The Theory and Practice of Group Psychotherapy (76 page)

The same staccato pattern of improvement is often true for the group as a whole. Sometimes groups struggle and lumber on for months with no visible change in any member, and then suddenly enter a phase in which everyone seems to get well together. Rutan uses the apt metaphor of building a bridge during a battle.
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The leader labors mightily to construct the bridge and may, in the early phases, suffer casualties (dropouts). But once the bridge is in place, it escorts many individuals to a better place.

There are certain clients for whom even a consideration of termination is problematic. These clients are particularly sensitized to abandonment; their self-regard is so low that they consider their illness to be their only currency in their traffic with the therapist and the group. In their minds growth is associated with dread, since improvement would result in the therapist’s leaving them. Therefore they must minimize or conceal progress. Of course, it is not until much later that they discover the key to this absurd paradox: Once they truly improve, they will no longer need the therapist!†

One useful sign suggesting readiness for termination is that the group becomes less important to the client. One terminating member commented that Mondays (the day of the group meetings) were now like any other day of the week. When she began in the group, she lived for Mondays, with the rest of the days inconsequential wadding between meetings.

I make a practice of recording the first individual interview with a client. Not infrequently, these tapes are useful in arriving at the termination decision. By listening many months later to their initial session, clients can obtain a clearer perspective of what they have accomplished and what remains to be done.

The group members are an invaluable resource in helping one another decide about termination, and a unilateral decision made by a member without consulting the other members is often premature. Generally, a well-timed termination decision will be discussed for a few weeks in the group, during which time the client works through feelings about leaving. There are times when clients make an abrupt decision to terminate membership in the group immediately. I have often found that such individuals find it difficult to express gratitude and positive feeling; hence they attempt to abbreviate the separation process as much as possible. These clients must be helped to understand and correct their jarring, unsatisfying method of ending relationships. In fact, for some, the dread of ending dictates their whole pattern of avoiding connections and avoiding intimacy. To ignore this phase is to neglect an important area of human relations. Ending is, after all, a part of almost every relationship, and throughout one’s life one must say good-bye to important people.

Many terminating members attempt to lessen the shock of departure by creating bridges to the group that they can use in the future. They seek assurances that they may return, they collect telephone numbers of the other members, or they arrange social meetings to keep themselves informed of important events of the group. These efforts are only to be expected, and yet the therapist must not collude in the denial of termination. On the contrary, you must help the members explore it to its fullest extent. Clients who complete individual therapy may return, but clients who leave the group can never return. They are truly leaving: the group will be irreversibly altered; replacements will enter the group; the present cannot be frozen; time flows on cruelly and inexorably. These facts are evident to the remaining members as well—there is no better stimulus than a departing member to encourage the group to deal with issues about the rush of time, loss, separation, death, aging, and the contingencies of existence. Termination is thus more than an extraneous event in the group. It is the microcosmic representation of some of life’s most crucial and painful issues.

The group members may need some sessions to work on their loss and to deal with many of these issues. The loss of a member provides an unusual work opportunity for individuals sensitized to loss and abandonment. Since they have compatriots sharing their loss, they mourn in a communal setting and witness others encompass the loss and continue to grow and thrive.
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After a member leaves the group, it is generally wise not to bring in new members without a hiatus of one or more meetings. A member’s departure is often an appropriate time for others to take inventory of their own progress in therapy. Members who entered the group at the same time as the terminating member may feel some pressure to move more quickly.

Some members may misperceive the member’s leaving as a forced departure and may feel a need to reaffirm a secure place in the group—by regressive means if necessary. More competitive members may rush toward termination prematurely. Senior members may feel envy or react with shame, experiencing the success of the comember as a reminder of their own selfdeficiency and failing.† In extreme cases, the shame- or envy-ridden client may seek to devalue and spoil the achievement of the graduating member. Newer members may feel inspired or awed and left doubting whether they will ever be able to achieve what they have just witnessed.

Should the group engage in some form of ritual to mark the termination of a member? Sometimes a member or several members may present a gift to the graduating member or bring coffee and cake to the meeting—which may be appropriate and meaningful, as long as, like any event in the group, it can be examined and processed. For example, the group may examine the meaning of the ritual; who suggests and plans it? Is it intended to avoid necessary and appropriate sadness?
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We therapists must also look to our own feelings during the termination process, because occasionally we unaccountably and unnecessarily delay a client’s termination. Some perfectionist therapists may unrealistically expect too much change and refuse to accept anything less than total resolution. Moreover, they lack faith in a client’s ability to continue growth after the termination of formal therapy.
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Other clients bring out Pygmalion pride in us: we find it difficult to part with someone who is, in part, our own creation; saying good-bye to some clients is saying good-bye to a part of ourselves. Furthermore, it is a permanent good-bye. If we have done our job properly, the client no longer needs us and breaks all contact.

Termination of the Therapist

In training programs, it is common practice for trainees to lead a group for six months to a year and then pass it on to a new student as their own training takes them elsewhere. This is generally a difficult period for the group members, and often they respond with repeated absences and threatened termination. It is a time for the departing therapist to attend to any unfinished business he or she has with any of the members. Some members feel that this is their last chance and share hitherto concealed material. Others have a recrudescence of symptoms, as though to say, “See what your departure has done to me!”
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Therapists must not avoid any of these concerns: the more complete their ending with the group, the greater the potential for an effective transfer of leadership. It is an excellent opportunity for helping members appreciate their own resources.

