The Theory and Practice of Group Psychotherapy (95 page)

4. Decreasing isolation

The inpatient group can help break down the isolation that exists between members. The group is a laboratory exercise intended to sharpen communication skills: the better the communication, the less the isolation. It helps individuals share with one another and permits them to obtain feedback about how others perceive them and to discover their blind spots.

Decreasing isolation between inpatient group members has
two distinct payoffs.
First, improved communication skills will help patients in their relationships with others outside the hospital. Virtually everyone who is admitted in crisis to an inpatient ward suffers from a breakdown or an absence of important supportive relationships with others. If the patient is able to transfer communication skills from the group to his or her outside life, then the group will have fulfilled a very important goal.

A second payoff is evident in the patient’s behavior on the ward: as isolation decreases, the patient becomes increasingly able to use the therapeutic resources available, including relationships with other patients.
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5. Being help ful to others

This goal, the therapeutic factor of altruism, is closely related to the previous one. Clients are not just helped by their peers, they are also helped by the knowledge that they themselves have been useful to others. Clients generally enter psychiatric hospitals in a state of profound demoralization. They feel that not only have they no way of helping themselves but they have nothing to offer others. The experience of being valuable to other ward members is enormously affirming to one’s sense of self-worth.

6. Alleviating hospital-related anxiety

The process of psychiatric hospitalization can be intensely anxiety provoking. Many patients experience great shame; they may be concerned about stigmatization and the effects of hospitalization on their job and friendships. Many patients are distressed by events on the ward—not only the bizarre and frightening behavior of other patients, but also the staff tensions.

Many of these secondary sources of tension compound the patient’s primary dysphoria and must be addressed in therapy. The small therapy groups (as well as the therapeutic community group) provide a forum in which patients can air these issues and often achieve reassurance simply from learning that these concerns are shared by other members. They can learn, for example, that their roommate is not hostile and intentionally rejecting of them, but rather is preoccupied and fearful.

Modification of Technique

We have now accomplished the first two steps of designing a group for the contemporary inpatient ward: (1) assessing the clinical setting, including identifying the intrinsic clinical facts of life, and (2) formulating an appropriate and realistic set of goals. Now we are ready to turn to the third step: designing (on the basis of intrinsic restraints and goals) a clinical strategy and technique.
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The Therapist’s Time Frame.
In the outpatient therapy group I have described in this text, the therapist’s time frame is many weeks or months, sometimes years. Therapists must be patient, must build cohesiveness over many sessions, must work through issues repetitively from meeting to meeting (they recognize that psychotherapy is often cyclotherapy, because they must return again and again to the same issues in the therapeutic work).
The inpatient group therapist faces an entirely different situation
: the group composition changes almost every day; the duration of therapy for members is often very brief—indeed, many attend the group for only a single session.

It is clear that the inpatient group therapist must adopt a radically shortened time frame: I believe that
the inpatient group therapist must consider the life of the group to be only a single session
. Perhaps there will be continuity from one meeting to the next; perhaps there will be culture bearers who will be present in several consecutive meetings, but do not count on it. The most constructive attitude to assume is that your group will last for only a single session and that you must strive to offer something useful for as many participants as possible during that session.

Efficiency and Activity.
The single-session time frame demands
efficiency
. You have no time to allow issues to build, to let things develop in the group and slowly work them through. You have no time to waste; you have only a single opportunity to engage a patient, and you must not squander it.

Efficiency demands activity on the part of the therapist. There is no place in inpatient group psychotherapy for the passive, reflective group therapist. A far higher level of activity is demanded in inpatient than in outpatient groups. You must activate the group and call on, actively support, and interact personally with members. This increased level of activity requires a major shift in technique for the therapist who has been trained in long-term group therapy, but it is an absolutely essential modification of technique.

Support.
Keep in mind that one of the major goals of the inpatient therapy group is to engage clients in a therapeutic process
they will wish to continue after leaving the hospital.
Thus, it is imperative that the therapist create in the group an atmosphere that members experience as supportive, positive, and constructive. Members must feel safe; they must learn to trust the group and to experience it as a place where they will be understood and accepted.

The inpatient therapy group is not the place for confrontation, for criticism, for the expression and examination of intense anger. There will often be patients in the group who are conning or manipulative and who may need powerful confrontation, but it is far better to let them pass unchallenged than to run the risk of making the group feel unsafe to the vast majority of patients. Group leaders need to recognize and incorporate both the needs of the group and the needs of the individual into their intervention. Consider, for example, Joe, an angry man with bipolar disorder who arrived at the small group the day after being forcibly restrained and secluded by unit staff after threatening to harm a nurse who refused his request for a pass off the ward. Joe pointedly sat silently outside of the circle with his back to the group members. Addressing Joe’s behavior was essential—it was too threatening to ignore—but it was also potentially inflammatory to engage Joe against his manifest wish. The group leader chose to acknowledge Joe’s presence, noting that it likely was hard for Joe to come to the group after the tensions of the night before. He was welcome to participate more fully if he chose, but if not, just coming would be viewed as a step toward his reentry. Joe maintained his silent posture, but the group was liberated and able to proceed.

In the long-term outpatient group, therapists provide support both directly and indirectly:
direct
support by personal engagement, by empathic listening, by understanding, by accepting glances, nods, and gestures;
indirect
support by building a cohesive group that then becomes a powerful agent of support.

