The Theory and Practice of Group Psychotherapy (6 page)

Neophyte group members do not at first appreciate the healing impact of other members. In fact, many prospective candidates resist the suggestion of group therapy with the question “How can the blind lead the blind?” or “What can I possibly get from others who are as confused as I am? We’ll end up pulling one another down.” Such resistance is best worked through by exploring a client’s critical self-evaluation. Generally, an individual who deplores the prospect of getting help from other group members is really saying, “I have nothing of value to offer anyone.”

There is another, more subtle benefit inherent in the altruistic act. Many clients who complain of meaninglessness are immersed in a morbid self-absorption, which takes the form of obsessive introspection or a teeth-gritting effort to actualize oneself. I agree with Victor Frankl that a sense of life meaning ensues but cannot be deliberately pursued: life meaning is always a derivative phenomenon that materializes when we have transcended ourselves, when we have forgotten ourselves and become absorbed in someone (or something) outside ourselves.
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A focus on life meaning and altruism are particularly important components of the group psychotherapies provided to patients coping with life-threatening medical illnesses such as cancer and AIDS.†
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THE CORRECTIVE RECAPITULATION OF THE PRIMARY FAMILY GROUP

The great majority of clients who enter groups—with the exception of those suffering from posttraumatic stress disorder or from some medical or environmental stress—have a background of a highly unsatisfactory experience in their first and most important group: the primary family. The therapy group resembles a family in many aspects: there are authority /parental figures, peer/sibling figures, deep personal revelations, strong emotions, and deep intimacy as well as hostile, competitive feelings. In fact, therapy groups are often led by a male and female therapy team in a deliberate effort to simulate the parental configuration as closely as possible. Once the initial discomfort is overcome, it is inevitable that, sooner or later, the members will interact with leaders and other members in modes reminiscent of the way they once interacted with parents and siblings.

If the group leaders are seen as parental figures, then they will draw reactions associated with parental/authority figures: some members become helplessly dependent on the leaders, whom they imbue with unrealistic knowledge and power; other blindly defy the leaders, who are perceived as infantilizing and controlling; others are wary of the leaders, who they believe attempt to strip members of their individuality; some members try to split the co-therapists in an attempt to incite parental disagreements and rivalry; some disclose most deeply when one of the co-therapists is away; some compete bitterly with other members, hoping to accumulate units of attention and caring from the therapists; some are enveloped in envy when the leader’s attention is focused on others: others expend energy in a search for allies among the other members, in order to topple the therapists; still others neglect their own interests in a seemingly selfless effort to appease the leaders and the other members.

Obviously, similar phenomena occur in individual therapy, but the group provides a vastly greater number and variety of recapitulative possibilities. In one of my groups, Betty, a member who had been silently pouting for a couple of meetings, bemoaned the fact that she was not in one-to-one therapy. She claimed she was inhibited because she knew the group could not satisfy her needs. She knew she could speak freely of herself in a private conversation with the therapist or with any one of the members. When pressed, Betty expressed her irritation that others were favored over her in the group. For example, the group had recently welcomed another member who had returned from a vacation, whereas her return from a vacation went largely unnoticed by the group. Furthermore, another group member was praised for offering an important interpretation to a member, whereas she had made a similar statement weeks ago that had gone unnoticed. For some time, too, she had noticed her growing resentment at sharing the group time; she was impatient while waiting for the floor and irritated whenever attention was shifted away from her.

Was Betty right? Was group therapy the wrong treatment for her? Absolutely not! These very criticisms—which had roots stretching down into her early relationships with her siblings—did not constitute valid objections to group therapy. Quite the contrary: the group format was particularly valuable for her, since it allowed her envy and her craving for attention to surface. In individual therapy—where the therapist attends to the client’s every word and concern, and the individual is expected to use up all the allotted time—these particular conflicts might emerge belatedly, if at all.

What is important, though, is not only that early familial conflicts are relived but that they are relived
correctively
. Reexposure without repair only makes a bad situation worse. Growth-inhibiting relationship patterns must not be permitted to freeze into the rigid, impenetrable system that characterizes many family structures. Instead, fixed roles must be constantly explored and challenged, and ground rules that encourage the investigation of relationships and the testing of new behavior must be established. For many group members, then, working out problems with therapists and other members is also working through unfinished business from long ago. (How explicit the working in the past need be is a complex and controversial issue, which I will address in chapter 5.)

DEVELOPMENT OF SOCIALIZING TECHNIQUES

Social learning—the development of basic social skills—is a therapeutic factor that operates in all therapy groups, although the nature of the skills taught and the explicitness of the process vary greatly, depending on the type of group therapy. There may be explicit emphasis on the development of social skills in, for example, groups preparing hospitalized patients for discharge or adolescent groups. Group members may be asked to role-play approaching a prospective employer or asking someone out on a date.

