The Theory and Practice of Group Psychotherapy (89 page)

Many therapists are reluctant to inflict a video camera on a group. They feel that it will inhibit the group’s spontaneity and that the group members will resent the intrusion—though not necessarily overtly. In my experience, the person who often experiences the most discomfort is the therapist. The fear of being exposed and shamed, particularly in supervision, is a leading cause of therapist resistance and must be addressed in supervision (see chapter 17).
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Clients who are to view the playback are usually receptive to the suggestion of videotaping. Of course, they are concerned about confidentiality and need reassurance on this issue. If the tape is to be viewed by anyone other than the group members (for example, students, researchers, or supervisors), the therapist must be explicit about the purpose of the viewing and the identity of the viewers and must also obtain written permission from each member with regard to each intended use: clinical, educational, and research. Clients should be full participants in the decision about the secure storage or erasure of the videotapes.

Videotaping in Teaching

Video recording has proven its value in the teaching of all forms of psychotherapy. Students and supervisors are able to view a session with a minimum of distortion. Important nonverbal aspects of behavior by both students and clients, which may be completely missed in the traditional supervisory format, become available for study. The student-therapist has a rich opportunity to observe his or her own presentation of self and body language. Frequently what gets missed in traditional supervision is not the students’ “mistakes,” but the very effective interventions that they employ intuitively without conscious awareness. Confusing aspects of the meeting may be viewed several times until some order appears. Valuable teaching sessions that clearly illustrate basic principles of therapy may be stored and a teaching videotape library created. This has become a mainstay of training psychotherapists for both clinical practice and for leading manual-based groups in clinical trials.†
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Videotaping in Research

The use of videotaping has also advanced the field significantly by allowing researchers to ensure that the psychotherapy being tested in clinical trials is delivered competently and adheres to the intent of the study.
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It is no less important in a psychotherapy trial than it is in a drug therapy trial to monitor the treatment delivery and demonstrate that clients received the right kind and right amount of treatment. In pharmacotherapy research, blood level assays are used for this purpose. In psychotherapy research, video recordings are an excellent monitoring tool for the same purpose.

WRITTEN SUMMARIES

For the past thirty years, I have regularly used the ancillary technique of written summaries in my group therapy. At the end of each session, I dictate a detailed summary of the group session.
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The summary is an editorialized narrative that describes the flow of the session, each member’s contribution, my contributions (not only what I said but what I wished I had said and what I did say but regretted), and any hunches or questions that occur to me after the session. This dictation is transcribed either by a typist or via voice recognition program and mailed to the members the following day. Dictation of the summaries (two to three single-spaced pages) requires approximately twenty to thirty minutes of a therapist’s time and is best done immediately after the session. To date, my students and colleagues and I have written and mailed thousands of group summaries to group members. It is my strong belief that the procedure greatly facilitates therapy.

But in these days of economically pressured psychotherapy, who can accommodate a task that requires yet another thirty minutes of therapist time and an hour or two of secretarial time? For that matter, look back through this chapter: Who has time for setting up cameras and selecting portions of the videotape to replay to the group? Who has time for even brief meetings with a co-therapist before and after meetings? Or for conferring with group members’ individual therapists? The answer, of course, is that harried therapists must make choices and often, alas, must sacrifice some potentially powerful but time-consuming adjuncts to therapy in order to meet the demands of the marketplace. Every therapist is dismayed by the draining off of time and effort in completing mountains of paperwork.

Managed health care administrators believe that time can be saved by streamlining therapy—making it slicker, briefer, more uniform. But in psychotherapy, uniformity is not synonymous with efficiency, let alone with effectiveness. Therapists sacrifice the very core of therapy if they sacrifice their ingenuity and their ability to respond to unusual clinical situations with creative measures. Hence, even though the practice is not in wide clinical use at present, I devote space in this text to such techniques as the written summary. I believe it is a potent facilitating technique. My experience has been that all group therapists willing to try it have found that it enhances the course of group therapy.†
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Moreover, a description of the summary technique raises many issues of great importance in the education of the young therapist.†
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The written summary may even do double service as a mechanism for documenting the course of therapy and meeting the requirements of third-party payers, turning the usually unrewarding and dry process of record keeping into a functional intervention.
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We are wise to remember that the client’s record belongs to the client and can be accessed by the client at any point. In all instances, it is appropriate to write notes expecting that they may be read by the client. Notes should therefore provide a transparent, therapeutic, depathologizing, considered, and empathic account of the treatment (and not include group members’ last names).

My first experience with the written summary was in individual therapy. A young woman, Ginny, had attended a therapy group for six months but had to terminate because she moved out of town and could not arrange transportation to get to the group on time. Moreover, her inordinate shyness and inhibition had made it difficult for her to participate in the group. Ginny was inhibited in her work as well: a gifted writer, she was crippled by severe writer’s block.

I agreed to treat her in individual therapy but with one unusual proviso: after each therapy hour, she had to write an impressionistic, freewheeling summary of the underground of the session, that is, what she was really thinking and feeling but had not verbally expressed. My hope was that the assignment would help penetrate the writing block and encourage greater spontaneity. I agreed to write an equally candid summary. Ginny had a pronounced positive transference. She idealized me in every way, and my hope was that a written summary conveying my honest feelings—pleasure, discouragement, puzzlement, fatigue—would permit her to relate more genuinely to me.

