The Theory and Practice of Group Psychotherapy (87 page)

It is especially difficult for beginning therapists to maintain objectivity in the face of massive group pressure. One of the more unpleasant and difficult chores for neophyte therapists is to weather a group attack on them and to help the group make constructive use of it. When you are under the gun, you may be too threatened either to clarify the attack or to encourage further attack without appearing defensive or condescending. There is nothing more squelching than an individual under fire saying, “It’s really great that you’re attacking me. Keep it going!” A co-therapist may prove invaluable here in helping the members continue to express their anger at the other therapist and ultimately to examine the source and meaning of that anger.

Whether co-therapists should openly express disagreement during a group session is an issue of some controversy. I have generally found co-therapist disagreement unhelpful to the group in the first few meetings. The group is not yet stable or cohesive enough to tolerate such divisiveness in leadership. Later, however, therapist disagreement may contribute greatly to therapy. In one study, I asked twenty clients who had concluded long-term group therapy about the effects of therapist disagreement on the course of the group and on their own therapy.
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They were unanimous in their judgment that it was beneficial. For many it was a model-setting experience: They observed individuals whom they respected disagree openly and resolve their differences with dignity and tact.

Consider a clinical example:

• During a group meeting my co-leader, a resident, asked me why I seemed so quick to jump in with support whenever one of the men, Rob, received feedback. The question caught me off guard. I commented first that I had not noticed that until she drew it to my attention. I then invited feedback from others in the group, who agreed with her observation. It soon became clear to me that I was overly protective of Rob, and I commented that although he had made substantial gains in controlling his anger and explosiveness, I still regarded him as fragile and felt I needed to protect him from overreacting and undoing his success. Rob thanked me and my co-leader for our openness and added that although he may have needed extra care in the past, he no longer did at this point. He was correct!

In this way, group members experience therapists as human beings who, despite their imperfections, are genuinely attempting to help the members. Such a humanization process is inimical to irrational stereotyping, and clients learn to differentiate others according to their individual attributes rather than their roles. Unfortunately, co-therapists take far too little advantage of this wonderful modeling opportunity. Research into communicational patterns in therapy groups shows exceedingly few therapist-totherapist remarks.
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Although some clients are made uncomfortable by co-therapists’ disagreement, which may feel like witnessing parental conflict, for the most part it strengthens the honesty and the potency of the group. I have observed many stagnant groups spring to life when the two therapists differentiated themselves as individuals.

The disadvantages of the co-therapy format flow from problems in the relationship between the two co-therapists. How the co-therapy goes, so will the group. That is one of the main criticisms of the use of co-therapy outside of training environments.
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Why add another relationship (and one that drains professional resources) to the already interpersonally complex group environment?
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Hence, it is important that the co-therapists feel comfortable and open with each other. They must learn to capitalize on each other’s strengths: one leader may be more able to nurture and support and the other more able to confront and to tolerate anger. If the co-therapists are competitive, however, and pursue their own star interpretations rather than support a line of inquiry the other has begun, the group will be distracted and unsettled.

It is also important that co-therapists speak the same professional language. A survey of forty-two co-therapy teams revealed that the most common source of co-therapy dissatisfaction was differing theoretical orientation.
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In some training programs a junior therapist is paired with a senior therapist, a co-therapy format that which offers much but is fraught with problems. Senior co-therapists must teach by modeling and encouragement, while junior therapists must learn to individuate while avoiding both nonassertiveness and destructive competition. Most important, they must be willing, as equals, to examine their relationship—not only for themselves but as a model for the members.† The choice of co-therapist is not to be taken lightly. I have seen many classes of psychotherapists choose co-therapists and have had the opportunity to follow the progress of these groups, and I am convinced that the ultimate success or failure of a group depends largely on the correctness of that choice. If the two therapists are uncomfortable with each other or are closed, rivalrous, or in wide disagreement about style and strategy (and if these differences are not resolvable through supervision), there is little likelihood that their group will develop into an effective work group.
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Differences in temperament and natural rhythm are inevitable. What is not inevitable, however, is that these differences get locked into place in ways that limit each co-therapist’s role and function. Sometimes the group’s feedback can be illuminating and lead to important work, as occurred in a group for male spousal abusers who questioned why the male co-therapist collected the group fee and the female co-therapist did the “straightening up.”

When consultants or supervisors are called in to assist with a group that is not progressing satisfactorily, they can often offer the greatest service by directing their attention to the relationship between the co-therapists. (This will be fully discussed in chapter 17.) One study of neophyte group leaders noted that the factor common to all trainees who reported a disappointing clinical experience was unaddressed and unresolved cotherapy tensions.
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One frustrated and demoralized co-therapist reported a transparent dream in supervision, just after her arrogant but incompetent co-therapist withdrew from the training program. In the dream she was a hockey goalie defending her team’s net, and one of her own players (guess who?) kept firing the puck at her.

Co-therapist choice should not be made blindly: do not agree to co-lead a group with someone you do not know well or do not like. Do not make the choice because of work pressures or an inability to say no to an invitation: it is far too important and too binding a relationship.
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You are far better off leading a solo group with good supervision than being locked into an incompatible co-therapy relationship.
If, as part of your training, you become a member of an experiential group, you have an ideal opportunity to gather data about the group behavior of other students. I always suggest to my students that they delay decisions about co-therapists until after meeting in such a group. You do well to select a co-therapist toward whom you feel close but who in personal characteristics is dissimilar to you: such complementarity enriches the experience of the group.

