The Theory and Practice of Group Psychotherapy (91 page)

We did not pursue that any further, but we wonder if that’s not an important event: that is, that it might be important not only to Laura but to Edith as well to know that Laura has this fear of her—a fear that Paul commented he also shared at times. The reason this might be important is that Edith stated that she wants to do some work on the attitude of attack that she often assumes.

The man she is dating has made similar comments to her. Is it possible that the aspect of Laura’s fear that may be important to Edith is that Laura has been attacked by Edith on several occasions in the past and that Laura remembers these and is (understandably) cautious? Edith, on the other hand, has a sense that, because she has forgotten or dismissed the previous attack, Laura should therefore, of course, do so also—and that’s where the discrepancy begins to come in. Indeed, in the previous meeting, Edith seemed rather astonished that Laura would still continue to feel that fear. This may be an important theme that should be examined in future meetings. People forget different things at different rates.

Irv attempted to bring Ted into the meeting because everyone has been aware that Ted has been withdrawn and silent in the meetings, and his participation has been much missed. Ted talked, once again, about feeling that the group was unsafe and feeling fearful of talking because he keeps being attacked for almost anything he says. But not so, the group said! We then talked about the fact that, as Laura pointed out, when he talked about issues that were personal and close to himself—like his loneliness or his difficulties making friends—then, indeed, there was no attack at all.

The group began to try to help differentiate that there are things that Ted may do that evoke attack, but there are plenty of other ways he could interact in the group that would, indeed, not culminate in any type of attack. What ways? Ted asked.

Well, Irv pointed out that Ted might make positive comments about people or focus on some of the things he liked about people in the group, and it was suggested that he do this. Edith asked him for some positive feedback, and for a few moments Ted was blocked and then finally commented that Edith had “a pleasant personality . . . usually.”

The phrasing of this sentence soon resulted in some antagonistic exchanges, and soon Ted was back in a very familiar and very unsafe situation in the group. Laura and others pointed out that he had phrased that compliment in such a way as to undo it and make it seem less like a compliment and almost more like something negative. Al and others pointed out how the adding of the word “usually” made it seem ironical rather than a genuine compliment. Ted defended himself by saying that he had to be honest and had to be accurate. He also pointed out that, if he were simply to say that Edith was intelligent or sensitive, she would immediately conclude that he meant that she was the most intelligent person in the room.

Edith pointed out that, indeed, that was not the case, and she would have been pleased to hear him give that kind, any kind, of compliment. Ted might have been in a little less of a bind, as Bill pointed out, had he made a more limited type of compliment: that is, rather than talk about something as global as personality, make it somewhat more narrow. For example, Ted might have commented on some aspect of Edith that he liked, some single act, something she said, even her dress or her hair or some particular mannerism.

When we questioned Ted about how he had gotten back into this situation in the group and whether he bore any responsibility for it, Ted was very quick to point out that, indeed, he had and that he did share a good part of the burden of responsibility for the position of being attacked that he was in. We attempted to point out to Ted that feeling the group as unsafe is an extremely important issue for him to work on because this is very much the way he experiences the world outside, and the more he can explore ways to live in the group so that it appears less dangerous, the more he will be able to generalize to his life outside.

In the last few minutes of the group, the focus turned to Bill. Edith and others commented that they had been missing his participation. Bill stated he’d been aware of his inactivity and been disappointed that he’d shared so little of himself. His silence has been somewhat different from Ted’s silence in that he does not experience the group as unsafe but instead has a sense of letting things pass by. If he has some questions or opinions, he’s perfectly willing to let them go by without expressing them. This posture of letting the life in the group go by may be extremely important for Bill because it reflects how he lives in the world at large—where he lets much of life go by and often experiences himself more as an observer than as a participant. Changing that posture in the group would be the first step to changing that posture in life.

Kathy was rather quiet in the group today, but the comments she did make earlier in the meeting reflected that she, at least visibly, appears less depressed and distressed than she was during the previous meeting.

This summary illustrates several of the functions I described earlier. It clarifies process. A good deal of the meeting was consumed by Paul’s obsessive, confusing monologue (which was rendered more confusing yet by his comment that he had gotten a great deal from his recitation). The summary explained the process of that transaction. It also reinforced norms (by, for example, supporting Laura for checking out surreptitious glances passing between two members). It increased therapeutic leverage by linking in-group behavior with out-group problems (two instances of this: Edith’s relationship with her boyfriend and Bill’s observer posture in life).

It added some afterthoughts (the comment to Al about filling time with questions about content to keep the group from questioning him). It attempted to identify behavioral and dynamic patterns (for example, Edith’s narcissistic sense of entitlement—that is, that she should be able to attack when she was angry and that the others should forget about it when she felt better). Lastly, it left no one out, reminding each that they were being seen and cared for.

GROUP THERAPY RECORD KEEPING

Documentation of therapy must protect confidentiality and meet a number of objectives: to demonstrate that an appropriate standard of care has been provided; to describe the process and effectiveness of the treatment; to facilitate continuity of care by another therapist at a later time; to verify that a billable service has been provided at a certain time and date.

