The Theory and Practice of Group Psychotherapy (68 page)

Freud once compared psychotherapy to chess in that far more is known and written about the opening and the end games than about the middle game. Accordingly, the opening stages of therapy and termination may be discussed with some degree of precision, but the vast bulk of therapy cannot be systematically described. Thus, the subsequent chapters follow no systematic group chronology but deal in a general way with the major issues and problems of later stages of therapy and with some specialized therapist techniques.

Chapter 12

THE ADVANCED GROUP

O
nce a group achieves a degree of maturity and stability, it no longer exhibits easily described, familiar stages of development. The rich and complex working-through process begins, and the major therapeutic factors I described earlier operate with increasing force and effectiveness. Members gradually engage more deeply in the group and use the group interaction to address the concerns that brought them to therapy. The advanced group is characterized by members’ growing capacity for reflection, authenticity, self-disclosure, and feedback.
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Hence, it is impossible to formulate specific procedural guidelines for all contingencies. In general, the therapist must strive to encourage development and operation of the therapeutic factors. The application of the basic principles of the therapist’s role and technique to specific group events and to each client’s therapy (as discussed in chapters 5, 6, and 7) constitutes the art of psychotherapy, and for this there is no substitute for clinical experience, reading, supervision, and intuition.

Certain issues and problems, however, occur with sufficient regularity to warrant discussion. In this chapter, I consider subgrouping, conflict, self-disclosure, and termination of therapy. In the next chapter, I discuss certain recurrent behavioral configurations in individuals that present a challenge to the therapist and to the group.

SUBGROUPING

Fractionalization—the splitting off of smaller units—occurs in every social organization. The process may be transient or enduring, helpful or harmful, for the parent organization. Therapy groups are no exception. Subgroup formation is an inevitable and often disruptive event in the life of the group, yet there too the process, if understood and harnessed properly, may further the therapeutic work.† How do we account for the phenomenon of subgrouping? We need to consider both individual and group factors.

Individual Factors

Members’ concerns about personal connection and status often motivate the creation of the subgroup.† A subgroup in the therapy group arises from the belief of two or more members that they can derive more gratification from a relationship with one another than from the entire group. Members who violate group norms by secret liaisons are opting for need gratification rather than for pursuit of personal change—their primary reason for being in therapy (see the discussion of primary task and secondary gratification in chapter 6). Need frustration occurs early in therapy: for example, members with strong needs for intimacy, dependency, sexual conquests, or dominance may soon sense the impossibility of gratifying these needs in the group and often attempt to gratify them outside the formal group.

In one sense, these members are “acting out”: they engage in behavior
outside
the therapy setting that relieves inner tensions and avoids direct expression or exploration of feeling or emotion. Sometimes it is only possible in retrospect to discriminate “acting out” from acting or participating in the therapy group. Let me clarify.

Keep in mind that the course of the therapy group is a continual cycle of action and analysis of this action. The social microcosm of the group depends on members’ engaging in their habitual patterns of behavior, which are then examined by the individual and the group. Acting out becomes resistance only
when one refuses to examine one’s behavior.
Extragroup behavior that is not examined in the group becomes a particularly potent form of resistance, whereas
extragroup behavior that is subsequently brought back into the group and worked through may prove to be of considerable therapeutic import.
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Group Factors

Subgrouping may be a manifestation of a considerable degree of undischarged hostility in the group, especially toward the leader. Research on styles of leadership demonstrates that a group is more likely to develop disruptive in-group and out-group factions under an authoritarian, restrictive style of leadership.
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Group members, unable to express their anger and frustration directly to the leader, release these feelings obliquely by binding together and mobbing or scapegoating one or more of the other members.

At other times, subgrouping is a sign of problems in group development. A lack of group cohesion will encourage members to retreat from large and complex group relationships into simpler, smaller, more workable subgroups.

Clinical Appearance of Subgrouping

Extragroup socializing is often the first stage of subgrouping. A clique of three or four members may begin to have telephone conversations, to meet over coffee or dinner, to visit each other’s homes, or even to engage in business ventures together. Occasionally, two members will become sexually involved. A subgroup may also occur completely within the confines of the group therapy room, as members who perceive themselves to be similar form coalitions.

There may be any number of common bonds: comparable educational level, similar values, ethno-cultural background, similar age, marital status, or group status (for example, the old-timer original members). Social organizations characteristically develop opposing factions—two or more conflicting subgroups. But such is not often the case in therapy groups: one clique forms but the excluded members lack effective social skills and do not usually coalesce into a second subgroup.

The members of a subgroup may be identified by a general code of behavior: they may agree with one another regardless of the issue and avoid confrontations among their own membership; they may exchange knowing glances when a member not in the clique speaks; they may arrive at and depart from the meeting together; their wish for friendship overrides their commitment to examination of their behavior.
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The Effects of Subgrouping

Subgrouping can have an extraordinarily disruptive effect on the course of the therapy group. In a study of thirty-five clients who prematurely dropped out from group therapy, I found that eleven (31 percent) did so largely because of problems arising from subgrouping.
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Complications arise whether the client is included in or excluded from a subgroup.

