The Theory and Practice of Group Psychotherapy (90 page)

• Ellen and Len were particularly vehement today in pointing out several times that Cynthia had been confrontative and insensitive to Ted and, as Len put it, was very, very hard on people. Is it possible that what was going on in the group today might be viewed from another perspective: the perspective of what types of message the group was giving to the new members about how they would like them to be in the group? Is it possible that the group was suggesting to Rick and Carla [new members] that they take pains not to be critical and that open criticism is something that simply is not done here in this group? It may also be true that, to some degree, Cynthia was “set up,” that she was made the “fall person” for this transaction: that is, is it possible that, at some unconscious level, the group concluded that she was tough enough to take this and they could get a message to the new members through Cynthia, through a criticism of her behavior?

Transmission of the Therapist’s Temporal Perspective

Far more than any member of the group, the therapist maintains a longrange temporal perspective and is cognizant of changes occurring over many weeks or months, both in the group and in each of the members. There are many times when the sharing of these observations offers hope, support, and meaning for the members. For example:

• Seymour spoke quite openly in the group today about how hurt he was by Jack and Burt switching the topic off him. We [the co-therapists] were struck by the ease and forthrightness with which he was able to discuss these feelings. We can clearly remember his hurt, passive, silence in similar situations in the past, and are impressed with how markedly he has changed his ability to express his feelings openly.

The summaries provide temporal perspective in yet another way. Since the clients almost invariably save and file the reports, they have a comprehensive account of their progression through the group, an account to which they may, with great profit, refer in the future.

Therapist Self-Disclosure

Therapists, in the service of the clients’ therapy, may use the summary as a vehicle to disclose personal here-and-now feelings (of puzzlement, of discouragement, of irritation, of pleasure) and their views about the theory and rationale underlying their own behavior in the group. Consider the therapist self-disclosure in these illustrative excerpts:

• Irv and Louise [the co-therapists] both felt considerable strain in the meeting. We felt caught between our feelings of wanting to continue more with Dinah, but also being very much aware of Al’s obvious hurting in the meeting. Therefore, even at the risk of Dinah’s feeling that we were deserting her, we felt strongly about bringing in Al before the end of the meeting.

• We felt very much in a bind with Seymour. He was silent during the meeting. We felt very much that we wanted to bring him into the group and help him talk, especially since we knew that the reason he had dropped out of his previous group was because of his feeling that people were uninterested in what he had to say. On the other hand, today we decided to resist the desire to bring him in because we knew that by continually bringing Seymour into the group, we are infantilizing him, and it will be much better if, sooner or later, he is able to do it by himself.

• Irv had a definite feeling of dissatisfaction with his own behavior in the meeting today. He felt he dominated things too much, that he was too active, too directive. No doubt this is due in large part to his feeling of guilt at having missed the previous two meetings and wanting to make up for it today by giving as much as possible.

Filling Gaps

An obvious and important function of the summary is to fill in gaps for members who miss meetings because of illness, vacation, or any other reason. The summaries keep them abreast of events and enable them to move more quickly back into the group.

New Group Members

The entrance of a new member may also be facilitated by providing summaries of the previous few meetings. I routinely ask new members to read such summaries before attending the first meeting.

General Impressions

I believe that the written summary facilitates therapy. Clients have been unanimous in their positive evaluation: most read and consider the summaries very seriously; many reread them several times; almost all file them for future use. The client’s therapeutic perspective and commitment is deepened; the therapeutic relationship is strengthened; and no serious transference complications occur. The dialogue and disagreement about summaries is always helpful and makes this a collaborative process. The intent of the summary should never be to convey a sense of the “last word” on something.

I have noted no adverse consequences. Many therapists have asked about confidentiality, but I have encountered no problems in this area. Clients are asked to regard the summary with the same degree of confidentiality as any event in the group. As an extra precaution, I use only first names, avoid explicit identification of any particularly delicate issue (for example, an extramarital affair), and mail it out in a plain envelope with no return address. E-mail may be another, even more time-efficient vehicle if security can be assured.

The only serious objection to written summaries I have encountered occurred in a six-month pilot research group of adult survivors of incest. In that group there was one member with a history of extreme abuse who slipped in and out of paranoid thinking. She was convinced that her abusers were still after her and that the summary would somehow constitute a paper trail leading them to her. She did not want any summaries mailed to her. Soon two other members expressed discomfort with any written record because of the extent of their shame around the incest. Consequently, my co-therapist and I announced that we would discontinue the written summary. However, the other members expressed so much grumbling disappointment that we ultimately agreed on a compromise: for the last ten minutes of each session, my co-therapist and I summarized our impressions and experiences of the meeting. Although the oral summary could not provide everything a written one did, it nonetheless proved a satisfactory compromise.

Like any event in the group, the summaries generate differential responses. For example, clients with severe dependency yearnings will cherish every word; those with a severe counterdependent posture will challenge every word or, occasionally, be unable to spare the time to read them at all; obsessive clients obsess over the precise meaning of the words; and paranoid individuals search for hidden meanings. Thus, although the summaries provide a clarifying force, they do not thwart the formation of the distortions whose corrections are intrinsic to therapy.

