The Theory and Practice of Group Psychotherapy (78 page)

Thus the process was overdetermined: A host of interlocking factors resulted in a dynamic equilibrium called monopolization. By halting the runaway process, uncovering and working through the underlying factors, the therapist obtained maximum therapeutic benefit from a potentially crippling group phenomenon. Each member moved closer to group involvement. Walt was no longer permitted or encouraged to participate in a fashion that could not possibly be helpful to him or the group.

It is essential to guide the monopolistic client into the self-reflective process of therapy. I urge such clients to reflect on the type of response they were originally hoping to receive from the group and then to compare that with what eventually occurred. How do they explain that discrepancy? What role did they play in it?

Often monopolistic clients may devalue the importance of the group’s reaction to them. They may suggest that the group consists of disturbed people or protest, “This is the first time something like this has ever happened to me.” If the therapist has prevented scapegoating, then this statement is always untrue: the client is in a particularly familiar place. What is different in the group is the presence of norms that permit the others to comment openly on her behavior.

The therapist increases therapeutic leverage by encouraging these clients to examine and discuss interpersonal difficulties in their life: loneliness, lack of close friends, not being listened to by others, being shunned without reason—all the reasons for which therapy was first sought. Once these are made explicit, the therapist can, more convincingly, demonstrate to monopolistic clients the importance and relevance of examining their in-group behavior. Good timing is necessary. There is no point in attempting to do this work with a closed, defensive individual in the midst of a firestorm. Repeated, gentle, properly timed interventions are required.

THE SILENT CLIENT

The silent member is a less disruptive but often equally challenging problem for the therapist. Is the silent member always a problem? Perhaps the client profits silently. A story, probably apocryphal, that has circulated among group therapists for decades tells of an individual who attended a group for a year without uttering a word. At the end of the fiftieth meeting, he announced to the group that he would not return; his problems had been resolved, he was due to get married the following day, and he wished to express his gratitude to the group for the help they had given him.

Some reticent members may profit from vicariously engaging in treatment through identifying with active members with similar problems. It is possible that changes in behavior and in risk taking can gradually occur in such a client’s relationships outside the group, although the person remains silent and seemingly unchanged in the group. The encounter group study of Lieberman, Yalom, and Miles indicated that some of the participants who changed the most seemed to have a particular ability to maximize their learning opportunities in a short-term group (thirty hours)
by engaging vicariously in the group experience of other members.
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In general, though, the evidence indicates that the more active and influential a member is in the group matrix, the more likely he or she is to benefit. Research in experiential groups demonstrates that regardless of what the participants said
, the more words they spoke, the greater the positive change in their picture of themselves.
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Other research demonstrates that vicarious experience, as contrasted with direct participation, was ineffective in producing either significant change, emotional engagement, or attraction to the group process.
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Moreover, there is much clinical consensus that in long-term therapy, silent members do not profit from the group. Group members who self-disclose very slowly may never catch up to the rest of the group and at best achieve only minimal gains.
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The greater the verbal participation, the greater the sense of involvement and the more clients are valued by others and ultimately by themselves. Self-disclosure is not only essential to the development of group cohesion, it is directly correlated to positive therapeutic outcome, as is the client’s “work” in therapy. I would suggest, then, that we not be lulled by the legendary story of the silent member who got well.
A silent client is a problem client and rarely benefits significantly from the group
.†

Clients may be silent for many reasons. Some may experience a pervasive dread of self-disclosure: every utterance, they feel, may commit them to progressively more disclosure. Others may feel so conflicted about aggression that they cannot undertake the self-assertion inherent in speaking. Some are waiting to be activated and brought to life by an idealized caregiver, not yet having abandoned the childhood wish for magical rescue. Others who demand nothing short of perfection in themselves never speak for fear of falling shamefully short, whereas others attempt to maintain distance or control through a lofty, superior silence. Some clients are especially threatened by a particular member in the group and habitually speak only in the absence of that member. Others participate only in smaller meetings or in alternate (leaderless) meetings. Some are silent for fear of being regarded as weak, insipid, or mawkish. Others may silently sulk to punish others or to force the group to attend to them.
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Here too, group dynamics may play a role. Group anxiety about potential aggression or about the availability of emotional supplies in the group may push a vulnerable member into silence to reduce the tension or competition for attention. Distinguishing between a transient “state” of silence or a more enduring “trait” of silence is therefore quite useful.

The important point, though, is that
silence is never silent
; it is behavior and, like all other behavior in the group, has meaning in the here-and-now as a representative sample of the client’s way of relating to his or her interpersonal world. The therapeutic task, therefore, is not only to change the behavior (that is essential if the client is to remain in the group) but to explore the meaning of the behavior.

