The Theory and Practice of Group Psychotherapy (75 page)

He deliberated for a moment and then said, “If I were to move it up a couple of rungs, I would tell the group that I was an alcoholic.”

This was a staggering bit of self-disclosure. Joe had been in the group for a year, and no one in the group—not even me and my cotherapist—had known of this. Furthermore, it was vital information. For weeks, for example, Joe had bemoaned the fact that his wife was pregnant and had decided to have an abortion rather than have a child by him. The group was baffled by her behavior and over the weeks became highly critical of his wife—some members even questioned why Joe stayed in the marriage. The new information that Joe was an alcoholic provided a crucial missing link. Now his wife’s behavior made sense!

My initial response was one of anger. I recalled all those futile hours Joe had led the group on a wild-goose chase. I was tempted to exclaim, “Damn it, Joe, all those wasted meetings talking about your wife! Why didn’t you tell us this before?” But that is just the time to bite your tongue. The important thing is not that Joe did not give us this information earlier but that he did tell us today. Rather than being punished for his previous concealment, he should be reinforced for having made a breakthrough and been willing to take an enormous risk in the group. The proper technique consisted of supporting Joe and facilitating further “horizontal” disclosure, that is, about the experience of disclosure (see chapter 5).
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It is not uncommon for members to withhold information, as Joe did, with the result that the group spends time inefficiently. Obviously, this has a number of unfortunate implications, not the least of which is the toll on the self-esteem of the withholding member who knows he or she is being duplicitous—acting in bad faith toward the other members. Often group leaders do not know the extent to which a member is withholding, but (as I discuss in chapter 14) as soon as they begin doing combined therapy (that is, treating the same individual both in individual and group therapy), they are amazed at how much new information the client reveals.

In chapter 7, I discussed aspects of group leader self-disclosure. The therapist’s transparency, particularly within the here-and-now, can be an effective way to encourage member self-disclosure.† But leader transparency must always be placed in the context of what is useful to the functioning of a particular group at a particular time. The general who, after making an important tactical decision, goes around wringing his hands and expressing his uncertainty will undercut the morale of his entire command.
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Similarly, the therapy group leader should obviously not disclose feelings that would undermine the effectiveness of the group, such as impatience with the group, a preoccupation with a client or a group seen earlier in the day, or any of a host of other personal concerns.
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TERMINATION

The concluding phase of group therapy is termination, a critically important but frequently neglected part of treatment.
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Group therapy termination is particularly complex: members may leave because they have achieved their goals, they may drop out prematurely, the entire group may end, and the therapist may leave. Furthermore, feelings about termination must be explored from different perspectives: the individual member, the therapist, the group as a whole.

Even the word termination has unfavorable connotations; it is often used in such negative contexts as an unwanted pregnancy or a poorly performing employee.
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In contrast, a mutual, planned ending to therapy is a positive, integral part of the therapeutic work that includes review, mourning, and celebration of the commencement of the next phase of life. The ending should be clear and focused—not a petering out. Confronting the ending of therapy is a boundary experience, a confrontation with limits.
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It reminds us of the precious nature of our relationships and the requirement to conclude with as few regrets as possible about work undone, emotions unexpressed, or feelings unstated.

Termination of the Client

If properly understood and managed, termination can be an important force in the process of change. Throughout, I have emphasized that group therapy is a highly individual process. Each client will enter, participate in, use, and experience the group in a uniquely personal manner. The end of therapy is no exception.

Only general assumptions about the length and overall goals of therapy may be made. Managed health care decrees that most therapy groups be brief and problem oriented—and, indeed, as reviewed in chapter 10, there is evidence that brief group approaches may effectively offer symptomatic relief. There is also evidence, however, that therapy is most effective when the ending of treatment is collaboratively determined and not arbitrarily imposed by a third party.
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Managed care is most interested in what will be most useful for the majority of a large pool of clients. Psychotherapists are less interested in statistics and aggregates of clients than in the individual distressed client in their office.

How much therapy is enough? That is not an easy question to answer. Although remoralization and recovery from acute distress often occur quickly, substantial change in character structure generally requires twelve to twenty-four months, or more, of therapy.†
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The goals of therapy have never been stated more succinctly than by Freud: “to be able to love and to work.”
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Freud believed that therapy should end when there is no prospect for further gains and the individual’s pathology has lost its hold. Some people would add other goals: the ability to love oneself, to allow oneself to be loved, to be more flexible, to learn to play, to discover and trust one’s own values, and to achieve greater self-awareness, greater interpersonal competence, and more mature defenses.
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Some group members may achieve a great deal in a few months, whereas others require years of group therapy. Some individuals have far more ambitious goals than others; it would not be an exaggeration to state that some individuals, satisfied with their therapy, terminate in approximately the same state in which others begin therapy. Some clients may have highly specific goals in therapy and, because much of their psychopathology is ego-syntonic, choose to limit the amount of change they are willing to undertake. Others may be hampered by important external circumstances in their lives. All therapists have had the experience of helping a client improve to a point at which further change would be countertherapeutic. For example, a client might, with further change, outgrow, as it were, his or her spouse; continued therapy would result in the rupture of an irreplaceable relationship unless concomitant changes occur in the spouse. If that contingency is not available (if, for example, the spouse adamantly refuses to engage in the change process), the therapist may be well advised to settle for the positive changes that have occurred, even though the personal potential for greater growth is clear.

