The Theory and Practice of Group Psychotherapy (32 page)

Thus far in this discussion I have, for pedagogical reasons, overstated two fundamental points that I must now qualify. Those points are: (1) the here-and-now approach is an ahistorical one, and (2) there is a sharp distinction between here-and-now experience and here-and-now process illumination.

Strictly speaking, an ahistorical approach is an impossibility: every process comment refers to an act that already belongs to the past. (Sartre once said, “Introspection is retrospection.”) Not only does process commentary involve behavior that has just transpired, but it frequently refers to cycles of behavior or repetitive acts that have occurred in the group over weeks or months.
Thus, the past events of the therapy group are a part of the here-and-now and an integral part of the data on which process commentary is based.

Often it is helpful to ask clients to review their past experiences in the group. If a member feels that she is exploited every time she trusts someone or reveals herself, I often inquire about her history of experiencing that feeling in this group. Other clients, depending upon the relevant issues, may be encouraged to discuss such experiences as the times they have felt most close to others, most angry, most accepted, or most ignored.

My qualification of the ahistorical approach goes even further. As I will discuss later in a separate section, no group can maintain a total here-and-now approach. There will be frequent excursions into the “then-and-there”—that is, into personal history and into current life situations. In fact, such excursions are so inevitable that one becomes curious when they do not occur. It is not that the group doesn’t deal with the past;
it is what is done with the past:
the crucial task is not to uncover, to piece together, to fully understand the past,
but to use the past for the help it offers in understanding (and changing) the individual’s mode of relating to the others in the present.

The distinction between here-and-now experience and here-and-now process commentary is not sharp: there is much overlap. For example, low-inference commentary (feedback) is both experience and commentary. When one member remarks that another refuses to look at her or that she is furious at another for continually deprecating her, she is at the same time commenting on process and involving herself in the affective here-and-now experience of the group. Process commentary, like nascent oxygen, exists for only a short time; it rapidly becomes incorporated into the experiential flow of the group and becomes part of the data from which future process comments will flow.

For example, in a experiential group of mental health trainees (a group experience that was part of their group therapy training curriculum—see chapter 17), one member, John, began the session with an account of some extreme feelings of depression and depersonalization. Instead of exploring the member’s dysphoria, the group immediately began offering him practical advice about his life situation. The leader commented on the process—on the fact that the group veered away from inquiring more about John’s experience. The leader’s intervention seemed useful: the group members became more emotionally engaged, and several discussed their admiration of John’s risk-taking and their own fear of self-revelation.

Soon afterward, however, a couple of counterdependent members objected to the leader’s intervention. They felt that the leader was dissatisfied with their performance in the group, that he was criticizing them, and, in his usual subtle manner, was manipulating the group to fit in with his preconceived notions of the proper conduct of a meeting. Other members took issue with the tendency of some members to challenge every move of the therapist. Thus, the leader’s process comments became part of the experiential ebb and flow of the group. Even the members’ criticism of the leader (which was at first process commentary) soon also became part of the group experience and, itself, subject to process commentary.

Summary

The effective use of the here-and-now focus requires two steps: experience in here-and-now and process illumination. The combination of these two steps imbues an experiential group with compelling potency.

The therapist has different tasks in each step.
First
the group must be plunged into the here-and-now experience;
second
, the group must be helped to understand the
process
of the here-and-now experience: that is, what the interaction conveys about the nature of the members’ relationships with one another.

The first step,
here-and-now activation
, becomes part of the group norm structure; ultimately the group members will assist the therapist in this task. The second step,
process illumination
, is more difficult. There are powerful injunctions against process commentary in everyday social intercourse that the therapist must overcome. The task of process commentary, to a large extent (but not exclusively), remains the responsibility of the therapist and consists, as I will discuss shortly, of a wide and complex range of behavior—from labeling single behavioral acts, to juxtaposing several acts, to combining acts over time into a pattern of behavior, to pointing out the undesirable consequences of a client’s behavioral patterns, to identifying here-and-now behaviors that are analogues to the members’ behavior in the world at large, to more complex inferential explanations or interpretations about the meaning and motivation of such behavior.

TECHNIQUES OF HERE-AND-NOW ACTIVATION

In this section I wish to describe (but not prescribe) some techniques: each therapist must develop techniques consonant with his or her personal style. Indeed, therapists have a more important task than mastering a technique: they must fully comprehend the strategy and theoretical foundations upon which all effective technique must rest.

First step: I suggest that you
think
here-and-now. When you grow accustomed to thinking of the here-and-now, you automatically steer the group into the here-and-now. Sometimes I feel like a shepherd herding a flock into an ever-tightening circle. I head off errant strays—forays into personal historical material, discussions of current life situations, intellectualisms—and guide them back into the circle. Whenever an issue is raised in the group, I think, “How can I relate this to the group’s primary task? How can I make it come to life in the here-and-now?”
I am relentless in this effort, and I begin it in the very first meeting of the group.

Consider a typical first meeting of a group. After a short, awkward pause, the members generally introduce themselves and proceed, often with help from the therapist, to tell something about their life problems, why they have sought therapy, and, perhaps, the type of distress they suffer. I generally intervene at some convenient point well into the meeting and remark something like, “We’ve done a great deal here today so far. Each of you has shared a great deal about yourself, your pain, your reasons for seeking help. But I have a hunch that something else is also going on, and that is that you’re sizing one another up, each arriving at some impressions of the others, each wondering how you’ll fit in with the others. I wonder now if we could spend some time discussing what each of us has come up with thus far.” Now this is no subtle, artful, shaping statement: it is a heavy-handed, explicit directive. Yet I find that most groups respond favorably to such clear guidelines and readily appreciate the therapeutic facilitation.