Proper management depends in part on the therapist’s understanding of the dynamics of the silence. A middle course must be steered between placing undue pressure on the client and allowing the client to slide into an extreme isolate role. The therapist may periodically include the silent client by commenting on nonverbal behavior: that is, when, by gesture or demeanor, the client is evincing interest, tension, sadness, boredom, or amusement. Not infrequently a silent member introduced into an ongoing group will feel awed by the clarity, directness, and insight of more experienced members. It is often helpful for the therapist to point out that many of these admired veteran group members also struggled with silence and self-doubt when they began. Often the therapist may hasten the member’s participation by encouraging other members to reflect on their own proclivities for silence.
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Even if repeated prodding or cajoling is necessary, the therapist should encourage client autonomy and responsibility by repeated process checks. “Is this a meeting when you want to be prodded?” “How did it feel when Mike put you on the spot?” “Did he go too far?” “Can you let us know when we make you uncomfortable?” “What’s the ideal question we could ask you today to help you come into the group?” The therapist should seize every opportunity to reinforce the client’s activity and underscore the value of pushing against his fears (pointing out, for example, the feelings of relief and accomplishment that follow his risk-taking.)
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If a client resists all these efforts and maintains a very limited participation even after three months of meetings, my experience has been that the prognosis is poor. The group will grow frustrated and tire of coaxing and encouraging the silent, blocked member. In the face of the group’s disapprobation, the client becomes more marginalized and less likely than ever to participate. Concurrent individual sessions may be useful in helping the client at this time. If this fails, the therapist may need to consider withdrawing the client from the group. Occasionally, entering a second therapy group later may prove profitable, since the client is now wellinformed of the hazards of silence.

THE BORING CLIENT

Rarely does anyone seek therapy because of being boring. Yet, in a different garb, thinly disguised, the complaint is not uncommon. Clients complain that they never have anything to say to others; that they are left standing alone at parties; that no one ever invites them out more than once; that others use them only for sex; that they are inhibited, shy, socially awkward, empty, or bland. Like silence, monopolization, or selfishness, boredom is to be taken seriously. It is an extremely important problem, whether the client explicitly identifies it as such or not.

In the social microcosm of the therapy group, boring members re-create these problems and bore the members of the group—and the therapist. The therapist dreads a small meeting in which only two or three boring members are present. If they were to terminate, they would simply glide out of the group, leaving nary a ripple in the pond.

Boredom is a highly individual experience. Not everyone is bored by the same situation, and it is not easy to make generalizations. In general, though, the boring client in the therapy group is one who is massively inhibited, who lacks spontaneity, who never takes risks. Boring patients’ utterances are always “safe” (and, alas, always predictable). Obsequious and carefully avoiding any sign of aggressivity, they are often masochistic (rushing into self-flagellation before anyone else can pummel them—or, to use another metaphor, catching any spears hurled at them in midair and then stabbing themselves with them). They say what they believe the social press requires—that is, before speaking, they scan the faces of the other members to determine what is expected of them to say and squelch any contrary sentiment coming from within. The particular social style of the individual varies considerably: one may be silent; another stilted and hyperrational; another timid and self-effacing; still another dependent, demanding, or pleading.

Some boring clients are alexithymic—an expressive difficulty stemming not only from neurotic inhibition but from cognitive deficits in the ability to identify and communicate feelings. The alexithymic client is concrete, lacks imaginative capacity, and focuses on operational details, not emotional experience.
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Individual therapy with such clients can be excruciatingly slow and arid, similar to work with clients with schizoid personality disorder. Group therapy alone, or concurrent with individual therapy, may be particularly helpful in promoting emotional expressiveness through modeling, support, and the opportunity to experiment with feelings and expressiveness.
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The inability to read their own emotional cues also may make these individuals vulnerable to medical and psychosomatic illness.
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Group therapy, because of its ability to increase emotional awareness and expression, can reduce alexithymia and has been shown to improve medical outcomes, for example in heart disease.
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Group leaders and members often work hard to encourage spontaneity in boring clients. They ask such clients to share fantasies about members, to scream, to curse—anything to pry something unpredictable from them.

• One of my clients, Nora, drove the group to despair with her constant clichés and self-deprecatory remarks. After many months in the group, her outside life began to change for the better, but each report of success was accompanied by the inevitable self-derogatory neutralizer. She was accepted by an honorary professional society (“That is good,” she said, “because it is one club that can’t kick me out”); she received her graduate degree (“but I should have finished earlier”); she had gotten all A’s (“but I’m a child for bragging about it”); she looked better physically (“shows you what a good sunlamp can do”); she had been asked out by several new men in her life (“must be slim pickings in the market”); she obtained a good job (“it fell into my lap”); she had had her first vaginal orgasm (“give the credit to marijuana”).

The group tried to tune Nora in to her self-effacement. An engineer in the group suggested bringing an electric buzzer to ring each time she knocked herself. Another member, trying to shake Nora into a more spontaneous state, commented on her bra, which he felt could be improved. (This was Ed, discussed in chapter 2, who generally related only to the sexual parts of women.) He said he would bring her a present, a new bra, next session. Sure enough, the following session he arrived with a huge box, which Nora said she would prefer to open at home. So there it sat, looming in the group and, of course, inhibiting any other topic. Nora was asked at least to guess what it contained, and she ventured, “A pair of falsies.”

She was finally prevailed upon to open the gift and did so laboriously and with enormous embarrassment. The box contained nothing but Styrofoam stuffing. Ed explained that this was his idea for Nora’s new bra: that she should wear no bra at all. Nora promptly apologized to Ed (for guessing he had given her falsies) and thanked him for the trouble he had taken. The incident launched much work for both members. (I shall not here discuss the sequel for Ed.) The group told Nora that, though Ed had humiliated and embarrassed her, she had responded by apologizing to him. She had politely thanked someone who had just given her a gift of precisely nothing! The incident created the first robust spark of self-observation in Nora. She began the next meeting with: “I’ve just set the world ingratiation record. Last night I received an obscene phone call and I apologized to the man!” (She had said, “I’m sorry, you must have the wrong number.”)