The Theory and Practice of Group Psychotherapy (40 page)

I may increase the power of my inquiry by citing the evidence for such a conclusion—for example, the whispering, the shift toward neutral topics and a noninteractive, impersonal mode of communication, my experience of being left out or of being deserted by the others when I mentioned the obvious distraction of the dog. Furthermore, I might add that the group is strangely avoiding all discussion both of the previous meeting and of John’s absence today. In one way or another, however, the problems of the group as a whole must be addressed before any meaningful interpersonal work can resume.

In this clinical example, would we be satisfied merely with getting the group back on the track of discussing more meaningful personal material? No! More is needed: the issues being avoided were too crucial to the group’s existence to be left submerged. This consideration was particularly relevant in this group, whose members had insufficiently explored their relationship to me. Therefore, I repeatedly turned the group’s attention back to the main issue (their trust and confidence in me) and tried not to be misled by substitute behavior—for example, the group’s offering another theme for discussion, perhaps even a somewhat charged one. My task was not simply to circumvent the resistance, to redirect the group to work areas, but to plunge the members into the source of the resistance—in other words, not
around
anxiety, but
through
it.

Another clue to the presence and strength of resistance is the group’s response to therapists’ resistance-piercing commentary. If therapists’ comments, even when repeated, fall on deaf ears, if therapists feel ignored by the group, if they find it extraordinarily difficult to influence the meeting, then it is clear that the resistance is powerful and that the group needs to be addressed as well as the individual members. It is not an easy undertaking. It is anxiety-provoking to buck the entire group, and therapists may feel deskilled in such meetings.

The group may also avoid work by more literal flight—absence or tardiness. Whatever the form, however, the result is the same: in the language of the group dynamicist,
locomotion toward the attainment of group goals is impeded
, and the group is no longer engaged in its primary task.

Not uncommonly, the issue precipitating the resistance is discussed symbolically. I have seen groups deal with their uneasiness about observers metaphorically by long discussions about other types of confidentiality violation: for example, public posting of grades for a school course, family members opening one another’s mail, and invasive credit company computers. Discomfort about the therapist’s absence may prompt discussions of parental inaccessibility or death or illness. Generally, the therapist may learn something of what is being resisted by pondering the question “Why is this particular topic being discussed, and
why now?
”

An experience in a therapy group at the height of the 2003 SARS (Severe Acute Respiratory Syndrome) epidemic may be illustrative.

• A group in a partial hospitalization program for depressed seniors was canceled for several weeks and finally reconvened, but with the proviso that all participants were required to wear uncomfortable and oppressive face masks (heeding the recommendation of infection control) that obscured nonverbal communication. The meeting was characterized by unusually hostile comments about deprivations: uncaring adult children, incompetent public health officials, unavailable, neglectful therapists. Soon the members began to attack one another and the group seemed on the brink of total disintegration.

The therapist, also struggling with the restrictive mask, asked for a “process check”—that is, he asked the group to stop for a moment and reflect on what was happening so far in the meeting. The members all agreed that they hated what the SARS crisis had done to their group. The masks not only were physically irritating, but they also blocked them from feeling close to others in the group. They realized, too, that the generalized anger in the group was misplaced, but they did not know what to do with their strong feelings.

The therapist made a group-as-a-whole interpretation: “There’s a sort of paradox here today: it’s evident that you cherish this group and are angry at being deprived of it, yet, on the other hand, the anger you experience and express threatens the warm supportive group atmosphere you so value.” A lot of head nodding followed the therapist’s interpretation, and the anger and divisiveness soon dissipated.

Antitherapeutic Group Norms

Another type of group obstacle warranting a group-as-a-whole interpretation occurs when antitherapeutic group norms are elaborated by the group. For example, a group may establish a “take turns” format in which an entire meeting is devoted, sequentially, to each member of the group. “Taking turns” is a comfortable or convenient procedure, but it is an undesirable norm, because it discourages free interaction in the here-and-now. Furthermore, members are often forced into premature self-disclosure and, as their turn approaches, may experience extreme anxiety or even decide to terminate therapy. Or a group may establish a pattern of devoting the entire session to the first issue raised in that session, with strong invisible sanctions against changing the subject. Or there may be a “Can you top this?” format in which the members engage in a spiraling orgy of self-disclosure. Or the group may develop a tightly knit, closed pattern that excludes outlying members and does not welcome new ones.

To intervene effectively in such instances, therapists may need to make a group-as-a-whole interpretation that clearly describes the process and the deleterious effects the taking-turns format has on the members or on the group and emphasizes that there are alternatives to this mode of opening each meeting.

Frequently a group, during its development, bypasses certain important phases or never incorporates certain norms into its culture. For example, a group may develop without ever going through a period of challenging or confronting the therapist. Or a group may develop without a whisper of intermember dissension, without status bids or struggles for control. Or a group may meet at length with no hint of real intimacy or closeness arising among the members. Such avoidance is a collaborative result of the group members implicitly constructing norms dictating this avoidance.

Therapists who sense that the group is providing a one-sided or incomplete experience for the members often facilitate the progress of the group work by commenting on the missing aspect of the group’s life. (Such an intervention assumes, of course, that there are regularly recurring, predictable phases of small group development with which the therapist is familiar—a topic I will discuss in chapter 11.)

