The Theory and Practice of Group Psychotherapy (108 page)

Another reason the leader should be selected with great care is that it is extremely difficult to lead groups of mental health professionals who will continue to work together throughout their training. The pace is slow; intellectualization is common; and self-disclosure and risk taking are minimal. The chief instrument in psychotherapy is the therapist’s own person. Realizing this truth, the neophyte therapist feels doubly vulnerable in self-disclosure: at stake are both personal and professional competence.

Should the Leader be a Staff or a Faculty Member of the Training Program?

A leader who wears two hats (group leader and member of training staff) compounds the problem for the group members who feel restricted by the presence of someone who may in the future play an evaluative role in their careers. Mere reassurance to the group that the leader will maintain strictest confidentiality or neutrality is insufficient to deal with this very real concern of the members.

I have on many occasions been placed in this double role and have approached the problem in various ways but with only limited success. One approach is to confront the problem energetically with the group. I affirm the reality that I
do
have a dual role, and that, although I will attempt in every way to be merely a group leader and will remove myself from any administrative or evaluative duties, I may not be able to free myself from all unconscious vestiges of the second role. I thus address myself uncompromisingly to the dilemma facing the group. But, as the group proceeds, I also address myself to the fact that each member must deal with the “two-hat” problem. Similar dilemmas occur throughout the practice of group therapy and are best embraced rather than avoided or denied.
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What can we learn through this dilemma? Each member may respond to it very differently: some may so distrust me that they choose to remain hidden in silence; some curry my favor; some trust me completely and participate with full abandon in the group; others persistently challenge me. All of these stances toward a leader reflect basic attitudes toward authority and are good grist for the mill, provided there is at least a modicum of willingness to work.

Another approach I often take when in this “two-hat” position is to be unusually self-disclosing—in effect, to give the members more on me than I have on them. In so doing, I model openness and demonstrate both the universality of human problems and how unlikely it would be for me to adopt a judgmental stance toward them. In other words, leader transparency offered in the service of training lowers the perceived stakes for the participants by normalizing their concerns.

My experience has been that, even using the best techniques, leaders who are also administrators labor under a severe handicap, and their groups are likely to be restricted and guarded. The group becomes a far more effective vehicle for personal growth and training if led by a leader from outside the institution who will play no role in student evaluation. It facilitates the work of a group if, at the outset, the leader makes explicit his or her unwillingness under any circumstances ever to contribute letters of reference—either favorable or unfavorable—for the members. All these issues—group goals, confidentiality, and participation should be made explicit at the beginning of the group experience.

Is the Training Groupa Therapy Group?

This is a vexing question. In training groups of professionals, no other issue is so often used in the service of group resistance. It is wise for leaders to present their views about training versus therapy at the outset of the group. I begin by asking that the members make certain commitments to the group. Each member should be aware of the requirements for membership: a willingness to invest oneself emotionally in the group, to disclose feelings about oneself and the other members, and to explore areas in which one would like to make personal changes.

There is a useful distinction to be made between a therapy group and a therapeutic group.
A training group, though it is not a therapy group, is therapeutic in that it offers the opportunity to do therapeutic work
. By no means, though, is each member expected to do extensive therapeutic work.

The basic contract of the group, in fact, its raison d’être, is training, not therapy. To a great extent, these goals overlap: a leader can offer no better group therapy training than that of an effective therapeutic group. Furthermore, every intensive group experience contains within it great therapeutic potential: members cannot engage in effective interaction, cannot fully assume the role of a group member, cannot get feedback about their interpersonal style and their blind spots without some therapeutic spin-off. Yet that is different from a therapy group that assembles for the purpose of accomplishing extensive therapeutic change for each member of the group.

In a therapy group, the intensive group experience, the expression and integration of affect, the recognition of here-and-now process are all essential but secondary considerations to the primary goal of individual therapeutic change. In a training group of mental health professionals, the reverse is true. There will be many times when the T-group leader will seize an opportunity for explication and teaching that a group therapist would seize for deeper emotional exploration.

Leader Technique

The leader of a training group of mental health professionals has a demanding task: he or she not only provides a role model by shaping and conducting an effective group but must also make certain modifications in technique to deal with the specific educational needs of the group members.

The basic approach, however, does not deviate from the guidelines I outlined earlier in this book. For example, the leader is well advised to retain an interactional, here-and-now focus. It is an error, in my opinion, to allow the group to move into a supervisory format where members describe problems they confront in their clinical work: such discussion should be the province of the supervisory hour. Whenever a group is engaged in discourse that can be held equally well in another formal setting, it is failing to use its unique properties and full potential. Instead, members can discuss these work-related problems in more profitable group-relevant ways: for example, they might discuss how it would feel to be the client of a particular member. The group is also an excellent place for two members who happen to work together in therapy groups, or in marital or family therapy, to work on their relationship.

There are many ways for a leader to use the members’ professional experience in the service of the group work. For example, I have often made statements to the training group in the following vein: “The group has been very slow moving today. When I inquired, you told me that you felt ‘lazy’ or that it was too soon after lunch to work. If you were the leader of a group and heard this, what would you make of it? What would you do?” Or: “Not only are John and Stewart refusing to work on their differences but others are lining up behind them. What are the options available to me as a leader today?” In a training group, I am inclined, much more than in a therapy group, to explicate group process. In therapy groups, if there is no therapeutic advantage in clarifying group process, I see no reason to do so. In training groups, there is always the superordinate goal of education.