Inclusion.
Those included in a twosome or a larger subgroup often find that group life is vastly more complicated and, ultimately, less rewarding. As a group member transfers allegiance from the group goals to the subgroup goals, loyalty becomes a major and problematic issue. For example, should one abide by the group procedural rules of free and honest discussion of feelings if that means breaking a confidence established secretly with another member?

• Christine and Jerry often met after the therapy session to have long, intense conversations. Jerry had remained withdrawn in the group and had sought out Christine because, as he informed her, he felt that she alone could understand him. After obtaining her promise of confidentiality, he soon was able to reveal to her his pedophilic obsessions and his deep distrust of the group leader. Back in the group, Christine felt restrained by her promise and avoided interaction with Jerry, who eventually dropped out unimproved. Ironically, Christine was an exceptionally sensitive member of the group and might have been particularly useful to Jerry by encouraging him to participate in the group had she not felt restrained by the antitherapeutic subgroup norm (that is, her promise of confidentiality).

Sharing with the rest of the members what one has learned in extragroup contacts is tricky. The leader addressing such an issue must take care to avoid situations where members feel humiliated or betrayed.

• An older, paternal man often gave two other group members a ride. On one occasion he invited them to watch television at his house. The visitors witnessed an argument between the man and his wife and at a subsequent group session told him that they felt he was mistreating his wife. The older group member felt so betrayed by the two members, whom he had considered his friends, that he began concealing more from the group and ultimately dropped out of treatment.

Severe clinical problems occur when group members engage in sexual relations: they often hesitate to “besmirch” (as one client phrased it) an intimate relationship by giving it a public airing. Freud never practiced clinical group therapy, but in 1921 he wrote a prescient essay on group psychology in which he underscored the incompatibility between a sexual love relationship and group cohesiveness.
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Though we may disagree with the cornerstone of his argument (that inhibited sexual instincts contribute to the cohesive energy of the group), his conclusions are compelling: that is, no group tie—be it race, nationality, social class, or religious belief—can remain unthreatened by the overriding importance that two people in love can have for each other.

Obviously, the ties of the therapy group are no exception. Members of a therapy group who become involved in a love/sexual relationship
will almost inevitably come to award their dyadic relationship higher priority than their relationship to the group.
In doing so, they sacrifice their value for each other as helpmates in the group; they refuse to betray confidences; rather than being honest in the group, they engage in courtship behavior—they attempt to be charming to each other, they assume poses in the group, they perform for each other, blotting out the therapists, other members of the group, and, most important, their primary goals in therapy. Often the other group members are dimly aware that something important is being actively avoided in the group discussion, a state of affairs that usually results in global group inhibition. An unusual chance incident provided evidence substantiating these comments.
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• A research team happened to be closely studying a therapy group in which two members developed a clandestine sexual relationship. Since the study began months before the liaison occurred, good baseline data are available. Several observers (as well as the clients themselves, in postgroup questionnaires) had for months rated each meeting along a seven-point scale for amount of affect expressed, amount of self-disclosure, and general value of the session. In addition, the communication-flow system was recorded with the number and direction of each member’s statements charted on a who-to-whom matrix.

During the observation period, Bruce and Geraldine developed a sexual relationship and kept it secret from the therapist and the rest of the group for three weeks. During these three weeks, the data (when studied in retrospect) showed a steep downward gradient in the scoring of the quality of the meetings, and reduced verbal activity, expression of affect, and self-disclosure. Moreover, scarcely any verbal exchanges between Geraldine and Bruce were recorded!

This last finding is the quintessential reason that subgrouping impedes therapy. The primary goal of group therapy is to facilitate each member’s exploration of his or her interpersonal relationships. Here were two people who knew each other well, had the potential of being deeply helpful to each other, and yet barely spoke to each other in the group.

The couple resolved the problem by deciding that one of them would drop out of the group (not an uncommon resolution). Geraldine dropped out, and in the following meeting, Bruce discussed the entire incident with relief and great candor. (The ratings by both the group members and the observers indicated this meeting to be valuable, with active interaction, strong affect expression, and much disclosure from others as well as Bruce.)

The positive, affiliative effects of subgrouping
within
the therapy group may be turned to therapeutic advantage.
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From the perspective of a general systems approach, the therapy group is a large and dynamic group made up of several smaller subgroups. Subgrouping occurs (and may be encouraged by the therapist) as a necessary component of elucidating, containing, and ultimately integrating areas of conflict or distress within the group. Clients who have difficulty acknowledging their feelings or disclosing themselves may do better if they sense they are not alone. Hence, the therapist may actively point out functional, but shifting, subgroups of members who share some basic intra- or interpersonal concern and urge that the subgroup work together in the group and share the risks of disclosure as well as the relief of universality.

Exclusion
. Exclusion from the subgroup also complicates group life. Anxiety associated with earlier peer exclusion experiences is evoked, and if it is not discharged by working-through, it may become disabling. Often it is exceptionally difficult for members to comment on their feelings of exclusion: they may not want to reveal their envy of the special relationship, or they may fear angering the involved members by “outing” the subgroup in the session.

Nor are therapists immune to this problem. I recall, a group therapist, one of my supervisees, observed two of his group members (both married) walking arm in arm along the street. The therapist found himself unable to bring his observation back into the group. Why? He offered several reasons: