The Theory and Practice of Group Psychotherapy (4 page)

Group therapists can capitalize on this factor by doing whatever we can to increase clients’ belief and confidence in the efficacy of the group mode. This task begins before the group starts, in the pregroup orientation, in which the therapist reinforces positive expectations, corrects negative preconceptions, and presents a lucid and powerful explanation of the group’s healing properties. (See chapter 10 for a full discussion of the pregroup preparation procedure.)

Group therapy not only draws from the general ameliorative effects of positive expectations but also benefits from a source of hope that is unique to the group format. Therapy groups invariably contain individuals who are at different points along a coping-collapse continuum. Each member thus has considerable contact with others—often individuals with similar problems—who have improved as a result of therapy. I have often heard clients remark at the end of their group therapy how important it was for them to have observed the improvement of others. Remarkably, hope can be a powerful force even in groups of individuals combating advanced cancer who lose cherished group members to the disease. Hope is flexible—it redefines itself to fit the immediate parameters, becoming hope for comfort, for dignity, for connection with others, or for minimum physical discomfort.
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Group therapists should by no means be above exploiting this factor by periodically calling attention to the improvement that members have made. If I happen to receive notes from recently terminated members informing me of their continued improvement, I make a point of sharing this with the current group. Senior group members often assume this function by offering spontaneous testimonials to new, skeptical members.

Research has shown that it is also vitally important that therapists believe in themselves and in the efficacy of their group.
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I sincerely believe that I am able to help every motivated client who is willing to work in the group for at least six months. In my initial meetings with clients individually, I share this conviction with them and attempt to imbue them with my optimism.

Many of the self-help groups—for example, Compassionate Friends (for bereaved parents), Men Overcoming Violence (men who batter), Survivors of Incest, and Mended Heart (heart surgery patients)—place heavy emphasis on the instillation of hope.
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A major part of Recovery, Inc. (for current and former psychiatric patients) and Alcoholics Anonymous meetings is dedicated to testimonials. At each meeting, members of Recovery, Inc. give accounts of potentially stressful incidents in which they avoided tension by the application of Recovery, Inc. methods, and successful Alcoholics Anonymous members tell their stories of downfall and then rescue by AA. One of the great strengths of Alcoholics Anonymous is the fact that the leaders are all alcoholics—living inspirations to the others.

Substance abuse treatment programs commonly mobilize hope in participants by using recovered drug addicts as group leaders. Members are inspired and expectations raised by contact with those who have trod the same path and found the way back. A similar approach is used for individuals with chronic medical illnesses such as arthritis and heart disease. These self-management groups use trained peers to encourage members to cope actively with their medical conditions.
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The inspiration provided to participants by their peers results in substantial improvements in medical outcomes, reduces health care costs, promotes the individual’s sense of self-efficacy, and often makes group interventions superior to individual therapies.
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UNIVERSALITY

Many individuals enter therapy with the disquieting thought that they are unique in their wretchedness, that they alone have certain frightening or unacceptable problems, thoughts, impulses, and fantasies. Of course, there is a core of truth to this notion, since most clients have had an unusual constellation of severe life stresses and are periodically flooded by frightening material that has leaked from their unconscious.

To some extent this is true for all of us, but many clients, because of their extreme social isolation, have a heightened sense of uniqueness. Their interpersonal difficulties preclude the possibility of deep intimacy. In everyday life they neither learn about others’ analogous feelings and experiences nor avail themselves of the opportunity to confide in, and ultimately to be validated and accepted by, others.

In the therapy group, especially in the early stages, the disconfirmation of a client’s feelings of uniqueness is a powerful source of relief. After hearing other members disclose concerns similar to their own, clients report feeling more in touch with the world and describe the process as a “welcome to the human race” experience. Simply put, the phenomenon finds expression in the cliché “We’re all in the same boat”—or perhaps more cynically, “Misery loves company.”

There is no human deed or thought that lies fully outside the experience of other people. I have heard group members reveal such acts as incest, torture, burglary, embezzlement, murder, attempted suicide, and fantasies of an even more desperate nature. Invariably, I have observed other group members reach out and embrace these very acts as within the realm of their own possibilities, often following through the door of disclosure opened by one group member’s trust or courage. Long ago Freud noted that the staunchest taboos (against incest and patricide) were constructed precisely because these very impulses are part of the human being’s deepest nature.

Nor is this form of aid limited to group therapy. Universality plays a role in individual therapy also, although in that format there is less opportunity for consensual validation, as therapists choose to restrict their degree of personal transparency.

During my own 600-hour analysis I had a striking personal encounter with the therapeutic factor of universality. It happened when I was in the midst of describing my extremely ambivalent feelings toward my mother. I was very much troubled by the fact that, despite my strong positive sentiments, I was also beset with death wishes for her, as I stood to inherit part of her estate. My analyst responded simply, “That seems to be the way we’re built.” That artless statement not only offered me considerable relief but enabled me to explore my ambivalence in great depth.