The same principles apply in situations in which a more established leader needs to end his leadership due to a move, illness, or professional change. If the group members decide to continue, it is the leader’s responsibility to secure new leadership. The transition process takes considerable time and planning, and the new leader must set about as quickly as possible to take over group leadership. One reported approach is to meet with all the group members individually in a pregroup format as described in chapter 9, while the old leader is still meeting with the group. After the first leader concludes, the new one begins to meet with the group at the set group time or at a mutually agreed-upon new time.
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Termination of the Group

Groups terminate for various reasons. Brief therapy groups, of course, have a preset termination date. Often external circumstances dictate the end of a group: for example, groups in a university mental health clinic usually run for eight to nine months and disband at the beginning of the summer vacation. Open groups often end only when the therapist retires or leaves the area (although this is not inevitable; if there is a co-therapist, he or she may continue the group). Occasionally, a therapist may decide to end a group because the great majority of its members are ready to terminate at approximately the same time.

Often a group avoids the difficult and unpleasant work of termination by denying or ignoring termination, and the therapist must keep the task in focus for them. In fact, as I discussed in chapter 10, it is essential for the leader of the brief therapy group to remind the group regularly of the approaching termination and to keep members focused on the attainment of goals. Groups hate to die, and members generally try to avoid the ending. They may, for example, pretend that the group will continue in some other setting—for example, reunions or regularly scheduled social meetings. But the therapist is well advised to confront the group with reality: the end of a group is a real loss. It never really can be reconvened, and even if relationships are continued in pairs or small fragments of the group, the entire group as the members then know it—in this room, in its present form, with the group leaders—will be gone forever.

The therapist must call attention to maladaptive modes of dealing with the impending termination. Some individuals have always dealt with the pain of separating from those they care about by becoming angry or devaluing the others. Some choose to deny and avoid the issue entirely. If anger or avoidance is extreme—manifested, for example, by tardiness or increased absence—the therapist must confront the group with this behavior. Usually with a mature group, the best approach is direct: the members can be reminded that it is their group, and they must decide how they want to end it. Members who devalue others or attend irregularly must be helped to understand their behavior. Do they feel their behavior or their absence makes no difference to the others, or do they so dread expressing positive feelings toward the group, or perhaps negative feelings toward the therapist for ending it, that they avoid confrontation?

Pain over the loss of the group is dealt with in part by a sharing of past experiences: exciting and meaningful past group events are remembered; members remind one another of the way they were then; personal testimonials are invariably heard in the final meetings. It is important that the therapist not bury the group too early, or the group will limp through ineffective lame-duck sessions. You must find a way to hold the issue of termination before the group and yet help the members keep working until the very last minute.

Some leaders of effective time-limited groups have sought to continue the benefits of the group by helping the group move into an ongoing leaderless format. The leader may help the transition by attending the meetings as a consultant at regular but decreasing intervals, for example biweekly or monthly. In my experience, it is particularly desirable to make such arrangements when the group is primarily a support group and constitutes an important part of the members’ social life—for example, groups of the elderly who, through the death of friends and acquaintances, are isolated. Others have reported to me the successful launching of ongoing leaderless groups for men, for women, for AIDS sufferers, Alzheimer’s caregivers, and the bereaved.

Keep in mind that the therapist, too, experiences the discomfort of termination. Throughout the final group stage, we must join the discussion. We will facilitate the group work by disclosing our own feelings. Therapists, as well as members, will miss the group. We are not impervious to feelings of loss and bereavement. We have grown close to the members and we will miss them as they miss us. To us as well as to the client, termination is a jolting reminder of the built-in cruelty of the psychotherapeutic process. Such openness on the part of the therapist invariably makes it easier for the group members to make their good-bye more complete. For us, too, the group has been a place of anguish, conflict, fear, and also great beauty: some of life’s truest and most poignant moments occur in the small and yet limitless microcosm of the therapy group.

Chapter 13

PROBLEM GROUP MEMBERS

I
have yet to encounter the unproblematic client, the one who coasts through the course of therapy like a newly christened ship gliding smoothly down the ramps into the water. Each group member
must
be a problem: the success of therapy depends on each individual’s encountering and then mastering basic life problems in the here-and-now of the group. Each problem is complex, overdetermined, and unique. The intent of this book is not to provide a compendium of solutions to problems but to describe a strategy and set of techniques that will enable a therapist to adapt to any problem arising in the group.

The term “problem client” is itself problematic. Keep in mind that the problem client rarely exists in a vacuum but is, instead, an amalgam consisting of several components: the client’s own psychodynamics, the group’s dynamics, and the client’s interactions with comembers and the therapist. We generally overestimate the role of the client’s character while underestimating the role of the interpersonal and social context.
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Certain illustrative behavioral constellations merit particular attention because of their common occurrence. A questionnaire sent by the American Group Psychotherapy Association to practicing group therapists inquired about the critical issues necessary for group therapists to master. Over fifty percent responded, “Working with difficult patients.”
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Accordingly, in this chapter, we shall turn our attention to difficult clients and specifically discuss eight problematic clinical types: the monopolist, the silent client, the boring client, the help-rejecting complainer, the psychotic or bipolar client, the schizoid client, the borderline client, and the narcissistic client.