The Theory and Practice of Group Psychotherapy (36 page)

A process review of a highly charged meeting is often necessary. It is important for the therapist to demonstrate that intense emotional expression provides material for significant learning. Sometimes you can divide such a meeting into two parts: the experiential segment and the analysis of that experience. At other times you may analyze the process at the following meeting; you can ask about the feelings that members took home with them after the previous meeting, or simply solicit further thoughts they have since had about what occurred there.

Obviously, you teach through modeling your own process orientation. There is nothing to lose and much to gain by your sharing your perspective on the group whenever possible. Sometimes you may do this in an effort to clarify the meeting: “Here are some of the things I’ve seen going on today.” Sometimes you may wish to use a convenient device such as summarizing the meeting to a late arrival, whether co-therapist or member. One technique I use that systematically shares my process observations with members is to write a detailed summary of the meeting afterward, including a full description of my spoken and unspoken process observations, and mail it to the members before the next meeting (see chapter 14). With this approach the therapist uses considerable personal and professional disclosure in a way that facilitates the therapy work, particularly by increasing the members’ perceptivity to the process of the group.

It is useful to encourage members to describe their views on the process of group meetings. Many group therapy instructors who teach by leading an experiential group of their students often begin each meeting with a report, prepared by some designated student, of the process of the previous meeting. Some therapists learn to call upon certain members who display unusual intuitive ability to recognize process. For example, Ormont describes a marginal member in his group who had unusual sensitivity to the body language of others. The therapist made a point of harnessing that talent for the service of therapy. A question such as: “Michael, what was Pam saying to Abner with that wave of her hand?” served a double purpose: illumination of process and helping Michael gain centrality and respect.
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HELPING CLIENTS ACCEPT PROCESS-ILLUMINATING COMMENTS

F. Scott Fitzgerald once wrote, “I was impelled to think. God, was it difficult! The moving about of great secret trunks.” Throughout therapy, we ask our clients to think, to shift internal arrangements, to examine the consequences of their behavior. It is hard work, and it is often unpleasant, frightening work. It is not enough simply to provide clients with information or explanations; you must also facilitate the assimilation of the new information. There are strategies to help clients in this work.

Be concerned with the framing of interpretive remarks and feedback. No comments, not even the most brilliant ones, can be of value if their delivery is not accepted, if the client rejects the package unopened and uninspected. The relationship, the style of delivery, and the timing are thus as essential as the content of the message.

Clients are
always
more receptive to observations that are framed in a supportive fashion. Rarely do individuals reject an observation that they distance or shut out others, or that they are too unselfish and never ask for anything for themselves, or that they are stingy with their feelings, or that they conceal much of what they have to offer. All of these observations contain a supportive message: that the member has much to give and that the observer wishes to be closer, wishes to help, wishes to know the other more intimately.

Beware of appellations that are categorizing or limiting: they are counterproductive; they threaten; they raise defenses. Clients reject global accusations—for example, dependency, narcissism, exploitation, arrogance—and with good reason, since a person is always more than any one or any combination of labels. It is far more acceptable (and true) to speak of traits or parts of an individual—for example, “I often can sense you very much wanting to be close to others, offering help as you did last week to Debbie. But there are other times, like today, when I see you as aloof, almost scornful of the others. What do you know about this part of you?”

Often in the midst of intense group conflict, members hurl important truths at one another. Under these conditions, one cannot acknowledge the truth: it would be aiding the aggressor, committing treason against oneself. To make the conflict-spawned truths available for consumption, the therapist must appreciate and neutralize the defensiveness of the combatants.

You may, for example, appeal to a higher power (the member’s desire for self-knowledge) or increase receptivity by limiting the scope of the accusation. For example, “Farrell, I see you now closed up, threatened, and fending off everything that Jamie is saying. You’ve been very adroit in pointing out the weaknesses of her arguments, but what happens is that you (and Jamie, too) end up getting nothing for yourself. I wonder if you could take a different tack for a while and ask yourself this (and, later: Jamie, I’d like to ask you to do the same): Is there
anything
in what Jamie is saying that is true for you? What parts seem to strike an inner chord? Could you forget for a moment the things that are not true and stay with those that
are
true?”

Sometimes group members, in an unusually open moment, make a statement that may at some future time provide the therapist with great leverage. The thrifty therapist underscores these comments in the group and stores them for later use. For example, one man who was both proud of and troubled by his ability to manipulate the group with his social charm, pleaded at one meeting, “Listen, when you see me smile like this, I’m really hurting inside. Don’t let me keep getting away with it.” Another member, who tyrannized the group with her tears, announced one day, “When I cry like this, I’m angry. I’m not going to fall apart, so stop comforting me, stop treating me like a child.” Store these moments of truth; they can be of great value if recalled later, in a constructive, supportive manner, when the client is closed and defensive. In the previous example, you could simply remind the member of her comment a few meetings ago and ask whether this (the smiling to cover the pain or the self protective crying) is happening now.

