The Theory and Practice of Group Psychotherapy (43 page)

As long as a group therapist assumes the responsibility of leadership, transference will occur. I have never seen a group develop without a deep, complex underpinning of transference. The problem is thus not evocation but resolution of transference. The therapist who is to make therapeutic use of transference must help clients recognize, understand, and change their distorted attitudinal set toward the leader.

How does the group resolve transference distortions? Two major approaches are seen in therapy groups:
consensual validation
and
increased therapist transparency
.

Consensual Validation

The therapist may encourage a client to validate his or her impressions of the therapist against those of the other members. If many or all of the group members concur in the client’s view of and feelings toward the therapist, then it is clear that either the members’ reaction stems from global group forces related to the therapist’s role in the group
or
that the reaction is not unrealistic at all—the group members are perceiving the therapist accurately. If, on the other hand, there is no consensus, if one member alone has a particular view of the therapist, then this member may be helped to examine the possibility that he or she sees the therapist, and perhaps other people too, through an internal distorting prism. In this process the therapist must take care to operate with a spirit of open inquiry, lest it turn into a process of majority rule. There can be some truth even in the idiosyncratic reaction of a single member.

Increased Therapist Transparency

The other major approach relies on the therapeutic use of the self. Therapists help clients confirm or disconfirm their impressions of the therapists by gradually revealing more of themselves. The client is pressed to deal with the therapist as a real person in the here-and-now. Thus you respond to the client, you share your feelings, you acknowledge or refute motives or feelings attributed to you, you look at your own blind spots, you demonstrate respect for the feedback the members offer you. In the face of this mounting real-life data, clients are impelled to examine the nature and the basis of their powerful fictitious beliefs about the therapist.

We use our transparency and self-disclosure to maintain a therapeutic position with our clients that balances us in a position midway between the client’s transference and its therapeutic disconfirmation.† Your disclosure about the client’s impact on you is a particularly effective intervention because it deepens understanding for the mutual impact between therapist and group member.
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The group therapist undergoes a gradual metamorphosis during the life of the group. In the beginning you busy yourself with the many functions necessary in the creation of the group, with the development of a social system in which the many therapeutic factors may operate, and with the activation and illumination of the here-and-now. Gradually, as the group progresses, you begin to interact more personally with each of the members, and as you become more of a fleshed-out person, the members find it more difficult to maintain the early stereotypes they had projected onto you.

This process between you and each of the members is not qualitatively different from the interpersonal learning taking place among the members. After all, you have no monopoly on authority, dominance, sagacity, or aloofness, and many of the members work out their conflicts in these areas not with the therapist (or
not only
with the therapist) but with other members who happen to have these attributes.

This change in the degree of transparency of the therapist is by no means limited to group therapy. Someone once said that when the analyst tells the analysand a joke, you can be sure the analysis is approaching its end. However, the pace, the degree, the nature of the therapist transparency and the relationship between this activity of the therapist and the therapist’s other tasks in the group are problematic and deserve careful consideration. More than any other single characteristic, the nature and the degree of therapist self-disclosure differentiate the various schools of group therapy. Judicious therapist self-disclosure is a defining characteristic of the interpersonal model of group psychotherapy.
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THE PSYCHOTHERAPIST AND TRANSPARENCY

Psychotherapeutic innovations appear and vanish with bewildering rapidity. Only a truly intrepid observer would attempt to differentiate evanescent from potentially important and durable trends in the diffuse, heterodox American psychotherapeutic scene. Nevertheless, there is evidence, in widely varying settings, of a shift in the therapist’s basic self-presentation. Consider the following vignettes.

• Therapists leading therapy groups that are observed through a one-way mirror reverse roles at the end of the meeting. The clients are permitted to observe while the therapist and the students discuss or rehash the meeting. Or, in inpatient groups, the observers enter the room twenty minutes before the end of the session to discuss their observations of the meeting. In the final ten minutes, the group members react to the observers’ comments.
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• At a university training center, a tutorial technique has been employed in which four psychiatric residents meet regularly with an experienced clinician who conducts an interview in front of a one-way mirror. The client is often invited to observe the postinterview discussion.

• Tom, one of two group co-therapists, began a meeting by asking a client who had been extremely distressed at the previous meeting how he was feeling and whether that session had been helpful to him. The co-therapist then said to him, “Tom, I think you’re doing just what I was doing a couple of weeks ago—pressing the clients to tell me how effective our therapy is. We both seem on a constant lookout for reassurance. I think we are reflecting some of the general discouragement in the group. I wonder whether the members may be feeling pressure that they have to improve to keep up our spirits.”

• In several groups at an outpatient clinic, the therapists write a thorough summary (see chapter 14) after each meeting and mail it to the members before the next session. The summary contains not only a narrative account of the meeting, a running commentary on process, and each member’s contribution to the session but also much therapist disclosure: the therapist’s ideas about what was happening to everyone in the group that meeting; a relevant exposition of the theory of group therapy; exactly what the therapist was attempting to do in the meeting; the therapist’s feelings of puzzlement or ignorance about events in the group; and the therapist’s personal feelings during the session, including both those said and those unsaid at the time. These summaries are virtually indistinguishable from summaries the therapists had previously written for their own private records.

Without discussing the merits or the disadvantages of the approaches demonstrated in these vignettes, it can be said for now that there is no evidence that these approaches corroded the therapeutic relationship or situation. On the psychiatric ward, in the tutorial, and in therapy groups, the group members did not lose faith in their all-too-human therapists but developed more faith in a process in which the therapists were willing to immerse themselves. The clients who observed their therapists in disagreement learned that although no one true way exists, the therapists are nonetheless dedicated and committed to finding ways of helping their clients.