For these purposes many recommend that the group therapist keep a combined record: a group record and a separate file for each individual member.
⁵⁷
If written group summaries are used, they should be included in the group record. For students the group record may also serve as the group
process notes
that will be reviewed in supervision. The group record should note attendance, scheduling issues, prominent group themes, the state of group cohesion, prominent interactions, transference and countertransference, what was engaged and what was avoided, and anticipations of what will need to be addressed in the next session. The group therapist should
always
review this record immediately before the following meeting.

In addition, a personal chart or record must be kept for each individual client. This record serves as the client’s personal
progress notes
, noting initial goals, symptoms; safety concerns if any; engagement with the psychotherapy process; and achievement of therapy goals. Whereas the group record should be made after each group meeting, the individual progress notes can be made at less frequent but regular intervals, with more frequent entries as the clinical situation warrants.

STRUCTURED EXERCISES

I use the term
structured exercise
to denote an activity in which a group follows some specific set of directions. It is an experiment carried out in the group, generally suggested by the leader but occasionally by some experienced member. The precise rationale of the structured exercises varies, but in general they are considered accelerating devices. Unlike some of the more time-consuming techniques described in this chapter, these exercises may be regarded as efficiency oriented and hence may be of special interest to managed health care therapists and policymakers.

Structured exercises attempt to speed up the group with warm-up procedures that bypass the hesitant, uneasy first steps of the group; they speed up interaction by assigning to interacting individuals tasks that circumvent ritualized, introductory social behavior; and they speed up each individual member’s work by techniques designed to help members move quickly to get in touch with suppressed emotions, with unknown parts of themselves, and with their physical selves.† In some settings and with some clinical populations, the structured exercise may be the central focus of the meeting. Some common models include action- and activity-oriented groups for the elderly (such as art, dance, and movement groups) that aim to reconnect clients to a sense of effectiveness, competence, and social interaction; structured activity groups for hospitalized psychotic patients; and body awareness for victims of trauma.
⁵⁸

Mindfulness-based stress reduction (MBSR) groups that teach meditation, deep breathing, and relaxation and focus awareness on members’ moment-to-moment state of being are also prominent and have been used to remarkably good effect in the treatment of medical illnesses and anxiety disorders and in the prevention of relapse in depression.
⁵⁹
These techniques can also be incorporated as smaller components of broader-based group interventions.

The structured exercise in interactional groups may require only a few minutes, or it may consume an entire meeting. It may be predominantly verbal or nonverbal. Almost all nonverbal procedures, however, include a verbal component; generally, the successful structured exercise will generate data that is subsequently discussed. Such exercises, common in the encounter groups but far less used in the therapy group, may involve the
entire group as a group
(the group may be asked, for example, to build something or to plan an outing);
one member vis-à-vis the group
(the “trust fall,” for example, in which one member stands, eyes closed, in the center and falls, allowing the group to catch, support, and then cradle and rock the person);
the entire group as individuals
(members may be asked in turn to give their initial impressions of everyone else in the group);
the entire group as dyads
(the “blind walk,” for example, in which the group is broken into dyads and each pair takes a walk with one member blindfolded and led by the other);
one designated dyad
(two members locked in a struggle may be asked to take turns pushing the other to the ground and then lifting him or her up again); or
one designated member
(“switching chairs”—a member may be asked to give voice to two or more conflicting inner roles, moving from one chair to another as he or she assumes one or the other role). Any prescribed exercise that involves physical contact needs to be carefully considered. If the usual boundaries of therapy are to be crossed, even in the best of faith and with clear therapeutic intent, it is essential to obtain informed consent from the group members.

Structured exercises were widely used in the T-group and later in the encounter group (see chapter 16), and their popularity received a boost from gestalt therapy in the 1960s and 1970s. For a time, such exercises were used to excess by many leaders and training programs. Some group leader training programs relied heavily on texts of structured exercises and trained technique-oriented leaders who reach into a grab bag of gimmicks whenever the proceedings flag. During the 1980s, the general public came to identify group therapy with structured exercises through large group awareness courses (for example, est and Lifespring). Such courses consisted entirely of a two-to-four-day potpourri of structured exercises and didactic and inspirational instruction.
⁶⁰

This injudicious use of structured exercises was a miscarriage of the intent of the approaches that spawned these techniques. The T-group field formulated exercises that were designed to demonstrate principles of group dynamics (both between and within groups) and to accelerate group development. Since the typical T-group met for a sharply limited period of time, the leaders sought methods to speed the group past the initial reserve and social ritualized behavior. Their aim was for members to experience as much as possible of the developmental sequence of the small group.

Gestalt therapy, another major source of structured exercises, is based on existential roots. Fritz Perls (the founder of gestalt therapy) left many recorded sessions with clients as well as theoretical essays that demonstrate that he was basically concerned with problems of existence, self-awareness, responsibility, contingency, and wholeness both within an individual and within the individual’s social and physical universe.
⁶¹
Although Perls’s technical approach was novel, his conception of the human being’s basic dilemma is one he shares with a long line of philosophers of life, stretching back to the beginning of recorded thought.

Paradoxically, gestalt therapy has come to be considered by some clinicians as a speedy, gimmick-oriented therapy, whereas, in fact, it is an ambitious and thoughtful venture. It attempts to penetrate denial systems and to bring clients to a new perspective on their position in the world. Although it decries a technical, packaged approach, some gestalt therapy trainees do not progress past technique, do not grasp the theoretical assumptions on which all technique must rest.