Often it is useful to enlist the client more actively in establishing contracts. For example, if a client has worked hard in a session on some important trait, I might say something like: “Jane, you worked hard today and were very open to our feedback about the way you mother others and the way you use that mothering to avoid facing your own needs and pain. How did it feel? Did we push you too hard?” If the client agrees that the work was helpful (as the client almost always does), then it is possible to nail down a future contract by asking, “Then is it all right for us to keep pressing you, to give you feedback whenever we note you doing this in future meetings?” This form of “contracting” consolidates the therapeutic alliance and the mutual, collaborative nature of the psychotherapy.
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PROCESS COMMENTARY: A THEORETICAL OVERVIEW

It is not easy to discuss, in a systematic way, the actual practice of process illumination. How can one propose crisp, basic guidelines for a procedure of such complexity and range, such delicate timing, so many linguistic nuances? I am tempted to beg the question by claiming that herein lies the art of psychotherapy: it will come as you gain experience; you cannot, in a systematic way, come to it. To a degree, I believe this to be so. Yet I also believe that it is possible to blaze crude trails, to provide the clinician with general principles that will accelerate education without limiting the scope of artistry.

The approach I take in this section closely parallels the approach I used in the beginning of this book to clarify the basic therapeutic factors in group therapy. At that time I asked the questions: “How does group therapy help clients? In the group therapeutic process, what is core and what is front?” This approach leads to the delineation of several basic therapeutic factors and does not, I believe, constrain the therapist in any way in the choice of methods to implement them.

In this section I proceed in a similar fashion. Here the issue is not how group therapy helps but how process illumination leads to change. The issue is complex and requires considerable attention, but the length of this discussion should not suggest that the interpretive function of the therapist take precedence over other tasks.

First, let me proceed to view in a dispassionate manner the entire range of therapist interventions. I ask of each intervention the simplistic but basic question, “How does this intervention, this process-illuminating comment, help a client to change?” Underlying this approach, is a set of basic operational patterns shared by all contemporary interpersonal models of therapy.
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I begin by considering a series of process comments that a therapist made to a male client over several sessions of group therapy:

1. You are interrupting me.

2. Your voice is tight, and your fists are clenched.

3. Whenever you talk to me, you take issue with me.

4. When you do that, I feel threatened and sometimes frightened.

5. I wonder if you don’t feel competitive with me and are trying to devalue me.

6. I’ve noticed that you’ve done the same thing with all the men in the group. Even when they try to approach you helpfully, you strike out at them. Consequently, they see you as hostile and threatening.

7. In the three meetings when there were no women present in the group, you were more approachable.

8. I think you’re so concerned about your sexual attractiveness to women that you view men only as competitors and deprive yourself of the opportunity of ever getting close to a man.

9. Even though you always seem to spar with me, there seems to be another side to it. You often stay after the group to have a word with me; you frequently look at me in the group. And there’s that dream you described three weeks ago about the two of us fighting and then falling to the ground in an embrace. I think you very much want to be close to me, but somehow you’ve got closeness and eroticism entangled and you keep pushing me away.

10. You are lonely here and feel unwanted and uncared for. That rekindles so many of your feelings of unworthiness.

11. What’s happened in the group now is that you’ve distanced yourself, estranged yourself, from all the men here. Are you satisfied with that? (Remember that one of your major goals when you started the group was to find out why you haven’t had any close men friends and to do something about that.)

Note, first of all, that the comments form a progression: they start with simple observations of single acts and proceed to a description of feelings evoked by an act, to observations about several acts over a period of time, to the juxtaposition of different acts, to speculations about the client’s intentions and motivations, to comments about the unfortunate repercussions of his behavior, to the inclusion of more inferential data (dreams, subtle gestures), to calling attention to the similarity between the client’s behavioral patterns in the here-and-now and in his outside social world. Inexperienced group therapists sometimes feel lost because they have not yet developed an awareness of this progressive sequence of interventions.
²¹

In this progression, the comments become more inferential. They begin with sense-data observations and gradually shift to complex generalizations based on sequences of behavior, interpersonal patterns, fantasy, and dream material. As the comments become more complex and more inferential, their author becomes more removed from the other person—in short, more a therapist process-commentator. Members often make some of the earlier statements to one another but, for reasons I have already presented, rarely make the ones at the end of the sequence.

There is, incidentally, an exceptionally sharp barrier between comments 4 and 5. The first four statements issue from the experience of the commentator. They are the commentator’s observations and feelings; the client can devalue or ignore them but cannot deny them, disagree with them, or take them away from the commentator. The fifth statement (“I wonder if you don’t feel competitive with me and are trying to devalue me”) is much more likely to evoke defensiveness and to close down constructive interactional flow. This genre of comment is intrusive; it is a guess about the other’s intention and motivation and is often rejected unless an important trusting, supportive relationship has been previously established. If members in a young group make many comments of this type to one another, they are not likely to develop a constructive therapeutic climate.
²²
Using the phrase “I wonder” of course softens it a bit. Where would we therapists be without the use of “I wonder?”

But back to our basic question: how does this series (or any series of process comments) help the client change? The answer is that the group therapist initiates change by escorting the client through the following sequence:

1.
Here is what your behavior is like
. Through feedback and later through self-observation, members learn to see themselves as seen by others.

2.
Here is how your behavior makes others feel
. Members learn about the impact of their behavior on the feelings of other members.

3.
Here is how your behavior influences the opinions others have of you.
Members learn that, as a result of their behavior, others value them, dislike them, find them unpleasant, respect them, avoid them, and so on.