Termination of professional treatment is but a stage in the individual’s career of growth. Clients continue to change, and one important effect of successful therapy is to enable individuals to use their psychotherapeutic resources constructively in their personal environment. Moreover, treatment effects may be time delayed: I have seen many successful clients in long-term follow-up interviews who have not only continued to change after termination but who, after they have left the group, recall an observation or interpretation made by another member or the therapist that only then—months, even years, later—became meaningful to them.

Setbacks, too, occur after termination: many successfully treated clients will, from time to time, encounter severe stress and need short-term help. In addition, almost all members experience anxiety and depression after leaving a group. A period of mourning is an inevitable part of the termination process. Present loss may evoke memories of earlier losses, which may be so painful that the client truncates the termination work. Indeed, some cannot tolerate the process and will withdraw prematurely with a series of excuses. This must be challenged: the client needs to internalize the positive group experience and the members and leader; without proper separation, that process will be compromised and the client’s future growth constricted.
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Some therapists find that termination from group therapy is less problematic than termination from long-term individual therapy, in which clients often become extremely dependent on the therapeutic situation. Group therapy participants are usually more aware that therapy is not a way of life but a process with a beginning, a middle, and an end. In the open therapy group, there are many living reminders of the therapeutic sequence. Members see new members enter and improved members graduate; they observe the therapist beginning the process over and over again to help the beginners through difficult phases of therapy. Thus, they realize the bittersweet fact that, although the therapist is a person with whom they have had a real and meaningful relationship, he or she is also a professional whose attention must shift to others and who will not remain as a permanent and endless source of gratification for them.

Not infrequently, a group places subtle pressure on a member not to terminate because the remaining members will miss that person’s presence and contributions. There is no doubt that members who have worked in a therapy group for many months or years acquire interpersonal and group skills that make them particularly valuable to the other members. (This is an important qualitative difference between group therapy and individual therapy outcome: Group therapy members routinely increase in emotional intelligence and become expert process diagnosticians and facilitators.)†

• One graduating member pointed out in his final meeting that Al usually started the meeting, but recently that role had switched over to Donna, who was more entertaining. After that, he noted that Al, aside from occasional sniping, often slumped into silence for the rest of the meeting. He also remarked that two other members never communicated directly to each other; they always used an intermediary. Another graduating member remarked that she had noted the first signs of the breakdown of a long-term collusion between two members in which they had, in effect, agreed never to say anything challenging or unpleasant to the other. In the same meeting, she chided the members of the group who were asking for clarification about the groups ground rules about subgrouping: “Answer it for yourselves. It’s your therapy. You know what you want to get out of the group. What would it mean to you? Will it get in your way or not?” All of these comments are sophisticated and interpersonally astute—worthy of any experienced group therapist.

Therapists may so highly value such a member’s contributions that they also are slow in encouraging him or her to terminate—of course, there is no justification for such a posture, and therapists should explore this openly as soon as they become aware of it. I have, incidentally, noted that a “role suction” operates at such times: once the senior member leaves, another member begins to exercise skills acquired in the group. Therapists, like other members, will feel the loss of departing members and by expressing their feelings openly do some valuable modeling for the group and demonstrate that this therapy and these relationships matter, not just to the clients but to them as well.

Some socially isolated clients may postpone termination because they have been using the therapy group for social reasons rather than as a means for developing the skills to create a social life for themselves in their home environment. The therapist must help these members focus on transfer of learning and encourage risk taking outside the group. Others unduly prolong their stay in the group because they hope for some guarantee that they are indeed safe from future difficulties. They may suggest that they remain in the group for a few more months, until they start a new job, or get married, or graduate from college. If the improvement base seems secure, however, these delays are generally unnecessary. Members must be helped to come to terms with the fact that one can never be certain; one is always vulnerable.

Not infrequently, clients experience a brief recrudescence of their original symptomatology shortly before termination. Rather than prolong their stay in the group, the therapist should help the clients understand this event for what it is: protest against termination. There are times, however, when this pretermination regression can serve as a last opportunity to revisit the concerns that led to treatment initially and allow some relapse prevention work. Ending does not undo good work, but it can profitably revisit the beginnings of the work.

• One man, three meetings before termination, re-experienced much of the depression and sense of meaninglessness that had brought him into therapy. The symptoms rapidly dissipated with the therapist’s interpretation that he was searching for reasons not to leave the group. That evening, the client dreamed that the therapist offered him a place in another group in which he would receive training as a therapist: “I felt that I had duped you into thinking I was better.” The dream represents an ingenious stratagem to defeat termination and offers two alternatives: the client goes into another of the therapist’s groups, in which he receives training as a therapist; or he has duped the therapist and has not really improved (and thus should continue in the group). Either way, he does not have to terminate.

Some members improve gradually, subtly, and consistently during their stay in the group. Others improve in dramatic bursts. I have known many members who, though hard working and committed to the group, made no apparent progress whatsoever for six, twelve, even eighteen months and then, suddenly, in a short period of time, seemed to transform themselves. (What do we tell our students? That change is often slow, that they should not look for immediate gratification from their clients. If they build solid, deep therapeutic foundations, change is sure to follow. So often we think of this as just a platitude designed to bolster neophyte therapists’ morale—we forget that it is true.)