The Theory and Practice of Group Psychotherapy (61 page)

Effective preparation for the group will reduce the
extrinsic
anxiety that stems from uncertainty. By clarifying the group goals, by explaining how group and personal goals are confluent, by presenting unambiguous guidelines for effective behavior, by providing the client with an accurate formulation of the group process, the therapist reduces uncertainty and the accompanying extrinsic anxiety.

A systematic preparation for group therapy by no means implies a rigid structuring of the group experience. I do not propose a didactic, directive approach to group therapy but, on the contrary, suggest a technique that will enhance the formation of a freely interacting, autonomous group. By averting lengthy ritualistic behavior in the initial sessions and by diminishing initial anxiety stemming from ambiguity, the group is enabled to plunge quickly into group work.

Although some group therapists eschew systematic preparation for the group, all group therapists attempt to clarify the therapeutic process and the behavior expected of clients: Differences between therapists or between therapeutic schools are largely in the timing and style of preparation. By subtle or even subliminal verbal and nonverbal reinforcement, even the most nondirective therapist attempts to persuade a group to accept his or her values about what is or is not important in the group process.
¹⁰⁴

Bureaucratic considerations add another component to preparation: informed consent. Contemporary therapists are under increasing pressure to provide (and to document in the record that it has been provided) sufficient information about treatment benefits, side effects, costs, and alternatives to make an informed choice about their therapy.
¹⁰⁵
Furthermore, informed consent cannot be dispensed with in a single discussion but must be revisited on a timely basis. Obtaining informed consent is rapidly evolving into a standard of practice enshrined in the Ethics Guidelines of the American Psychological Association
¹⁰⁶
and the American Psychiatric Association.
¹⁰⁷
Though this procedure may seem onerous, it is here to stay, and adaptive therapists must find a way to transform it into something useful: periodic frank discussions about the course of therapy convey respect for the client and strengthen the therapeutic alliance.

One final practical observation about preparation is in order. Group therapists often find themselves pressed to find group members. A sudden loss of members may provoke therapists into hasty activity to rebuild the group, often resulting in the selection of unsuitable, inadequately prepared members. The therapist then has to assume the position of selling the group to the prospective member—a position that is generally obvious to the client. The therapist does better to continue the group with reduced membership, to select new members carefully, and then to present the group in such a way as to maximize a client’s desire to join it. In fact, research indicates that the more difficult it is to enter a group and the more one wants to join, the more the individual will subsequently value the group.
¹⁰⁸
This is the general principle underlying initiation rites to fraternities and arduous selection and admission criteria for many organizations. An applicant cannot but reason that a group so difficult to join must be very valuable indeed.

Chapter 11

IN THE BEGINNING

T
he work of the group therapist begins long before the first group meeting. As I have already emphasized, successful group outcome depends largely on the therapist’s effective performance of the pretherapy tasks. In previous chapters, I discussed the crucial importance of proper group selection, composition, setting, and preparation. In this chapter I consider the birth and development of the group: first, the stages of development of the therapy group, and then problems of attendance, punctuality, membership turnover, and addition of new members—important issues in the life of the developing group.

FORMATIVE STAGES OF THE GROUP

Every therapy group, with its unique cast of characters and complex interaction, undergoes a singular development. All the members begin to manifest themselves interpersonally, each creating his or her own social microcosm. In time, if therapists do their job effectively, members will begin to understand their interpersonal style and eventually to experiment with new behavior. Given the richness of human interaction, compounded by the grouping of several individuals with maladaptive styles, it is obvious that the course of a group over many months or years will be complex and, to a great degree, unpredictable. Nevertheless, group dynamic forces operate in all groups to influence their development, and it is possible to describe an imperfect but nonetheless useful schema of developmental phases.

One well-known group developmental theory postulates five stages: forming, storming, norming, performing, and adjourning.
¹
This simple, rhythmic phrase captures well the range of group development models articulated by diverse researchers and applies to both time-limited and open-ended groups.†
²

In general, groups are first preoccupied with the tasks of initial member engagement and affiliation. This phase is followed by one with a focus on control, power, status, competition, and individual differentiation. Next comes a long, productive working phase marked by intimacy, engagement, and genuine cohesion. The final stage is termination of the group experience. These models also share a premise that development is
epigenetic
—that is, each stage builds on the success of preceding ones. Hence, early developmental failures will express themselves throughout the group’s life. Another premise of development is that groups are likely to regress under conditions threatening group integrity.†

As group development unfolds, we see shifts in group member behavior and communication. As the group matures, increased empathic, positive communication will be evident. Members describe their experience in more personal, affective and less intellectual ways. Group members focus more on the here-and-now, are less avoidant of productive conflict, offer constructive feedback, are more disclosing, and are more collaborative. Advice is replaced with exploration, and the group is more interactional, self-directed and less leader centered.
³
This developmental shift to more meaningful work has also been demonstrated repeatedly in reliable studies of task and work groups and correlates significantly with enhanced productivity and achievement.
⁴

There are compelling reasons for you as the therapist to familiarize yourself with the developmental sequence of groups. If you are to perform your task of assisting the group to form therapeutic norms and to prevent the establishment of norms that hinder therapy, then you must have a clear conception of the optimal development of a therapy group. If you are to diagnose group blockage and to intervene strategically to encourage healthy development, you must have a sense of favorable and of flawed development. Furthermore, knowledge of a broad developmental sequence will provide you with a sense of mastery and direction in the group; a confused and anxious leader engenders similar feelings in the group members.