There are, as I discussed, advantages in a male-female team, but you will also be better off leading a group with someone compatible of the same sex than with a colleague of the opposite sex with whom you do not work well. Husbands and wives frequently co-lead marital couples groups (generally short term and focused on improvement of dyadic relationships) ; co-leadership of a long-term traditional group, however, requires an unusually mature and stable marital relationship. I advise therapists who are involved in a newly formed romantic relationship with each other not to lead a group together; it is advisable to wait until the relationship has developed stability and permanence. Two former lovers, now estranged, do not make a good co-therapy team.

Characterologically difficult clients (see chapter 13) who are unable to integrate loving and hateful feelings may project feelings on the therapists that end up “splitting” the co-therapy team. One co-therapist may become the focus of the positive part of the split and is idealized while the other becomes the focus of hateful feelings and is attacked or shunned. Often client’s overwhelming fears of abandonment or of engulfment trigger this kind of splitting.

Some groups become split into two factions, each co-therapist having a “team” of clients with whom he or she has a special relationship. Sometimes this split has its genesis in the relationship the therapist established with those clients before the group began, in prior individual therapy or in consultation. (For this reason, it is advisable that
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therapists interview all clients, preferably simultaneously, in the pregroup screening. I have seen clients continue to feel a special bond throughout their entire group therapy course with the member of the co-therapy team who first interviewed them.) Other clients align themselves with one therapist because of his or her personal characteristics, or because they feel a particular therapist is more intelligent, more senior, or more sexually attractive than the other or more ethnically or personally similar to themselves. Whatever the reasons for the subgrouping,
the process should be noted and openly discussed.

One essential ingredient of a good co-therapy team is discussion time. The co-therapy relationship takes time to develop and mature. Co-therapists must
set aside time to talk and tend to their relationship.
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At the very least, they need a few minutes before each meeting (to talk about the last session and to examine possible agendas for that day’s meeting) and fifteen to twenty minutes at the end to debrief and to share their reflections about each other’s behavior. If the group is supervised, it is imperative that
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therapists attend the supervisory session. Many busy HMO clinics, in the name of efficiency and economy, make the serious mistake not setting aside time for co-therapist discussion.

THE LEADERLESS MEETING

Beginning in the 1950s, some clinicians experimented with leaderless meetings. Groups would meet without the leader when he was on vacation, or the group might meet more than once weekly and schedule regular leaderless meetings. Over the past two decades, however, interest in leaderless meetings has waned. Almost no articles on the subject have appeared, and my own informal surveys indicate that few contemporary clinicians use regularly scheduled leaderless meetings in their practice.
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In contemporary practice, therapists occasionally arrange for a leaderless meeting on the infrequent occasions when they are out of town. This is one option for dealing with the absence of the therapist. Other options include, of course, canceling the meeting, rescheduling it, extending the time of the next group, and providing a substitute leader.
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Members generally do not initially welcome the suggestion of the leaderless meeting. It evokes many unrealistic fears and consequences of the therapist’s absence. In one study, I asked a series of clients who had been in group therapy for at least eight months what would have happened in the group if the group therapists were absent.
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(This is another way of asking what function the group therapists perform in the group.) The replies were varied. Although a few members stated that they would have welcomed leaderless meetings, most of the others expressed, in order of frequency, these general concerns:

1. The group would stray from the primary task. A cocktail-hour atmosphere would prevail; members would avoid discussing problems, there would be long silences, and the discussions would become increasingly irrelevant: “We would end up in left field without the doctor to keep us on the track”; “I could never express my antagonisms without the therapist’s encouragement”; “We need him there to keep things stirred up”; “Who else would bring in the silent members?”; “Who would make the rules? We’d spend the entire meeting simply trying to make rules.”

2. The group would lose control of its emotions. Anger would be unrestrained, with no one there either to rescue the damaged members or to help the aggressive ones maintain control.

3. The group would be unable to integrate its experiences and to make constructive use of them: “The therapist is the one who keeps track of loose ends and makes connections for us. She helps clear the air by pointing out where the group is at a certain time.” The members viewed the therapist as the time binder—the group historian who sees patterns of behavior longitudinally and points out that what a member did today, last week, and last month fits into a coherent pattern. The members were saying, in effect, that however great the action and involvement without the therapist, they would be unable to make use of it.

Many of the members’ concerns are clearly unrealistic and reflect a helpless, dependent posture. It is for this very reason that a leaderless meeting may play an important role in the therapy process. The alternate meeting helps members experience themselves as autonomous, responsible, resourceful adults who, though they may profit from the therapist’s expertise, are nevertheless able to control their emotions, to pursue the primary task of the group, and to integrate their experience.

The way a group chooses to communicate to the therapist the events of the alternate meeting is often of great interest. Do the members attempt to conceal or distort information, or do they compulsively brief the therapist on all details? Sometimes the ability of a group to withhold information from the therapist is in itself an encouraging sign of group maturation, although therapists are usually uncomfortable with being excluded. In the group, as in the family, members must strive for autonomy, and the leaders must facilitate that striving. Often the leaderless session and subsequent events allow the therapist to experience and understand his or her own desires for control and feelings of being threatened as clients become less dependent.