The Timing of Group Interventions

For pedagogical reasons, I have discussed interpersonal phenomena and group-as-a-whole phenomena as though they were quite distinct. In practice, of course, the two often overlap, and the therapist is faced with the question of when to emphasize the interpersonal aspects of the transaction and when to emphasize the group-as-a-whole aspects. This matter of clinical judgment cannot be neatly prescribed. As in any therapeutic endeavor, judgment develops from experience (particular supervised experience) and from intuition. As Melanie Klein stated, “It is a most precious quality in an analyst to be able at any moment to pick out the point of urgency.”
⁴²

The point of urgency is far more elusive in group therapy than in individual treatment. As a general rule, however,
an issue critical to the existence or functioning of the entire group always takes precedence over narrower interpersonal issues.
As an illustration, let me return to the group that engaged in whispering, discussion of neutral topics, and other forms of group flight during the meeting after a member had inadvertently discovered the indiscreet group observers. In that meeting, Mary, who had been absent at the previous meeting, brought her dog. Under normal circumstances, this act would clearly have become an important group issue: Mary had consulted neither with the therapist nor with other members about bringing her dog to the group; she was, because of her narcissism, an unpopular member, and her act was representative of her insensitivity to others. However, in this meeting there was a far more urgent issue—one threatening the entire group—and the dog was discussed not from the aspect of facilitating Mary’s interpersonal learning but as he was used by the group in its flight. Only later, after the obstacle to the group’s progress had been worked through and removed, did the members return to a meaningful consideration of their annoyance about Mary bringing the dog.

To summarize, group-as-a-whole forces are continuously at play in the therapy group. The therapist needs to be aware of them in order to harness group forces in the service of therapy and to counter them when they obstruct therapy.†

Chapter 7

THE THERAPIST: TRANSFERENCE AND TRANSPARENCY

H
aving discussed the mechanisms of therapeutic change in group therapy, the tasks of the therapist, and the techniques by which the therapist accomplishes these tasks, I turn in this chapter from
what the therapist must do
in the group to
how the therapist must be
. Do you, as therapist, play a role? To what degree are you free to be yourself? How “honest” can you be? How much transparency can you permit yourself?

Any discussion of therapist freedom should begin with transference, which can be either an effective therapeutic tool or a set of shackles that encumbers your every movement. In his first and extraordinarily prescient essay on psychotherapy (the final chapter of
Studies on Hysteria
[1895]), Freud noted several possible impediments to the formation of a good working relationship between client and therapist.
¹
Most of them could be resolved easily, but one stemmed from deeper sources and resisted efforts to banish it from the therapeutic work. Freud labeled this impediment
transference
, since it consisted of attitudes toward the therapist that had been “transferred” from earlier attitudes toward important figures in the client’s life. These feelings toward the therapist were “false connections”—new editions of old impulses.

Freud soon realized, however, that transference was far from being an impediment to therapy; on the contrary, if used properly, it could be the therapist’s most effective tool.
²
What better way to help the clients recapture the past than to allow them to reexperience and reenact ancient feelings toward parents through the current relationship to the therapist? Furthermore, the intense and conflicted relationship that often develops with the therapist, which he termed the
transference neurosis
, was amenable to reality testing; the therapist could treat it and, in so doing, simultaneously treat the infantile conflict. Although some of these terms may seem dated, many of today’s psychotherapeutic approaches, including cognitive therapy, acknowledge a concept similar to transference but refer to it as the client’s “schema.”
³

Although considerable evolution in theory and technique has occurred in psychoanalysis over the past half century, until recently some basic principles regarding the role of transference in psychoanalytic therapy have endured with relatively little change:
⁴

1. Analysis of transference is the major therapeutic task of the therapist.

2. Because the development (and then the resolution) of transference is crucial, it is important that therapists facilitate its development by remaining opaque, so that the client can encloak them in transferred feelings and attitudes, much as one might dress a mannequin after one’s own fancy. (This is the rationale behind the “blank screen” role of the analyst, a role that enjoys little currency these days even among traditional analysts.)

3. The most important type of interpretation the therapist can make is one that clarifies some aspect of transference. (In the early days of analysis the transference interpretation was referred to as the “mutative interpretation.”)

In recent decades, however, many analysts have shifted their assumptions as they have recognized the importance of other factors in the therapeutic process. Judd Marmor, a prominent American analyst, anticipated this evolution in a 1973 article in which he wrote, “Psychoanalysts have begun, in general, to feel more free to enter into active communicative exchanges with patients instead of remaining bound to the incognito ‘neutral mirror’ model of relative silence and impassivity.”
⁵
More recently, Stephen Mitchell, a leader in relational approaches to mainstream psychoanalysis commented:

Many patients are now understood to be suffering not from conflictual infantile passions that can be tamed and transformed through reason and understanding but from stunted personal development. Deficiencies in caregiving in the earliest years are understood to have contributed to interfering with the emergence of a fully centered, integrated sense of self, of the patient’s own subjectivity. What the patient needs is not clarification or insight so much as a sustained experience of being seen, personally engaged, and, basically valued and cared about.
⁶

Mitchell and many others argue that the “curative” factor in both individual and group therapy is the
relationship
, which requires the therapist’s authentic engagement and empathic attunement to the client’s internal emotional and subjective experience.†
⁷
Note that this new emphasis on the nature of the relationship means that psychotherapy is changing its focus from a one-person psychology (emphasizing the client’s pathology) to a two-person psychology (emphasizing mutual impact and shared responsibility for the relationship).†
⁸
In this model, the therapist’s emotional experience in the therapy is a relevant and powerful source of data about the client. How to make wise use of this data will be elaborated shortly. Few would quarrel with the importance of the development, recognition, and resolution of transference in individual, dynamically oriented therapy.
^o