The Theory and Practice of Group Psychotherapy (54 page)

Unfolding from these clinical observations is the rule that a degree of incompatibility must exist between the client and the interpersonal culture of the group if change is to occur. This principle—
that change is preceded by a state of dissonance or incongruity
—is backed by considerable clinical and social-psychological research; I will return to it later in this chapter. In the absence of adequate ego strength, however, group members cannot profit from the dissonance.

Therefore, for the long-term intensive therapy group, the rule that will serve clinicians in good stead is:
heterogeneity for conflict areas and homogeneity for ego strength.
We seek
heterogeneity
of individuals with regard to gender, level of activity or passivity, thinking and feeling, and interpersonal difficulties, but
homogeneity
with regard to intelligence, capacity to tolerate anxiety, and ability to give and receive feedback and to engage in the therapeutic process.

But heterogeneity must not be maintained at the price of creating a group isolate. Consider the age variable: If there is one sixty-year-old member in a group of young adults, that individual may choose (or be forced) to personify the older generation. Thus, this member is stereotyped (as are the younger members), and the required interpersonal honesty and intimacy will fail to materialize. A similar process may occur in an adult group with a lone late adolescent who assumes the unruly teenager role. Yet there are advantages to having a wide age spread in a group. Most of my ambulatory groups have members ranging in age from twenty-five to sixty-five. Through working out their relationships with other members, they come to understand their past, present, and future relationships with a wider range of significant people: parents, peers, and children.

Sexual orientation, cultural, and ethno-racial factors similarly need to be considered. Group members from minority backgrounds will need to trust that other group members are willing to consider each individual’s specific context and not to view that individual as a stereotype of his culture.†

Some therapists employ another concept—
role heterogeneity
—in their approach to group composition. Their primary consideration when adding a new member is what role in the group is open. Theoretically, such an orientation seems desirable. Practically, however, it suffers from lack of clarity. An extraordinary range of therapy group roles have been suggested: task leader, social-emotional leader, provocateur, doctor’s helper, help-rejecting complainer, self-righteous moralist, star, fight/flight leader, dependency leader, pairing leader, group hysteric, technical executive leader, social secretary, group stud, group critic, group romantic, guardian of democracy, timekeeper, aggressive male, vigilante of honesty, the sociable role, the structural role, the divergent role, the cautionary role, the scrutinizer, the innocent, the scapegoat, the intellectualizer, the child, the puritan, the reintegrater, and so on. Can we expand the list arbitrarily and indefinitely by including all behavior trait constellations? Or is there a fixed set of roles, constant from group to group, that members are forced to fill? Until we have some satisfactory frame of reference to deal with these questions, asking “What role is open in the group?” will contribute little toward an effective approach to group composition.

Clinical experience demonstrates that groups do better if some members can be exemplars and advocates of constructive group norms. Placing one or two “veterans” of group therapy into a new group may pay large dividends. Conversely, we can sometimes predict that clients will fit poorly with a particular group because of the likelihood that they will assume an unhealthy role in it. Consider this clinical illustration:

• Eve, a twenty-nine-year-old woman with prominent narcissistic personality difficulties, was evaluated for group therapy. She was professionally successful but interpersonally isolated, and she experienced chronic dysthymia that was only partially ameliorated with antidepressants. When she came to my office for a pregroup consultation, within minutes I experienced her as brittle, explosive, highly demanding, and devaluing of others. In many ways, Eve’s difficulties echoed those of another woman, Lisa, who had just quit this group (thereby creating the opening for which Eve was being evaluated). Lisa’s intense, domineering need to be at the center of the group, coupled with an exquisite vulnerability to feedback, had paralyzed the group members, and her departure had been met with clear relief by all. At another time, this group and Eve could have been a constructive fit. So soon after Lisa’s departure, however, it was very likely that Eve’s characteristic style of relating would trigger strong feelings in the group of “here we go again,” shifting the group members back into feelings that they had just painfully processed. An alternative group for Eve was recommended.

One final clinical observation. As a supervisor and researcher, I had an opportunity to study closely the entire thirty-month course of an ambulatory group led by two competent psychiatric residents. The group consisted of seven members, all in their twenties, six of whom could be classified as having schizoid personality disorder. The most striking feature of this homogeneous group was its extraordinary dullness. Everything associated with the group meetings, tape recordings, written summaries, and supervisory sessions seemed low-keyed and plodding. Often nothing seemed to be happening: there was no discernible movement individually among the members or in the group as a whole. And yet attendance was near perfect, and the group cohesiveness extraordinarily high.

At that time many ambulatory groups in the Stanford outpatient clinic were part of a study involving the measurement of group cohesiveness. This homogeneous schizoid group scored higher on cohesiveness (measured by self-administered questionnaires) than any other group. Since all the group participants in the Stanford clinic during this period were subjects in outcome research,
⁶²
thorough evaluations of clinical progress were available at the end of one year and again at thirty months. The members of this group, both the original members and the replacements, did extraordinarily well and underwent substantial characterological changes as well as complete symptomatic remission. In fact, few other groups I’ve studied have had comparably good results. My views about group composition were influenced by this group, and I have come to attach great importance to group stability, attendance, and cohesiveness.