A Summary of a Group’s Twentieth Meeting

The complete summary below is unedited aside from minor stylistic improvements and change of names. I dictated it on a microcassette recorder in approximately twenty minutes (driving home after the session). A few weeks are required to learn to dictate meetings comfortably and quickly, but it is not a difficult feat. My co-therapists, generally psychiatry residents, do the dictating on alternate weeks, and after only a few weeks the clients cannot differentiate whether I or my co-leader did the summary.
It is essential that the summary be dictated immediately after a session
and, if co-leading, after the postgroup debriefing with your co-therapist. This is very important! The sequence of events in the group fades quickly. Do not let even a phone call intervene between the meeting and your dictation.

I suggest this dictating plan: first try to construct the skeleton of the meeting by recalling the two to four major issues of the meeting. When that is in place, next try to recall the transitions between issues. Then go back to each issue and try to describe each member’s contribution to the discussion of each issue. Pay special attention to your own role, including what you said (or didn’t say) and what was directed toward you.

Do not be perfectionistic: One cannot recall or remember everything. Do not try to refresh your memory by listening to a tape of a meeting—that would make the task far too time-consuming. I mail it out without proofreading it; clients overlook errors and omissions. Voice-activated computer technology makes the task even simpler and less time-consuming.

This is a sample summary of a meeting of a long-term open ambulatory group. It is better written (polished for this text) and more lucid than the great majority of my summaries. Do not be dissuaded from trying the summary technique after reading this. Don’t be dismayed, either, by the length of this summary. Because I want to take advantage of this opportunity to describe a meeting in great detail, I have selected a summary that is about 25 percent longer than most.

• Terri was absent because of illness. Laura opened the meeting by raising an important question for her left over from last week. During her interchange with Edith, she thought that she had seen Paul give Kathy a knowing glance. Paul assured Laura that that was, indeed, not the case. He had looked at Kathy—but it was for a different reason entirely: it had been because of his deep concern about Kathy’s depression last week, hoping to find a way to involve Kathy more in the group. The matter was dropped there, but it seemed a particularly useful way for Laura to have used the group. It is not an uncommon experience for individuals to feel that others exchange glances when they are talking, and it seemed as though Laura had a certain sense of being excluded or perhaps of Paul dismissing her or possibly Paul being uninterested in what she and Edith were up to.

The next issue that emerged consumed a considerable portion of the meeting and, in some ways, was tedious for many of the members but, at the same time, was an exceptionally valuable piece of work. Paul took the floor and began talking about certain types of insight he had had during the couple of weeks. He took a very long time to describe what he had been feeling, and did so in a highly intelligent but intellectualized and vague fashion. People in the group, at this point, were either straining to stay with Paul and understand what he was coming to or, as in the case of Bill and Ted, had begun to tune Paul out. Eventually what transpired was that Paul communicated to the group that he had some real doubts about whether or not he, indeed, really wanted to go back to law school, and was wrestling with those doubts.

During Paul’s entire presentation he seemed, at some level, aware that he was being unclear and that he was communicating what he had to say in a highly oblique fashion. He asked, on several occasions, whether the group was following him and whether he was clear. At the end of his presentation, he puzzled individuals in the group by commenting that he felt very good about what had happened in the group and felt that he was in exactly the place he wanted to be in. Kathy questioned this. She, like others in the group, felt a little puzzled about what on earth it was that Paul had gotten from the whole sequence.

But apparently what had happened was that Paul had been able to convey to the group the struggle he was having about this decision and, at the same time, covertly to make it clear to the group that he did not want any active help with the content of the decision. When we wondered why Paul couldn’t just come out and say what it took him a very long time to say in just a sentence or two—that is, “I’m struggling with the decision to enter law school and I’m not certain if I want to go”—he said he would have felt extremely frightened had he said that. It seemed, as we analyzed it, that what he was frightened of was that somehow the group, as his family had, would take the decision away from him, would rob him of his autonomy, would leap in and make the decision for him in some fashion.

Then we suggested another approach for Paul. Would it have been possible for him to have started the meeting by being explicit about the whole process: that is, “I’m struggling with an important decision. I don’t know if I really want to go to law school. I want you all to know this and be able to share this with you, but I don’t want anyone in the group to help me actually make the decision.” Paul reflected upon this and commented that sounded very possible—something, indeed, he could have done. We’ll need to keep that in mind for the future: when Paul becomes intellectualized and vague, we should help him find ways to communicate his thoughts and needs succinctly and directly. That is, if he wants to get something from others and, at the same time, not puzzle or discourage them.

At the very end of this, the group seemed to have some difficulty letting Paul go, and more questions kept being asked of him. Al, in particular, asked Paul several questions about the content of his decision, until Edith finally commented that she’d like to change the topic, and it was clear that Paul was more than glad to do so.

We did not discuss in the group today Al’s questioning of Paul, which is not dissimilar from some other meetings in the past where Al became intensely interested in the content of the enterprise. One speculation we have (which will undoubtedly be rejected outright!) is that Al may be filling the time of the group as a way to keep the group away from asking him some questions about the pain in his life.

There was a very brief interchange between Edith and Laura. After their confrontation last week, Edith said that Laura had come up to her after the meeting and made it clear to her that Edith should not be upset about what was, at least in part, Laura’s problem. Edith felt grateful at that and let Laura know that. At the same time, however, Laura could comment to Edith that when Edith first started to talk to her in the meeting today, she felt this rush of fear again.