The First Meeting

The first group therapy session is invariably a success. Clients (as well as neophyte therapists) generally anticipate it with such dread that they are always relieved by the actual event. Any actions therapists take to reduce clients’ anxiety and unease are generally useful. It is often helpful to call members a few days before the first meeting to reestablish contact and remind them of the group’s beginning. Greeting group members outside the group room before the first meeting or posting signs on the hallway directing clients to the group room for the first meeting are easy and reassuring steps to take.

Some therapists begin the meeting with a brief introductory statement about the purpose and method of the group (especially if they have not thoroughly prepared the clients beforehand); others may simply mention one or two basic ground rules—for example, honesty and confidentiality. The therapist may suggest that the members introduce themselves; if the therapist instead remains silent, invariably some member will suggest that the members introduce themselves. In North American groups the use of first names is usually established within minutes. Then a very loud silence ensues, which, like most psychotherapy silences, seems eternal but lasts only a few seconds.

Generally, the silence is broken by the individual destined to dominate the early stages of the group, who will say, “I guess I’ll get the ball rolling,” or words to that effect. Usually that person then recounts his or her reasons for seeking therapy, which often elicits similar descriptions from other members. An alternative course of events occurs when a member (perhaps spurred by the tension of the group during the initial silence) comments on his or her social discomfort or fear of groups. This remark may stimulate related comments from others who have similar feelings.

As I stressed in chapter 5, the therapist wittingly or unwittingly begins to shape the norms of the group at its inception. This task can be more efficiently performed while the group is still young. The first meeting is therefore no time for the therapist to be passive and inactive;
⁵
in chapter 5 I described a number of techniques to shape norms in a beginning group.

The Initial Stage: Orientation, Hesitant Participation,
Search for Meaning, Dependency

Two tasks confront members of any newly formed group. First, they must understand how to achieve their primary task—the purpose for which they joined the group. Second, they must attend to their social relationships in the group so as to create a niche for themselves that will provide not only the comfort necessary to achieve their primary task but also gratification from the sheer pleasure of group membership. In many groups, such as athletic teams, college classrooms, and work settings, the primary task and the social task are well differentiated.
⁶
In therapy groups, although this fact is not often appreciated at first by members, the tasks are confluent—a fact vastly complicating the group experience of socially ineffective individuals.

Several simultaneous concerns are present in the initial meetings. Members, especially if not well prepared by the therapist, search for the rationale of therapy; they may be confused about the relevance of the group’s activities to their personal goals in therapy. The initial meetings are often peppered with questions reflecting this confusion. Even months later, members may wonder aloud, “How is this going to help? What does all this have to do with solving my problems?”

At the same time, the members are attending to their social relationships: they size up one another and the group. They search for viable roles for themselves and wonder whether they will be liked and respected or ignored and rejected. Although clients ostensibly come to a therapy group for treatment, social forces impel them to invest most of their energy in a search for approval, acceptance, respect, or domination. To some, acceptance and approval appear so unlikely that they defensively reject or depreciate the group by mentally derogating the other members and by reminding themselves that the group is unreal and artificial, or that they are too special to care about a group that requires sacrificing even one particle of their prized individuality. Many members are particularly vulnerable at this time.†
⁷

In the beginning, the therapist is well advised to keep one eye on the group as a whole, and the other eye on each individual’s subjective experience in this new group. Members wonder what membership entails. What are the admission requirements? How much must one reveal or give of oneself? What type of commitment must one make? At a conscious or near-conscious level, they seek the answers to questions such as these and maintain a vigilant search for the types of behavior that the group expects and approves. Most clients crave both a deep, intimate one-to-one connection and a connection to the whole group.†
⁸
Occasionally, however, a member with a very tenuous sense of self may fear losing his identity through submersion in the group. If this fear is particularly pronounced it may impede engagement in the group. For such individuals, differentiation trumps belonging.
⁹

If the early group is puzzled, testing, and hesitant, then it is also dependent. Overtly and covertly, members look to the leader for structure and answers as well as for approval and acceptance. Many comments and reward-seeking glances are cast at you as members seek to gain approval from authority. Your early comments are carefully scrutinized for directives about desirable and undesirable behavior. Clients appear to behave as if salvation emanates solely or primarily from you, if only they can discover what it is you want them to do. There is considerable realistic evidence for this belief: you have a professional identity as a healer, you host the group by providing a room, you prepare members, and you charge a fee for your services. All of this reinforces their expectation that you will take care of them. Some therapists unwittingly compound this belief by absorbing the client projections of special powers and unconsciously offering unfulfillable promise of succor.
¹⁰

The existence of initial dependency thus stems from many sources: the therapeutic setting, the therapist’s behavior, a morbid dependency state on the part of the client and, as I discussed in chapter 7, the many irrational sources of the members’ powerful feelings toward the therapist. Among the strongest of these is the human need for an omnipotent, omniscient, all-caring parent or rescuer—a need that colludes with the infinite human capacity for self-deception to create a yearning for and a belief in a superbeing.†