Although in theory I agree with the concept of composing a group of individuals with varied interpersonal stresses and needs, I feel that in practice it may be a spurious issue. Given the limited predictive value of our traditional screening interview, it is probable that our expectations exceed our abilities if we think we can achieve the type of subtle balance and personality interlocking necessary to make a real difference in group functioning. For example, although six of the seven members in the group I just discussed were diagnosed as schizoid personalities, they differed far more than they resembled one another. This apparently homogeneous group, contrary to the clinical dictum, did not remain at a superficial level and effected significant personality changes in its members. Although the interaction seemed plodding to the therapists and researchers, it did not to the participants. None of them had ever had intimate relationships, and many of their disclosures, though objectively unremarkable, were subjectively exciting first-time disclosures.

Many so-called homogeneous groups remain superficial,
not because of homogeneity but because of the psychological set of the group leaders and the restricted group culture they fashion
. Therapists who organize a group of individuals around a common symptom or life situation must be careful not to convey powerful implicit messages that generate group norms of restriction, a search for similarities, submergence of individuality, and discouragement of self-disclosure and interpersonal honesty. Norms, as I elaborated in chapter 5, once set into motion, may become self-perpetuating and difficult to change. We should aim to reduce negative outcomes by forming groups with members who offer care, support, mutual engagement, regular attendance, and openness, but
composition itself is not always destiny
.†

What about gender and group composition? Some authors, arguing from theory or clinical experience, advocate single-gender groups, but the limited empirical research does not support this.
⁶³
Men in all-male groups are less intimate and more competitive, whereas men in mixed-gender groups are more self-disclosing and less aggressive. Unfortunately, the benefit of gender heterogeneity does not accrue to the women in these groups: women in mixed-gender groups may become less active and deferential to the male participants. Men may do poorly in mixed-gender groups composed of only one or two men and several women; men in this instance may feel peripheral, marginalized, and isolated.
⁶⁴

OVERVIEW

It would be most gratifying at this point to integrate these clinical and experimental findings, to point out hitherto unseen lines of cleavage and coalescence, and to emerge with a crisp theory of group composition that has firm experimental foundations as well as immediate practicality. Unfortunately, the data do not permit such a definitive synthesis. But there is value in highlighting major research findings that pertain to group composition.

The culture and functioning of every group—its ethos, values, and modus vivendi—will be influenced by the composition of its members. Our approach to composition must be informed by our understanding of the group’s tasks. The group must be able to respond to members’ needs for emotional support
and
for constructive challenge. In psychotherapy groups we should aim for a composition that balances similarity and divergence in interpersonal engagement and behavior; relationship to authority; emotional bonding; and task focus. Moreover, it is essential that members agree with the values that guide the therapeutic enterprise.

The research also points to certain unequivocal findings.
The composition of a group does make a difference and influences many aspects of group function.
† A group’s composition influences certain predictable short-term characteristics—for example, high cohesion and engagement, high conflict, high flight, high dependency. Furthermore, we can, if we choose to use available procedures, predict to some degree the group behavior of the individual.

What we are uncertain of, however, is the relationship between any of these group characteristics and the ultimate therapy outcome of the group members. Furthermore, we do not know how much the group leader may alter these characteristics of the group or how long an ongoing group will manifest them. We do know, however, that cohesive groups with higher engagement generally produce better clinical outcomes.†

In practice there are two major theoretical approaches to group composition: the homogeneous and the heterogeneous approach. Let us examine briefly the theoretical underpinnings of these two approaches. Underlying the
heterogeneous
approach to composition are two theoretical rationales that may be labeled the social microcosm theory and the dissonance theory. Underlying the
homogeneous
group composition approach is the group cohesiveness theory.

The Heterogeneous Mode of Composition

The social microcosm theory
postulates that because the group is regarded as a miniature social universe in which members are urged to develop new methods of interpersonal interaction, the group should be heterogeneous in order to maximize learning opportunities. It should resemble the real social universe by being composed of individuals of different sexes, professions, ages, and socioeconomic and educational levels. In other words, it should be a demographic assortment.

The dissonance theory
as applied to group therapy also suggests a heterogeneous compositional approach, but for a different reason. Learning or change is likely to occur when the individual, in a state of dissonance, acts to reduce that dissonance. Dissonance creates a state of psychological discomfort and propels the individual to attempt to achieve a more consonant state. Individuals who find themselves in a group in which membership has many desirable features (for example, hopes of alleviation of suffering, attraction to the leader and other members) but which, at the same time, makes tension-producing demands (for example, self-disclosure or interpersonal confrontation) will experience a state of dissonance or imbalance.
⁶⁵

Similarly, a state of discomfort occurs when, in a valued group, one finds that one’s interpersonal needs are unfulfilled or when one’s customary style of interpersonal behavior produces discord. The individual in these circumstances will search for ways to reduce discomfort—for example, by leaving the group or, preferably, by beginning to experiment with new forms of behavior. To facilitate the development of adaptive discomfort, the heterogeneous argument suggests that clients be exposed to other individuals in the group who will not reinforce neurotic positions by fulfilling interpersonal needs but instead will be frustrating and challenging, making clients aware of different conflict areas and also demonstrating alternative interpersonal modes.

Therefore, it is argued,
a group should include members with varying interpersonal styles and conflicts.
It is a delicate balance, because if frustration and challenge are too great, and the staying forces (the attraction to the group) too small, no real asymmetry or dissonance occurs; the individual does not change but instead physically or psychologically leaves the group. If, on the other hand, the challenge is too small, no learning occurs; members will collude, and exploration will be inhibited. The dissonance theory thus argues for a broad personality assortment.