The therapist moves the focus from outside to inside, from the abstract to the specific, from the generic to the personal, from the personal into the interpersonal. If a member describes a hostile confrontation with a spouse or roommate, the therapist may, at some point, inquire, “If you were to be angry like that with anyone in the group, with whom would it be?” or, “With whom in the group can you foresee getting into the same type of struggle?” If a member comments that one of his problems is that he lies, or that he stereotypes people, or that he manipulates groups, the therapist may inquire, “What is the main lie you’ve told in the group thus far?” or, “Can you describe the way you’ve stereotyped some of us?” or, “To what extent have you manipulated the group thus far?”

If a client complains of mysterious flashes of anger or suicidal compulsions, the therapist may urge the client to signal to the group the very moment such feelings occur during the session, so that the group can track down and relate these experiences to events in the session.

If a member describes her problem as being too passive, too easily influenced by others, the therapist may move her directly into the issue by asking, “Who in the group could influence you the most? The least?”

If a member comments that the group is too polite and too tactful, the therapist may ask, “Who are the leaders of the peace-and-tact movement in the group?” If a member is terrified of revealing himself and fears humiliation, the therapist may bring it into the here-and-now by asking him to identify those in the group he imagines might be most likely to ridicule him. Don’t be satisfied by answers of “the whole group.” Press the member further. Often it helps to rephrase the question in a gentler manner, for example, “Who in the group is
least
likely to ridicule you?”

In each of these instances, the therapist can deepen interaction by encouraging further responses from the others. For example, “How do you feel about his fear or prediction that you would ridicule him? Can you imagine doing that? Do you, at times, feel judgmental in the group? Even simple techniques of asking group members to speak directly to one another, to use second-person (“you”) rather than third-person pronouns, and to look at one another are very useful.

Easier said than done! Such suggestions are not always heeded. To some group members, they are threatening indeed, and the therapist must here, as always, employ good timing and attempt to experience what the client is experiencing. Search for methods that lessen the threat.
Begin by focusing on positive interaction
: “Toward whom in the group do you feel most warm?” “Who in the group is most like you?” or, “Obviously, there are some strong vibes, both positive and negative, going on between you and John. I wonder what you most envy or admire about him? And what parts of him do you find most difficult to accept?”

• A group meeting of elderly clients attending a psychiatric day hospital for treatment of depression groaned with feelings of disconnection and despair. The initial focus of the meeting was Sara—an eighty-two-year-old Holocaust survivor. Sara lamented the persistent prejudice, hatred, and racism so prominent in the news headlines. Feeling scared and helpless, she discussed her wartime memories of being dehumanized by those who hated her without knowing anything about her as a real person. Group members, including other Holocaust survivors, also shared their tortured memories.

The group leader attempted to break into the group’s intense preoccupation with the past by shifting into the here-and-now. What did Sara experience talking to the group today? Did she feel that the group members were engaging her as a real person? Why had she chosen to be different today—to speak out rather than silence herself as she has done so often before? Could she take credit for that? How did others feel about Sara speaking out in this meeting?

Gradually the meeting’s focus shifted from the recounting of despairing memories to lively interaction, support for Sara, and strong feelings of member connectivity.

Sometimes, it is easier for group members to work in tandem or in small subgroups. For example, if they learn that there is another member with similar fears or concerns, then a subgroup of two (or more) members can, with less threat, discuss their here-and-now concerns.
⁷
This may occur spontaneously or by the therapist directly creating a bridge between specific members—for example, by pointing out that the concerns just disclosed by one member have also been expressed by another.†

Using the conditional verb form provides safety and distance and often is miraculously facilitative. I use it frequently when I encounter initial resistance. If, for example, a client says, “I don’t have any response or feelings at all about Mary today. I’m just feeling too numb and withdrawn,” I often say something like, “If you were
not
numb or withdrawn today, what
might
you feel about Mary?” The client generally answers readily; the once-removed position affords a refuge and encourages the client to answer honestly and directly. Similarly, the therapist might inquire, “If you
were
to be angry at someone in the group, whom would it be?” or, “If you
were
to go on a date with Albert (another group member), what kind of experience might it be?”

The therapist must teach members the art of requesting and offering feedback by explicit instruction, by modeling, or by reinforcing effective feedback.
⁸
One important principle to teach clients is the avoidance of global questions and observations. Questions such as “Am I boring?” or “Do you like me?” are not usually productive. A client learns a great deal more by asking, “What do I do that causes you to tune out?” “When are you most and least attentive to me?” or, “What parts of me or aspects of my behavior do you like least and most?” In the same vein, feedback such as “You’re OK” or “You’re a nice guy” is far less useful than “I feel closer to you when you’re willing to be honest with your feelings, like in last week’s meeting when you said you were attracted to Mary but feared she would scorn you. I feel most distant from you when you’re impersonal and start analyzing the meaning of every word said to you, like you did early in the meeting today.”
(These comments, like most of the therapist comments in this text, have equal applicability in individual therapy.)