Inpatient group therapists must learn to offer support more quickly and directly. Support is not something that therapists reflexively provide. In fact, many training programs in psychotherapy unwittingly extinguish a therapist’s natural propensity to support patients. Therapists are trained to become sniffers of pathology, experts in the detection of weaknesses. They are often so sensitized to transferential and countertransferential issues that they hold themselves back from engaging in basically human, supportive behavior with their clients.

Support may be offered in a myriad of ways.† The most direct, the most valued by clients, and the most often overlooked by well-trained professional therapists is to acknowledge openly the members’ efforts, intentions, strengths, positive contributions, and risks.
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If, to take an obvious example, one member states that he finds another member in the group very attractive, it is important that this member be supported for the risk he has taken. You may wonder whether he has previously been able to express his admiration of another so openly and note, if appropriate, that this is reflective of real progress for him in the group. Or, suppose you note that several members have been more self-disclosing after one particular member took a risk and revealed delicate and important material—then openly comment on it! Do not assume that members automatically realize that their disclosures have helped others take risks. Identify and reinforce the adaptive parts of the client’s presentation.
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Try to emphasize the positive rather than the negative aspects of a defensive posture. Consider, for example, members who persist in playing assistant therapist. Do not confront them by challenging their refusal to work on personal issues, but offer instead positive comments about how helpful they have been to others and then gently comment on their unselfishness and reluctance to ask for something personal from the group. It is the rare individual who resists the therapist’s suggestion that he or she needs to learn to be more selfish and to ask for more from others.

The therapist also supports by helping members obtain support from the group. Some clients, for example, obtain very little support because they characteristically present themselves in a highly objectionable fashion. A self-centered member who incessantly ruminates about a somatic condition will rapidly exhaust the patience of any group. When you identify such behavior, it is important to intervene quickly before animosity and rejection have time to well up. You may try any number of tactics—for example, directly instructing the client about other modes of behaving in the group or assigning the client the task of introducing new members into the group, giving feedback to other members, or attempting to guess and express what each person’s evaluation of the group is that day.

Consider a woman who talked incessantly about her many surgical procedures.
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It became clear from listening to this woman’s description of her life situation that she felt she had given everything to her children and had received nothing in return. She also described a deep sense of unworthiness and of being inferior to the other members of the group. I suggested that when she talked about her surgical procedures she was really saying, “I have some needs, too, but I have trouble asking for them. My preoccupation with my surgery is a way of asking, ‘Pay some attention to me.’” Eventually, she agreed with my formulation and to my request for her permission, whenever she talked about her surgery, to translate that into the real message, “Pay more attention to me.” This client’s explicit request for help was effective, and the members responded to her positively—which they never had when she recited her irritating litany of somatic complaints.

Another approach to support is to make certain the group is safe by anticipating and avoiding conflict whenever possible. If clients are irritable or want to learn to be more assertive or to challenge others, it is best to channel that work onto yourself: you are, let us hope, in a far better position to handle criticism than are any of the group members.

If two members are locked in conflict, it is best to intervene quickly and to search for positive aspects of the conflict. For example, keep in mind that sparks often fly between two individuals because of the group phenomenon of
mirroring
: one sees aspects of oneself (especially negative aspects) in another whom one dislikes because of what one dislikes in oneself. Thus, you can deflect conflict by asking individuals to discuss the various ways in which they resemble their adversary.

There are many other conflict-avoiding strategies.
Envy
is often an integral part of interpersonal conflict (see chapter 10); it is often constructive to ask adversaries to talk about those aspects of each other that they admire or envy. Role switching is sometimes a useful technique: ask adversaries to switch places and present the other’s point of view. Often it is helpful to remind the group that opponents generally prove to be very helpful to each other, whereas those who are indifferent rarely help each other grow. Sometimes an adversarial position is a method of showing that one cares.†

One reason some members experience the group as unsafe is that they fear that things will go too far, that the group may coerce them to lose control—to say, think, or feel things that will result in interpersonal catastrophe. You can help these members feel safe in the group by allowing them to exercise control over their own participation. Check in with members repeatedly with such questions as: “Do you feel we’re pushing you too hard?” “Is this too uncomfortable for you?” “Do you think you’ve revealed too much of yourself today?” “Have I been too intrusive by asking you such direct questions today?”

When you lead groups of severely disturbed, regressed patients, you must provide even more direct support. Examine the behavior of the severely regressed patients and find in it some positive aspect. Support the mute patient for staying the whole session; compliment the patient who leaves early for having stayed twenty minutes; support the member who arrives late for having shown up; support inactive members for having paid attention throughout the meeting. If members try to give advice, even inappropriate advice, reward them for their intention to help. If statements are unintelligible or bizarre, nonetheless label them as attempts to communicate. One group member, Jake, hospitalized because of a psychotic decompensation, angrily blurted out in the group that he intended to get Satan to rain “Hellfire and Brimstone upon this Godforsaken hospital.” Group members withdrew into silence. The therapist wondered aloud what provoked this angry explosion. Another member commented that Jake had been agitated since his discharge planning meeting. Jake then added that he did not want to go to the hostel that was recommended. He wanted to go back to his boarding house, because it was safer from theft and assault. That was something all in the group could understand and support. Finding the underlying and understandable human concern brought Jake and the group members back together—a far better situation than Jake being isolated because of his bizarre behavior.