In other groups, social learning is more indirect. Members of dynamic therapy groups, which have ground rules encouraging open feedback, may obtain considerable information about maladaptive social behavior. A member may, for example, learn about a disconcerting tendency to avoid looking at the person with whom he or she is conversing; about others’ impressions of his or her haughty, regal attitude; or about a variety of other social habits that, unbeknownst to the group member, have been undermining social relationships. For individuals lacking intimate relationships, the group often represents the first opportunity for accurate interpersonal feedback. Many lament their inexplicable loneliness: group therapy provides a rich opportunity for members to learn how they contribute to their own isolation and loneliness.
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One man, for example, who had been aware for years that others avoided social contact with him, learned in the therapy group that his obsessive inclusion of minute, irrelevant details in his social conversation was exceedingly off-putting. Years later he told me that one of the most important events of his life was when a group member (whose name he had long since forgotten) told him, “When you talk about your feelings, I like you and want to get closer; but when you start talking about facts and details, I want to get the hell out of the room!”

I do not mean to oversimplify; therapy is a complex process and obviously involves far more than the simple recognition and conscious, deliberate alteration of social behavior. But, as I will show in chapter 3, these gains are more than fringe benefits; they are often instrumental in the initial phases of therapeutic change. They permit the clients to understand that there is a huge discrepancy between their intent and their actual impact on others.†

Frequently senior members of a therapy group acquire highly sophisticated social skills: they are attuned to process (see chapter 6); they have learned how to be helpfully responsive to others; they have acquired methods of conflict resolution; they are less likely to be judgmental and are more capable of experiencing and expressing accurate empathy. These skills cannot but help to serve these clients well in future social interactions, and they constitute the cornerstones of emotional intelligence.
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IMITATIVE BEHAVIOR

Clients during individual psychotherapy may, in time, sit, walk, talk, and even think like their therapists. There is considerable evidence that group therapists influence the communicational patterns in their groups by modeling certain behaviors, for example, self-disclosure or support.
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In groups the imitative process is more diffuse: clients may model themselves on aspects of the other group members as well as of the therapist.
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Group members learn from watching one another tackle problems. This may be particularly potent in homogeneous groups that focus on shared problems—for example, a cognitive-behavior group that teaches psychotic patients strategies to reduce the intensity of auditory hallucinations.
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The importance of imitative behavior in the therapeutic process is difficult to gauge, but social-psychological research suggests that therapists may have underestimated it. Bandura, who has long claimed that social learning cannot be adequately explained on the basis of direct reinforcement, has experimentally demonstrated that imitation is an effective therapeutic force.†
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In group therapy it is not uncommon for a member to benefit by observing the therapy of another member with a similar problem constellation—a phenomenon generally referred to as vicarious or spectator therapy.
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Imitative behavior generally plays a more important role in the early stages of a group, as members identify with more senior members or therapists.
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Even if imitative behavior is, in itself, short-lived, it may help to unfreeze the individual enough to experiment with new behavior, which in turn can launch an adaptive spiral (see chapter 4). In fact, it is not uncommon for clients throughout therapy to “try on,” as it were, bits and pieces of other people and then relinquish them as ill fitting. This process may have solid therapeutic impact; finding out what we are not is progress toward finding out what we are.

Chapter 2

INTERPERSONAL LEARNING

I
nterpersonal learning, as I define it, is a broad and complex therapeutic factor. It is the group therapy analogue of important therapeutic factors in individual therapy such as insight, working through the transference, and the corrective emotional experience. But it also represents processes unique to the group setting that unfold only as a result of specific work on the part of the therapist. To define the concept of interpersonal learning and to describe the mechanism whereby it mediates therapeutic change in the individual, I first need to discuss three other concepts:

1. The importance of interpersonal relationships

2. The corrective emotional experience

3. The group as social microcosm

THE IMPORTANCE OF INTERPERSONAL RELATIONSHIPS

From whatever perspective we study human society—whether we scan humanity’s broad evolutionary history or scrutinize the development of the single individual—we are at all times obliged to consider the human being in the matrix of his or her interpersonal relationships. There is convincing data from the study of nonhuman primates, primitive human cultures, and contemporary society that human beings have always lived in groups that have been characterized by intense and persistent relationships among members and that the need to belong is a powerful, fundamental, and pervasive motivation.
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Interpersonal relatedness has clearly been adaptive in an evolutionary sense: without deep, positive, reciprocal interpersonal bonds, neither individual nor species survival would have been possible.

John Bowlby, from his studies of the early mother-child relationship, concludes not only that attachment behavior is necessary for survival but also that it is core, intrinsic, and genetically built in.
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If mother and infant are separated, both experience marked anxiety concomitant with their search for the lost object. If the separation is prolonged, the consequences for the infant will be profound. Winnicott similarly noted, “There is no such thing as a baby. There exists a mother-infant pair.”
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We live in a “relational matrix,” according to Mitchell: “The person is comprehensible only within this tapestry of relationships, past and present.”
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Similarly, a century ago the great American psychologist-philosopher William James said:

We are not only gregarious animals liking to be in sight of our fellows, but we have an innate propensity to get ourselves noticed, and noticed favorably, by our kind. No more fiendish punishment could be devised, were such a thing physically possible, than that one should be turned loose in society and remain absolutely unnoticed by all the members thereof.
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Indeed, James’s speculations have been substantiated time and again by contemporary research that documents the pain and the adverse consequences of loneliness. There is, for example, persuasive evidence that the rate for virtually every major cause of death is significantly higher for the lonely, the single, the divorced, and the widowed.
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Social isolation is as much a risk factor for early mortality as obvious physical risk factors such as smoking and obesity.
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The inverse is also true: social connection and integration have a positive impact on the course of serious illnesses such as cancer and AIDS.
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