Often process commentary combined with a view from the leader’s seat is particularly useful. For example:

Let me tell you what I felt today as a group leader. A half hour ago I felt uncomfortable with the massive encouragement and support everyone was giving Tom. This has happened before, and though it was reassuring, I haven’t felt it was really helpful to Tom. I was tempted to intervene by inquiring about Tom’s tendency to pull this behavior from the group, but I chose not to—partly because I’ve gotten so much flak lately for being nonsupportive. So I remained silent. I think I made the right choice, since it seems to me that the meeting developed into a very productive one, with some of you getting deeply into your feelings of needing care and support. How do the rest of you see what’s happened today?

In a particularly helpful essay, Aveline, an experienced group leader of student groups, suggests that the leader has five main tasks:

1. Containment of anxiety (through exploration of sources of anxiety in the group and provision of anxiety-relieving group structure)

2. Establishment of a therapeutic atmosphere in the group by shaping norms of support, acceptance, and group autonomy

3. Establishing appropriate goals that can be addressed in the time available

4. Moderating the pace so that the group moves neither too fast nor too slow and that members engage in no forced or damaging self-disclosure

5. Ending well
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PERSONAL PSYCHOTHERAPY

A training group rarely suffices to provide all the personal self-exploration a student therapist requires. Few would dispute that personal psychotherapy is necessary for the maturation of the group therapist. A substantial number of training programs require a personal therapy experience.
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A large survey of 318 practicing psychologists indicated that 70 percent had entered therapy during their training—often more than one type of therapy: 63 percent in individual therapy (mean = 100 hours); 24 percent in group therapy (mean = 76 hours); 36 percent in couples therapy (mean = 37 hours). This survey determined that over their lifetime, 18 percent of practicing psychologists never entered therapy.

What factors influenced the decision to enter therapy? Psychologists were more likely to engage in therapy if they had an earlier therapy experience in their training, if they were dynamically oriented in their practice, and if they conducted many hours of therapy during the week.
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In another survey, over half of psychotherapists entered personal psychotherapy after their training, and over 90 percent reported considerable personal and professional benefit from the experience.
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Without doubt, the training environment influences the students’ decision to pursue personal therapy. In the past, psychiatry training programs had very high participation rates. Although a few still do, the trend is downward and, regrettably, fewer residents choose to enter therapy.
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I consider my personal psychotherapy experience, a five-times-a-week analysis during my entire three-year residency, the most important part of my training as a therapist.
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I urge every student entering the field not only to seek out personal therapy but to do so more than once during their career—different life stages evoke different issues to be explored. The emergence of personal discomfort is an opportunity for greater self-exploration that will ultimately make us better therapists.
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Our knowledge of self plays an instrumental role in every aspect of the therapy. An inability to perceive our countertransference responses, to recognize our personal distortions and blind spots, or to use our own feelings and fantasies in our work will severely limit our effectiveness. If you lack insight into your own motivations, you may, for example, avoid conflict in the group because of your proclivity to mute your feelings; or you may unduly encourage confrontation in a search for aliveness in yourself. You may be overeager to prove yourself or to make consistently brilliant interpretations, and thereby disempower the group. You may fear intimacy and prevent open expression of feelings by premature interpretations—or do the opposite: overemphasize feelings, make too few explanatory comments, and overstimulate clients so that they are left in agitated turmoil. You may so need acceptance that you are unable to challenge the group and, like the members, be swept along by the prevailing group current. You may be so devastated by an attack on yourself and so unclear about your presentation of self as to be unable to distinguish the realistic from the transference aspects of the attack.

Several training programs—for example, the British Group Analytic Institute and the Canadian Group Psychotherapy Association—recommend that their candidates participate as bona fide members in a therapy group led by a senior clinician and composed of nonprofessionals seeking personal therapy.
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Advocates of such programs point out the many advantages to being a real member of a therapy group. There is less sibling rivalry than in a group of one’s peers, less need to perform, less defensiveness, less concern about being judged. The anticipated pitfalls are surmountable. If a trainee attempts to play assistant therapist or in some other way avoids genuine therapeutic engagement, a competent group leader will be able to provide the proper direction.

Experience as a full member of a bona fide therapy group is invaluable, and I encourage any trainee to seek such therapy. Unfortunately, the right group can be hard to find. Advocates of personal group therapy as a part of training hail from large metropolitan areas (London, New York, Toronto, Geneva). But in smaller urban areas, the availability of personal group therapy is limited. There are simply not enough groups that meet the proper criteria—that is, an ongoing high-functioning group led by a senior clinician with an eclectic dynamic approach (who, incidentally, is neither a personal nor professional associate of the trainee).

There is one other method of obtaining both group therapy training and personal psychotherapy. For several years, I led a therapy group for practicing psychotherapists. It is a straightforward therapy group, not a training group. Admission to the group is predicated on the need and the wish for personal therapy, and members are charged standard therapy group fees. Naturally, in the course of their therapy, the members—most but not all of whom are also group therapists—learn a great deal about the group therapy process.