The Theory and Practice of Group Psychotherapy (92 page)

How has it come about that the substance has so often been mistaken for the essence of the gestalt approach? The cornerstone for the error was unwittingly laid by Perls himself, whose creative, technical virtuosity acted in such consort with his flair for showmanship as to lead many people to mistake the medium for the message. Perls had to do battle with the hyperintellectualized emphasis of the early analytic movement and often overreacted and overstated his opposition to theory. “Lose your mind and come to your senses,” Perls proclaimed. Consequently, he did not write a great deal but taught by illustration, trusting that his students would discover their own truths through experience rather than through the intellectual process. Descriptions of the contemporary practice of gestalt therapy emphasize a more balanced approach, which employs structured exercises (or “therapist-induced experiments”) in a judicious fashion.
⁶²

How useful are structured exercises? What does research tell us about the effects of these procedures on the process and outcome of the group? Lieberman, Yalom, and Miles’s encounter group project (see chapter 16) closely studied the impact of the structured exercise and came to the following conclusions.
⁶³
Leaders who used many exercises were popular with their groups. Immediately at the end of a group, the members regarded them as
more competent, more effective, and more perceptive
than leaders who used these techniques sparingly.
Yet the members of groups that used the most exercises had significantly less favorable outcomes than did the members of groups with the fewest exercises
. (The groups with the most exercises had fewer high changers, fewer total positive changers, and more negative changers. Moreover, the high changers of the encounter groups with the most exercises were
less
likely to maintain change over time.)

In short, the moral of this study is that
if your goal is to have your group members think you’re competent and that you know what you’re doing, then use an abundance of structured interventions
; in doing so, in leading by providing explicit directions, in assuming total executive function, you fulfill the group’s fantasies of what a leader should do. However, your group members will
not be improved; in fact, excessive reliance on these techniques renders a group less effective
.

The study explored other differences between the groups with the most and the least exercises. The amount of self-disclosure and the emotional climate of the groups was the same. But there were differences in the themes emphasized:
The groups with more exercises focused on the expression of positive and negative feelings; those with fewer exercises had a greater range of thematic concerns: the setting of goals; the selection of procedural methods; closeness versus distance; trust versus mistrust; genuineness versus phoniness; affection; and isolation.

It would seem, then, that groups using many structured exercises never deal with several important group themes. There is no doubt that the structured exercises appear to plunge the members quickly into a great degree of expressivity,
but the group pays a price for its speed
; it circumvents many group developmental tasks and does not develop a sense of autonomy and potency.

It is not easy for group clinicians to evaluate their own use of structured techniques. In the encounter group project almost all leaders used some structured exercises. Some of the more effective leaders attributed their success in large measure to these techniques. To take one example, many leaders used the “hot seat” technique (a format popularized by Perls in which one member sits in the central chair, and the leader in particular as well as the other members focus on that member exclusively and exhaustively for a long period of time).

However, the approach was as highly valued by the most ineffective leaders as by the effective ones
. Obviously, other aspects of leader behavior accounted for the effective leaders’ success, but if they erroneously credit their effectiveness to the structured exercise, then it is given a value it does not deserve (and is unfortunately passed on to students as the central feature of the process of change).

The Lieberman, Yalom, and Miles encounter group project also demonstrated that it was not just the leaders’ interactions with a member that mediated change. Of even greater importance were many psychosocial forces in the change process: Change was heavily influenced by an individual’s role in the group (centrality, level of influence, value congruence, and activity) and by characteristics of the group (cohesiveness, climate of high intensity and harmoniousness, and norm structure). In other words, the data failed to support the importance of the leaders’ direct therapeutic interaction with each member.

Though these findings issue from short-term encounter groups, they have much relevance for the therapy group. First, consider speed: structured exercises do indeed bypass early, slow stages of group interaction and do indeed plunge members quickly into an expression of positive and negative feelings. But whether or not they accelerate the process of therapy is another question entirely.

In short-term groups—T-groups or very brief therapy groups—it is often legitimate to employ techniques to bypass certain difficult stages, to help the group move on when it is mired in an impasse. In long-term therapy groups, the process of bypassing is less germane; the leader more often wishes to guide the group
through
anxiety,
through
the impasse or difficult stages, rather than
around
them. Resistance, as I have emphasized throughout this text, is not an impediment to therapy but is the stuff of therapy. The early psychoanalysts conceived of the analytic procedure in two stages: the analysis of resistance and then the true analysis (which consists of strip-mining the infantile unconscious roots of behavior). Later they realized that the analysis of resistance, if pursued thoroughly, is sufficient unto itself.

Interactional group therapy functions similarly: There is more to be gained by experiencing and exploring great timidity or suspiciousness or any of a vast number of dynamics underlying a member’s initial guardedness than by providing the member with a vehicle that plunges him or her willy-nilly into deep disclosure or expressivity. Acceleration that results in material being wrenched in an untimely way from individuals may be counterproductive if the proper context of the material has not been constructed.

Yet another reason for urging caution in the use of multiple structured exercises in therapy groups is that leaders who do so run the risk of infantilizing the group. Members of a highly structured, leader-centered group begin to feel that help (all help) emanates from the leader; they await their turn to work with the leader; they deskill themselves; they cease to avail themselves of the help and resources available in the group. They divest themselves of responsibility.

