The Theory and Practice of Group Psychotherapy (69 page)

• He did not want to assume the position of spy or disapproving parent in the eyes of the group.

• He works in the here-and-now and is not free to bring up nongroup material.

• The involved members would, when psychologically ready, discuss the problem.

These are rationalizations, however. There is no more important issue than the interrelationship of the group members. Anything that happens between group members is part of the here-and-now of the group. The therapist who is unwilling to bring in all material bearing on member relationships can hardly expect members to do so. If you feel yourself trapped in a dilemma—on the one hand, knowing that you must bring in such observations and, on the other, not wanting to seem a spy—then generally the best approach is to
share your dilemma with the group
, both your observations
and
your personal uneasiness and reluctance to discuss them.†

Therapeutic Considerations

By no means is subgrouping, with or without extragroup socializing, invariably disruptive. If the goals of the subgroup are consonant with those of the parent group, subgrouping may ultimately enhance group cohesiveness. For example, a coffee group or a bowling league may operate successfully and increase the morale of a larger social organization. In therapy groups, some of the most significant incidents occur as a result of some extragroup member contacts that are then fully worked through in therapy.

• Two women members who went to a dance together after a meeting discussed, in the following meeting, their observations of each other in that purely social setting. One of them had been far more flirtatious, even openly seductive, than she had been in the group; furthermore, much of this was “blind spot” behavior—out of her awareness.

• Another group scheduled a beer party for one member who was terminating. Unfortunately, he had to leave town unexpectedly, and the party was canceled. The member acting as social secretary notified the others of the cancellation but by error neglected to contact one member, Jim. On the night of the party Jim waited, in vain, at the appointed place for two hours, experiencing many familiar feelings of rejection, exclusion, and bitter loneliness. The discussion of these reactions and of Jim’s lack of any annoyance or anger and his feeling that his being excluded was natural, expected, the way it should be, led to much fruitful therapeutic work for him. When the party was finally held, considerable data was generated about the group. Members displayed different aspects of themselves. For example, the member who was least influential in the group because of his emotional isolation and his inability or unwillingness to disclose himself assumed a very different role because of his wit, store of good jokes, and easy social mannerisms. A sophisticated and experienced member reencountered his dread of social situations and inability to make small talk, and took refuge behind the role of host, devoting his time busily to refilling empty glasses.

• In another group, a dramatic example of effective subgrouping occurred when the members became concerned about one member who was in such despair that she considered suicide. Several group members maintained a weeklong telephone vigil, which proved to be beneficial both to that client and to the cohesiveness of the entire group.

• The vignette of the man who liked Robin Hood, described in chapter 2, is another example of subgrouping that enhanced therapeutic work. The client attempted to form an extragroup alliance with every member of the group and ultimately, as a result of his extragroup activity, arrived at important insights about his manipulative modes of relating to peers and about his adversarial stance toward authority figures.

The principle is clear: any contact outside a group may prove to be of value
provided that the goals of the parent group are not relinquished
. If such meetings are viewed as part of the group rhythm of action and subsequent analysis of this action, much valuable information can be made available to the group. To achieve this end, the involved members must inform the group of all important extragroup events. If they do not, the disruptive effects on cohesiveness I have described will occur. The cardinal principle is:
it is not the subgrouping per se that is destructive to the group, but the conspiracy of silence that generally surrounds it.

In practice, groups that meet only once a week often experience more of the disruptive than the beneficial effects of subgrouping. Much extragroup socializing never comes directly to the group’s attention, and the behavior of the involved members is never made available for analysis in the group. For example, the extragroup relationship I described between Christine and Jerry, in which Jerry revealed in confidence his pedophilic obsessions, was never made known to the group. Christine disclosed the incident more than a year later to a researcher who interviewed her in a psychotherapy outcome study.

The therapist should encourage open discussion and analysis of all extragroup contacts and all in-group coalitions and continue to emphasize the members’ responsibility to bring extragroup contacts into the group. The therapist who surmises from glances between two members in the group, or from their appearance together outside the group, that a special relationship exists between them should not hesitate to present this thought to the group. No criticism or accusation is implied, since the investigation and understanding of an affectionate relationship between two members may be as therapeutically rewarding as the exploration of a hostile impasse. The therapist must attempt to disconfirm the misconception that psychotherapy is reductionistic in its ethos, that all experience will be reduced to some fundamental (and base) motive. Furthermore, other members must be encouraged to discuss their reaction to the relationship, whether it be envy, jealousy, rejection, or vicarious satisfaction.
⁹

One practical caveat: clients engaged in some extragroup relationship that they are not prepared to discuss in the therapy group may ask the therapist for an individual session and request that the material discussed not be divulged to the rest of the group. If you make such a promise, you may soon find yourself in an untenable collusion from which extrication is difficult. I would suggest that you refrain from offering a promise of confidentiality but instead assure the clients that you will be guided by your professional judgment and act sensitively, in their therapeutic behalf. Though this may not offer sufficient reassurance to all members, it will protect you from entering into awkward, antitherapeutic pacts.

Therapy group members may establish sexual relationships with one another, but not with great frequency. The therapy group is not prurient; clients often have sexual conflicts resulting in such problems as impotence, nonarousal, social alienation, and sexual guilt. I feel certain that far less sexual involvement occurs in a therapy group than in any equally long-lasting social or professional group.