Despite the complexity of human problems, certain common denominators between individuals are clearly evident, and the members of a therapy group soon perceive their similarities to one another. An example is illustrative: For many years I asked members of T-groups (these are nonclients—primarily medical students, psychiatric residents, nurses, psychiatric technicians, and Peace Corps volunteers; see chapter 16) to engage in a “top-secret” task in which they were asked to write, anonymously, on a slip of paper the one thing they would be most disinclined to share with the group. The secrets prove to be startlingly similar, with a couple of major themes predominating. The most common secret is a deep conviction of basic inadequacy—a feeling that one is basically incompetent, that one bluffs one’s way through life. Next in frequency is a deep sense of interpersonal alienation—that, despite appearances, one really does not, or cannot, care for or love another person. The third most frequent category is some variety of sexual secret. These chief concerns of nonclients are qualitatively the same in individuals seeking professional help. Almost invariably, our clients experience deep concern about their sense of worth and their ability to relate to others.
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Some specialized groups composed of individuals for whom secrecy has been an especially important and isolating factor place a particularly great emphasis on universality. For example, short-term structured groups for bulimic clients build into their protocol a strong requirement for self-disclosure, especially disclosure about attitudes toward body image and detailed accounts of each member’s eating rituals and purging practices. With rare exceptions, patients express great relief at discovering that they are not alone, that others share the same dilemmas and life experiences.
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Members of sexual abuse groups, too, profit enormously from the experience of universality.
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An integral part of these groups is the intimate sharing, often for the first time in each member’s life, of the details of the abuse and the ensuing internal devastation they suffered. Members in such groups can encounter others who have suffered similar violations as children, who were not responsible for what happened to them, and who have also suffered deep feelings of shame, guilt, rage, and uncleanness. A feeling of universality is often a fundamental step in the therapy of clients burdened with shame, stigma, and self-blame, for example, clients with HIV/AIDS or those dealing with the aftermath of a suicide.
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Members of homogeneous groups can speak to one another with a powerful authenticity that comes from their firsthand experience in ways that therapists may not be able to do. For instance, I once supervised a thirty-five-year-old therapist who was leading a group of depressed men in their seventies and eighties. At one point a seventy-seven-year-old man who had recently lost his wife expressed suicidal thoughts. The therapist hesitated, fearing that anything he might say would come across as naive. Then a ninety-one-year-old group member spoke up and described how he had lost his wife of sixty years, had plunged into a suicidal despair, and had ultimately recovered and returned to life. That statement resonated deeply and was not easily dismissed.

In multicultural groups, therapists may need to pay particular attention to the clinical factor of universality. Cultural minorities in a predominantly Caucasian group may feel excluded because of different cultural attitudes toward disclosure, interaction, and affective expression. Therapists must help the group move past a focus on concrete cultural differences to transcultural—that is, universal—responses to human situations and tragedies.
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At the same time, therapists must be keenly aware of the cultural factors at play. Mental health professionals are often sorely lacking in knowledge of the cultural facts of life required to work effectively with culturally diverse members. It is imperative that therapists learn as much as possible about their clients’ cultures as well as their attachment to or alienation from their culture.
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Universality, like the other therapeutic factors, does not have sharp borders; it merges with other therapeutic factors. As clients perceive their similarity to others and share their deepest concerns, they benefit further from the accompanying catharsis and from their ultimate acceptance by other members (see chapter 3 on group cohesiveness).

IMPARTING INFORMATION

Under the general rubric of imparting information, I include didactic instruction about mental health, mental illness, and general psychodynamics given by the therapists as well as advice, suggestions, or direct guidance from either the therapist or other group members.

Didactic Instruction

Most participants, at the conclusion of successful interactional group therapy, have learned a great deal about psychic functioning, the meaning of symptoms, interpersonal and group dynamics, and the process of psychotherapy. Generally, the educational process is implicit; most group therapists do not offer explicit didactic instruction in interactional group therapy. Over the past decade, however, many group therapy approaches have made formal instruction, or psychoeducation, an important part of the program.

One of the more powerful historical precedents for psychoeducation can be found in the work of Maxwell Jones, who in his work with large groups in the 1940s lectured to his patients three hours a week about the nervous system’s structure, function, and relevance to psychiatric symptoms and disability.
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Marsh, writing in the 1930s, also believed in the importance of psychoeducation and organized classes for his patients, complete with lectures, homework, and grades.
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Recovery, Inc., the nation’s oldest and largest self-help program for current and former psychiatric patients, is basically organized along didactic lines.
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Founded in 1937 by Abraham Low, this organization has over 700 operating groups today.
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Membership is voluntary, and the leaders spring from the membership. Although there is no formal professional guidance, the conduct of the meetings has been highly structured by Dr. Low; parts of his textbook,
Mental Health Through Will Training
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are read aloud and discussed at every meeting. Psychological illness is explained on the basis of a few simple principles, which the members memorize—for example, the value of “spotting” troublesome and self-undermining behaviors; that neurotic symptoms are distressing but not dangerous; that tension intensifies and sustains the symptom and should be avoided; that the use of one’s free will is the solution to the nervous patient’s dilemmas.

Many other self-help groups strongly emphasize the imparting of information. Groups such as Adult Survivors of Incest, Parents Anonymous, Gamblers Anonymous, Make Today Count (for cancer patients), Parents Without Partners, and Mended Hearts encourage the exchange of information among members and often invite experts to address the group.
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The group environment in which learning takes place is important. The ideal context is one of partnership and collaboration, rather than prescription and subordination.