I do not wish to overstate the case against the use of structured exercises. Surely there is a middle ground between allowing the group, on the one hand, to flounder pointlessly in some unproductive sequence and, on the other, assuming a frenetically active, overly structured leadership role. Indeed, that is the conclusion the Lieberman, Yalom, and Miles study reached.
⁶⁴
The study demonstrated that an active, executive, managerial leadership style function relates to outcome in a curvilinear fashion: that is
, too much structure and too little structure were negatively correlated with good outcome
. Too much structure created the types of problem discussed above (leader-centered, dependent groups), and too little (a laissez-faire approach) resulted in plodding, unenergetic, high-attrition groups.

We do not need to look toward any unusual types of groups to find structured exercises—many of the techniques I described in chapter 5, which the leader employs in norm setting, in here-and-now activation, and in process-illumination functions, have a prescriptive quality. (“Who in the group do you feel closest to?” “Can you look at Mary as you talk to her?” “If you were going to be graded for your work in the group, what grade would you receive?” And so on.) Therapists also may use a guided-fantasy structured exercise during a meeting. For example, they might ask members to close their eyes and then describe to them some relaxing scene (like a barefoot walk on the beach with warm, gentle waves rippling in), then ask them to imagine meeting one or more of the group members or leaders and to complete the fantasy. Later, members would be asked to share and explore their fantasies in the group.

Every experienced group leader employs some structured exercises.
For example, if a group is tense and experiences a silence of a minute or two (a minute’s silence feels very long in a group), I often ask for a go-around in which each member says, quickly, what he or she has been feeling or has thought of saying, but did not, during that silence. This simple exercise usually generates much valuable data.†

What is important in the use of structured exercises are the degree, accent, and purpose associated with them. If structured interventions are suggested to help mold an autonomously functioning group, or to steer the group into the here-and-now, or to explicate process, they may be of value. In a brief group therapy format, they may be invaluable tools for focusing the group on its task and plunging the group more quickly into its task. If used, they should be properly timed; nothing is as disconcerting as the right idea in the wrong place at the wrong time. It is a mistake to use exercises as emotional space filler—that is, as something interesting to do when the group seems at loose ends.

Nor should a structured exercise be used to generate affect in the group. A properly led therapy group should not need energizing from outside. If there seems insufficient energy in the group, if meetings seem listless, if time and time again the therapist feels it necessary to inject voltage into the group, there is most likely a significant developmental problem that a reliance on accelerating devices will only compound. What is needed instead is to explore the obstructions, the norm structure, the members’ passive posture toward the leader, the relationship of each member to his or her primary task, and so forth. My experience is that if the therapist prepares clients adequately and actively shapes expressive, interactional, self-disclosing norms in the manner described in chapter 5, there will be no paucity of activity and energy in the group.

Structured exercises often play a more important role in brief, specialized therapy groups than in the long-term general ambulatory group. In the next chapter, I shall describe uses of structured exercises in a number of specialty therapy groups.

Chapter 15

SPECIALIZED THERAPY GROUPS

G
roup therapy methods have proved to be so useful in so many different clinical settings that it is no longer correct to speak of group therapy. Instead, we must refer to the group
therapies.
Indeed, as a cursory survey of professional journals would show, the number and scope of the group therapies are mind-boggling.

There are groups for incest survivors, for people with HIV/AIDS, for clients with eating disorders or with panic disorder, for the suicidal, the aged, for parents of sexually abused children, for parents of murdered children, for compulsive gamblers and for sex addicts, for people with herpes, for women with postpartum depression, for sexually dysfunctional men, and for sexually dysfunctional gay men. There are groups for people with hypercholesteremia, for survivors of divorce, for children of people with Alzheimer’s, for spouses of people with Alzheimer’s, for alcoholics, for children of alcoholics, for male batterers, for mothers of drug addicts, for families of the mentally ill, for fathers of delinquent daughters, for depressed older women, for angry adolescent boys, for survivors of terrorist attacks, for children of Holocaust survivors, for women with breast cancer, for dialysis patients, for people with multiple sclerosis, leukemia, asthma, sickle-cell anemia, deafness, agoraphobia, mental retardation. And for transsexuals and people with borderline personality disorder, gastric dyspepsia, or irritable bowel, for amputees, paraplegics, insomniacs, kleptomaniacs, asthmatics, nonorgasmic women, college dropouts, people who have had a myocardial infarction or a stroke, adopting parents, blind diabetics, clients in crisis, bereaved spouses, bereaved parents, the dying, and many, many others.†
¹

Obviously no single text could address each of these specialized groups. Even if that were possible, it would not constitute an intelligent approach to education. Does any sensible teacher of zoology, to take one example, undertake to teach vertebrate anatomy by having the students memorize the structures of each subspecies separately? Of course not. Instead, the teacher teaches basic and general principles of form, structure, and function and then proceeds to teach the anatomy of a
prototypic
primal specimen that serves as a template for all other vertebrates. Commonly teachers use a representative amphibian. Remember those frog dissection laboratories?

The extension of this analogy to group therapy is obvious. The student must first master fundamental group therapy theory and then obtain a deep understanding of a prototypic therapy group. But which group therapy represents the most archaic common ancestor? There has been such a luxuriant growth of group therapies that it requires some perspicacity to find, amid the thicket, the primal trunk of group therapy.

If there is an ancestral group therapy, it is the
open, long-term outpatient group therapy
described in this book. It was the first group therapy, and it has been deeply studied, since its members are sufficiently motivated, cooperative, and stable to have allowed systematic research. Furthermore, it has stimulated, over the past fifty years, an imposing body of professional literature containing the observations and conclusions of thoughtful clinicians.