responsibility, and self- revelation. Make these attributes part of your way of being in the therapy group and in your outside life. |
| 11. Sought through prayer and meditation to improve our conscious contact with God as we understand Him, praying only for knowledge of His will for us and the power to carry that out | No direct psychotherapeutic focus, but the therapy group may support mind-calming meditation and spiritual exploration. |
| 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to other addicts, and to practice these principles in all our affairs | Become actively concerned for others, beginning with your fellow group members. Embracing an altruistic way of being in the world will raise your love and respect for yourself. |
| Adapted from Matano and Yalom. 20 |
CO-THERAPISTS
Some group therapists choose to meet alone with a group, but the great majority prefer to work with a co-therapist.
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Limited research has been conducted to determine the relative efficacy of the two methods, although a study of co-therapy in family and marital therapy demonstrates that that in those modalities co-therapy is at least as effective as single therapist treatment and in some ways superior.
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Clinicians differ in their opinions.
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My own clinical experience has taught me that co-therapy presents both special advantages and potential hazards.
First, consider the advantages, both for the therapists and the clients. Co-therapists complement and support each other. Together, they have greater cognitive and observational range, and with their dual points of view they may generate more hunches and more strategies. When one therapist, for example, is intensively involved with one member, the co-therapist may be far more aware of the remaining members’ responses to the interchange and hence may be in a better position to broaden the range of the interaction and exploration.
Co-therapists also catalyze transferential reactions and make the nature of distortions more evident, because clients will differ so much among themselves in their reactions to each of the co-therapists and to the co-therapists’ relationship. In groups in which strong therapist countertransference reactions are likely (for example, groups for clients with HIV or cancer or in trauma groups), the supportive function of co-therapy becomes particularly important for both clients and therapists.†
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Most co-therapy teams deliberately or, more often, unwittingly split roles: one therapist assumes a provocative role—much like a Socratic gadfly—while the other is more nurturing and serves as a harmonizer in the group.† When the co-therapists are male and female, the roles are usually (but not invariably) assumed accordingly. In well-functioning co-therapy teams these roles are fluid, not rigid. Each leader should have access to the full range of therapeutic postures and interventions.
Many clinicians agree that a male-female co-therapist team may have unique advantages: the image of the group as the primary family may be more strongly evoked; many fantasies and misconceptions about the relationship between the two therapists arise and may profitably be explored. Many clients benefit from the model setting of a male-female pair working together with mutual respect and inclusiveness, without the destructive competition, mutual derogation, exploitation, or pervasive sexuality they may associate with male-female pairings. For victims of early trauma and sexual abuse, a male-female co-therapy team increases the scope of the therapy by providing an opportunity to address issues of mistrust, abuse of power, and helplessness that are rooted in early paradigms of male-female relationships. Clients from cultures in which men are dominant and women are subservient may experience a co-therapy team of a strong, competent woman and a tender, competent man as uniquely facilitative.
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From my observations of over eighty therapy groups led by neophyte therapists, I consider the co-therapy format to have special advantages for the beginning therapist. Many students, in retrospect, consider the co-leader experience one of their most effective learning experiences. Where else in the training curriculum do two therapists have the opportunity to participate simultaneously in the same therapy experience and supervision?
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For one thing, the presence of a co-therapist lessens initial therapist anxiety and permits therapists to be more objective in their efforts to understand the meeting. In the post-meeting rehash, the co-therapists can provide valuable feedback about each other’s behavior. Until therapists obtain sufficient experience to be reasonably clear of their own self-presentation in the group, such feedback is vital in enabling them to differentiate what is real and what is transference distortion in clients’ perceptions. Similarly, co-therapists may aid each other in the identification and working-through of countertransference reactions toward various members.