The therapist cannot, by edict, prevent the formation of sexual relations or any other form of subgrouping. Sexual acting out and compulsivity are often symptoms of relationship difficulties that led to therapy in the first place. The emergence of sexual acting out in the group may well present a unique therapeutic opportunity to examine the behavior.

Consider the clinical example of the Grand Dame described in chapter 2. Recall that Valerie seduced Charles and Louis as part of her struggle for power with the group therapist. The episode was, in one sense, disruptive for the group: Valerie’s husband learned of the incident and threatened Charles and Louis, who, along with other members, grew so distrustful of Valerie that dissolution of the group appeared imminent. How was the crisis resolved? The group expelled Valerie, who then, somewhat sobered and wiser, continued therapy in another group. Despite these potentially catastrophic complications, some considerable benefits occurred. The episode was thoroughly explored within the group, and the participants obtained substantial help with their sexual issues. For example, Charles, who had a history of a Don Juan style of relationships with women, at first washed his hands of the incident by pointing out that Valerie had approached him and, as he phrased it, “I don’t turn down a piece of candy when it’s offered.” Louis also tended to disclaim responsibility for his relationships with women, whom he customarily regarded as a “piece of ass.” Both Charles and Louis were presented with powerful evidence of the implications of their act—the effects on Valerie’s marriage and on their own group—and so came to appreciate their personal responsibility for their acts. Valerie, for the first time, realized the sadistic nature of her sexuality; not only did she employ sex as a weapon against the therapist but, as I have already described, as a means of depreciating and humiliating Charles and Louis.

Though extragroup subgrouping cannot be forbidden, neither should it be encouraged. I have found it most helpful to make my position on this problem explicit to members in the preparatory or initial sessions. I tell them that extragroup activity often impedes therapy, and I clearly describe the complications caused by subgrouping. I emphasize that if extragroup meetings occur, fortuitously or by design, then it is the subgroupers’ responsibility to the other members and to the group to keep the others fully informed. As I noted in chapter 10, the therapist must help the members understand that the group therapy experience is a dress rehearsal for life; it is the bridge, not the destination. It will teach the skills necessary to establish durable relationships but will not provide the relationships. If group members do not transfer their learning, they derive their social gratification exclusively from the therapy group and therapy becomes interminable.

It is my experience that it is unwise to include two members in a group who already have a long-term special relationship: husband and wife, roommates, business associates, and so on. Occasionally, the situation may arise in which two members naively arrive for a first meeting and discover that they know one another from a prior or preexisting personal or employment relationship. It is not the most auspicious start to a group, but the therapist must not avoid examining the situation openly and thoroughly. Is the relationship ongoing? Will the two members be less likely to be fully open in the group? Are there concerns about confidentiality? How will it affect other group members? Is there a better or more workable option? A quick and a shared decision must be reached about how to proceed.

It is possible for group therapy to focus on current long-term relationships, but that entails a different kind of therapy group than that described in this book—for example, a marital couples’ group, conjoint family therapy, and multiple-family therapy.†

In inpatient psychotherapy groups and day hospital programs, the problem of extragroup relationships is even more complex, since the group members spend their entire day in close association with one another. The following case is illustrative.

• In a group in a psychiatric hospital for criminal offenders, a subgrouping problem had created great divisiveness. Two male members—by far the most intelligent, articulate, and educated of the group—had formed a close friendship and spent much of every day together. The group sessions were characterized by an inordinate amount of tension and hostile bickering, much of it directed at these two men, who by this time had lost their separate identities and were primarily regarded, and regarded themselves, as a dyad. Much of the attacking was off target, and the therapeutic work of the group had become overshadowed by the attempt to destroy the dyad.

As the situation progressed, the therapist, with good effect, helped the group explore several themes. First, the group had to consider that the two members could scarcely be punished for their subgrouping, since everyone had had an equal opportunity to form such a relationship. The issue of envy was thus introduced, and gradually the members discussed their own longing and inability to establish friendships. Furthermore, they discussed their feelings of intellectual inferiority to the dyad as well as their sense of exclusion and rejection by them. The two members had, however, augmented these responses by their actions. Both had, for years, maintained their self-esteem by demonstrating their intellectual superiority whenever possible. When addressing other members, they deliberately used polysyllabic words and maintained a conspiratorial attitude, which accentuated the others’ feelings of inferiority and rejection. Both members profited from the group’s description of the subtle rebuffs and taunts they had meted out and came to realize that others had suffered painful effects from their behavior.

Nota bene
that my comments on the potential dangers of subgrouping apply to groups that rely heavily on the therapeutic factor of interpersonal learning. In other types of groups, such as cognitive-behavioral groups for eating disorders, extragroup socializing has been shown to be beneficial in altering eating patterns.
¹⁰
Twelve-step groups, self-help groups, and support groups also make good use of extragroup contact. In support groups of, for example, cancer patients extragroup contact becomes an essential part of the process, and participants may be actively encouraged to contact one another between sessions as an aid in coping with the illness and its medical treatment.
¹¹
On many occasions, I have seen the group rally around members in deep despair and provide extraordinary support through telephone contact.

Clinical Example

I end this section with a lengthy clinical illustration—the longest in the book. I include it because it shows in depth not only many of the issues involved in subgrouping but also other aspects of group therapy discussed in other chapters, including the differentiation between primary task and secondary gratification and the assumption of personal responsibility in therapy.