In each of the vignettes, the therapists abandon their traditional role and share some of their many uncertainties with their clients. Gradually the therapeutic process is demystified and the therapist in a sense defrocked. The past four decades have witnessed the demise of the concept of psychotherapy as an exclusive domain of psychiatry. Formerly, therapy was indeed a closed-shop affair: psychologists were under surveillance of psychiatrists lest they be tempted to practice psychotherapy rather than counseling; social workers could do casework but not psychotherapy. Eventually these three professions—psychiatry, psychology, and social work—joined in their resistance to the emergence of new psychotherapy professions: the master’s-level psychologists, the marriage and family counselors, psychiatric nurse practitioners, pastoral counselors, body workers, movement and dance therapists, art therapists. The “eggshell” era of therapy—in which the client was considered so fragile and the mysteries of technique so deep that only the individual with the ultimate diploma dared treat one—is gone forever.†

Nor is this reevaluation of the therapist’s role and authority solely a modern phenomenon. There were adumbrations of such experimentation among the earliest dynamic therapists. For example, Sandor Ferenczi, a close associate of Freud who was dissatisfied with the therapeutic results of psychoanalysis, continually challenged the aloof, omniscient role of the classical psychoanalyst. Ferenczi and Freud in fact parted ways because of Ferenczi’s conviction that it was the mutual, honest, and transparent relationship that therapist and client created together, not the rational interpretation, that was the mutative force of therapy.
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In his pioneering emphasis on the interpersonal relationship, Ferenczi influenced American psychotherapy through his impact on future leaders in the field such as William Alanson White, Harry Stack Sullivan, and Frieda Fromm-Reichman. Ferenczi also had a significant but overlooked role in the development of group therapy, underscoring the relational base of virtually all the group therapeutic factors.
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During his last several years, he openly acknowledged his fallibility to clients and, in response to a just criticism, felt free to say, “I think you may have touched upon an area in which I am not entirely free myself. Perhaps you can help me see what’s wrong with me.”
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Foulkes, a British pioneer group therapist, stated sixty years ago that the mature group therapist was truly modest—one who could sincerely say to a group, “Here we are together facing reality and the basic problems of human existence. I am one of you, not more and not less.”
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I explore therapist transparency more fully in other literary forms: two books of stories based on my psychotherapy cases—
Love’s Executioner
and
Momma and the Meaning of Life
—and in novels—
When Nietzsche Wept
(in which the client and therapist alternate roles), and
Lying on the Couch
in which the therapist protagonist reruns Ferenczi’s mutual analysis experiment by revealing himself fully to a client.
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After the publication of each of these books, I received a deluge of letters, from both clients and therapists, attesting to the widespread interest and craving for a more human relationship in the therapy venture. My most recent novel, (
The Schopenhauer Cure
)
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is set in a therapy group in which the therapist engages in heroic transparency.

Those therapist who attempt greater transparency argue that therapy is a rational, explicable process. They espouse a humanistic attitude to therapy, in which the client is considered a full collaborator in the therapeutic venture. No mystery need surround the therapist or the therapeutic procedure; aside from the ameliorative effects stemming from expectations of help from a magical being, there is little to be lost and probably much to be gained through the demystification of therapy. A therapy based on a true alliance between therapist and enlightened client reflects a greater respect for the capacities of the client and, with it, a greater reliance on self-awareness rather than on the easier but precarious comfort of self-deception.

Greater therapist transparency is, in part, a reaction to the old authoritarian medical healer, who, for many centuries, has colluded with the distressed human being’s wish for succor from a superior being. Healers have harnessed and indeed cultivated this need as a powerful agent of treatment. In countless ways, they have encouraged and fostered a belief in their omniscience: Latin prescriptions, specialized language, secret institutes with lengthy and severe apprenticeships, imposing offices, and power displays of diplomas—all have contributed to the image of the healer as a powerful, mysterious, and prescient figure.

In unlocking the shackles of this ancestral role, the overly disclosing therapist of today has at times sacrificed effectiveness on the altar of self-disclosure. However, the dangers of indiscriminate therapist transparency (which I shall consider shortly) should not deter us from exploring the judicious use of therapist self-disclosure.

The Effect of Therapist Transparency on the Therapy Group

The primary sweeping objection to therapist transparency emanates from the traditional analytic belief that the paramount therapeutic factor is the resolution of client-therapist transference. This view holds that the therapist must remain relatively anonymous or opaque to foster the development of unrealistic feelings toward him or her. It is my position, however, that other therapeutic factors are of equal or greater importance, and that the therapist who judiciously uses his or her own person increases the therapeutic power of the group by encouraging the development of these factors. In doing so, you gain considerable role flexibility and maneuverability and may, without concerning yourself about spoiling your role, directly attend to group maintenance, to the shaping of the group norms (there is considerable research evidence that therapist self-disclosure facilitates greater openness between group members
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as well as between family members in family therapy
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), and to here-and-now activation and process illumination. By decentralizing your position in the group, you hasten the development of group autonomy and cohesiveness. We see corroborating evidence from individual therapy: therapist self-disclosure is often experienced by clients as supportive and normalizing. It fosters deeper exploration on the client’s part.† Therapist self-disclosure is particularly effective when it serves to engage the client authentically and does not serve to control or direct the therapeutic relationship.†
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