For a year and a half, Ginny and I wrote weekly summaries. We handed them, sealed, to my secretary, and every few months we read each other’s summaries. The experiment turned out to be highly successful: Ginny did well in therapy, and the summaries contributed greatly to that success.
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I developed sufficient courage from the venture (and courage is needed: it is difficult at first for a therapist to be so self-revealing) to think about adapting the technique to a therapy group. The opportunity soon arose in two groups of alcoholic clients.
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My co-therapists and I had attempted to lead these groups in an interactional mode. The groups had gone well in that the members were interacting openly and productively. However, here-and-now interaction always entails anxiety, and alcoholic clients are notoriously poor anxiety binders. By the eighth meeting, members who had been dry for months were drinking again (or threatening to drink again if they “ever had another meeting like the one last week!”). We hastily sought methods of modulating anxiety: increased structure, a suggested (written) agenda for each meeting, video playback, and written summaries distributed after each meeting. The group members considered the written summary to be the most efficacious method by far, and soon it replaced the others.

I believe that the summaries are most valuable if they are honest and straightforward about the process of therapy. They are virtually identical to summaries I make for my own files (which provide most of the clinical material for this book) and are based on the assumption that the client is a full collaborator in the therapeutic process—that
psychotherapy is strengthened, not weakened, by demystification.

The summary serves several functions: it provides understanding of the events of the session, takes note of good (or resistive) sessions; comments on client gains; predicts (and, by doing so, generally prevents) undesirable developments; brings in silent members; increases cohesiveness (by underscoring similarities and caring in the group, and so on); invites new behavior and interactions; provides interpretations (either repetition of interpretations made in the group or new interpretations occurring to the therapist later); and provides hope to the group members (helping them realize that the group is an orderly process and that the therapists have some coherent sense of the group’s long-term development). In fact, the summary may be used to augment every one of the group leader’s tasks in a group. In the following discussion of the functions of the summary, I shall cite excerpts from summaries and end the section with an entire summary.

Revivification and Continuity

The summary becomes another group contact during the week. The meeting is revivified for the members, and the group is more likely to assume continuity. In chapter 5 I stated that groups assume more power if the work is continuous, if themes begun one week are not dropped but explored, more deeply, in succeeding meetings. The summary augments this process. Not infrequently, group members begin a meeting by referring to the previous summary—either a theme they wish to explore or a statement with which they disagree.

Understanding Process

The summary helps clients reexperience and understand important events of a meeting. In chapter 6, I described the here-and-now as consisting of two phases:
experience
and
the understanding of that experience
.
The summary facilitates the second stage
, the understanding and integration of the affective experience. Sometimes group sessions may be so threatening or unsettling that members close down and move into a defensive, survival position. Only later (often with the help of the summary) can they review significant events and convert them into constructive learning experiences. The therapist’s interpretations (especially complex ones) delivered in the midst of a melee tend to fall on deaf ears. Interpretations repeated in the summary are often effective because the client is able to consider them at length, far from the intensity of engagement.

Shaping Group Norms

The summaries may be used to reinforce norms both implicitly and explicitly. For example, the following excerpt reinforces the here-and-now norm:

• Phil’s relationship with his boss is very important and difficult for him at this time, and as such is certainly material for the group. However, the members do not know the boss, what he is like, what he is thinking and feeling and thus are limited in offering help. However, they are beginning to know one another and can be more certain of their own reactions to one another in the group. They can give more accurate feedback about feelings that occur between them rather than trying to guess what the boss may be thinking.

Or consider the following excerpt, which encourages the group members to comment on process and to approach the therapist in an egalitarian manner:

• Jed did something very different in the group today, which was to make an observation about the bind that Irv [the therapist] was in. He noted, quite correctly, that Irv was in a bind of not wishing to change the topic from Dinah because of Irv’s reluctance to stir up any of Dinah’s bad feelings about being rejected or abandoned in the group, but on the other hand Irv wanted very much to find out what was happening to Pete, who was obviously hurting today.

Therapeutic Leverage

The therapist may, in the summary, reinforce risk taking and focus clients on their primary task, their original purpose in coming to therapy. For example:

• Irene felt hurt at Jim’s calling her an observer of life and fell silent for the next forty-five minutes. Later she said she felt clamped up and thought about leaving the group. It is important that Irene keep in mind that her main reason for being in therapy was that she felt estranged from others and unable to create closer, sustained relationships, especially with men. In that context, it is important for her to recognize, understand, and eventually overcome her impulse to clamp up and withdraw as a response to feedback.

Or the therapist may take care to repeat statements by clients that will offer leverage in the future. For example:

• Nancy began weeping at this point, but when Ed tried to console her, she snapped, “Stop being so kind. I don’t cry because I’m miserable, I cry when I’m pissed off. When you console me or let me off the hook because of my tears, you always stop me from looking at my anger.”

New Thoughts

Often the therapist understands an event after the fact. On other occasions, the timing is not right for a clarifying remark during a session (there are times when too much cognition might squelch the emotional experience), or there has simply been no time available in the meeting, or a member has been so defensive that he or she would reject any efforts at clarification. The summaries provide the therapist with a second chance to convey important thoughts. This excerpt communicates a message that emerged in the co-therapist’s postmeeting discussion. The summary describes and attempts to counteract undesirable developments in the session—the shaping of countertherapeutic norms and scapegoating: