The Theory and Practice of Group Psychotherapy (82 page)

Although there is considerable debate about the psychodynamics and the developmental origins of the borderline personality disturbance,
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this debate is tangential to group therapy practice and need not be discussed here. What is important for the group therapist, as I have stressed throughout this book, is not the elusive and unanswerable question—how one
got to be the way one is
—but rather the nature of the current forces, both conscious and unconscious, that influence the way the characterologically difficult client relates to others.

Not only has there been a recent explosion of interest in the diagnosis, the psychodynamics, and the individual therapy of the borderline client, but also much group therapy literature has focused on the borderline personality disturbance. Group therapists have developed an interest in these clients for two major reasons. First, because borderline personality disorder is difficult to diagnose in a single screening session, many clinicians unintentionally introduce borderline clients into therapy groups consisting of clients functioning at a higher level of integration. Second, there is growing evidence that group therapy is an effective form of treatment. Some of the most impressive research results emerge from homogeneous and intensive partial hospitalization programs in which therapy groups offer the borderline individual containment, emotional support, and interpersonal learning while demanding personal accountability in an environment that counters regression and unhealthy intensification of transference reactions. Significant and enduring improvements in mood, psychosocial stability, and self-harm behavior have been reported.
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The majority of borderline clients, however, are likely to be treated in heterogeneous ambulatory groups. There is mounting consensus that combined or concurrent individual and group treatment may be the treatment of choice for the borderline client. Some experts have arrived at the conclusion that the preferred treatment is combined treatment with two group meetings and one individual meeting weekly. Furthermore, research evidence indicates that borderline clients highly value their group therapy experience—often more than their individual therapy experience.
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Keep in mind that the client’s pathology places great demands on the treating therapist, who may at times be frustrated by the inability to make secure gains in therapy and may at other times experience strong wishes to rescue these clients, even to modify the traditional procedures and boundaries of the therapeutic situation. Keep in mind also that many therapists suggest group therapy for borderline clients
not because these clients work well or easily in therapy groups but because they are extraordinarily difficult to treat in individual therapy
.

Often, individual therapists find that the borderline client cannot easily tolerate the intensity and intimacy of the one-to-one treatment setting. Crippling transference and countertransference problems regularly emerge in therapy. Therapists often find it difficult to deal with the demands and the primitive anger of the borderline client, particularly since the client so often acts them out (for example, through absence, lateness, drug abuse, or self-mutilation). Massive regression often occurs, and many clients are so threatened by the emergence of painful, primitive affects that they flee therapeutic engagement or cause the therapist to reject them. Though the evidence suggests that group therapy may be quite effective for these clients, their primitive affects and highly distorted perceptual tendencies vastly influence the course of group therapy and severely tax the resources of the group. The duration of therapy is long: There is considerable clinical consensus that borderline clients require many years of therapy and will generally stay in a group longer than any of the other members.

Separation anxiety and the fear of abandonment play a crucial role in the dynamics of the borderline client. A threatened separation (the therapist’s vacation, for example—and sometimes even the end of a session) characteristically evokes severe anxiety and triggers the characteristic defenses of this syndrome: splitting, projective identification, devaluation, and flight.

The therapy group may assuage separation anxiety in two ways. First, one or (preferably) two group therapists are introduced into the client’s life, thus shielding the client from the great dysphoria occurring when the individual therapist is unavailable. Second, the group itself becomes a stable entity in the client’s life, one that exists even when some of its members are absent. Repeated loss (that is, the termination of members) within the secure continued existence of the group helps clients come to terms with their extreme sensitivity to loss. The therapy group offers a singular opportunity to mourn the loss of an important relationship in the comforting presence of others who are simultaneously dealing with the same loss. Real relationships can offset the intense hunger the borderline client feels, but in a more mutual, less intense fashion.
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Once the borderline client develops trust in the group, he or she may serve as a major stabilizing influence. Because borderline clients’ separation anxiety is so great and they are so anxious to preserve the continued presence of important figures in their environment, they help keep the group together, often becoming the most faithful attendees and chiding other members for being absent or tardy.

One of the major advantages a therapy group may have for the treatment of a borderline client is the powerful reality testing provided by the ongoing stream of feedback and observations from the members. Thus, regression is far less pronounced. The client may distort, act out, or express primitive, chaotic needs and fears, but the continuous reminders of reality in the therapy group keep these feelings muted.

• Marge, forty-two, was referred to the group by her individual therapist, who had been unable to make headway with her. Marge’s feelings toward her therapist alternated between great rage at him and hunger for him. The intensity of these feelings was so great that no work could be done on them and the therapist was on the verge of discontinuing therapy. Placing her in a therapy group was his last resort.

Upon entry into the group, Marge refused to talk for several meetings because she wanted to determine how the group ran. After four meetings in silence, she suddenly unleashed a ferocious attack on one of the group co-leaders, labeling him as cold, powerful, and rejecting. She offered no reasons or data for her comments aside from her gut feeling about him. Furthermore, she expressed contempt for those members of the group who felt affection for this co-therapist.

Her feelings for the other leader were quite the opposite: she experienced him as soft, warm, and caring. Other members were startled by her black-and-white view of the co-therapists and urged her, unsuccessfully, to work on her great propensity for judgment and anger. Her positive attachment to the one leader contained her sufficiently to permit her to continue in the group and allowed her to tolerate the intense hostile feeling toward the other leader and to work on other issues in the group—though she continued to snipe intermittently at the hated leader.

A notable change occurred with the “bad” therapist’s vacation. When Marge expressed a fantasy of wanting to kill him, or at least to see him suffer, members expressed astonishment at the degree of her rage. Perhaps, one member suggested, she hated him so much because she badly wanted to be closer to him and was convinced it would never happen. This feedback had a dramatic impact on Marge. It touched not only on her feelings about the therapist but also on deep, conflicted feelings about her mother. Gradually, her anger softened, and she described her longing for a different kind of relationship with the therapist. She expressed sadness also at her isolation in the group and described her wish for more closeness with other members. Some weeks after the return of the “bad” therapist, her anger had diminished sufficiently to work with him in a softer, more productive manner.

This example illustrates how, in a number of ways, the group therapy situation can reduce intense and crippling transference distortions. First, other members offered different views of the therapist, which ultimately helped Marge correct her distorted views. Second, borderline clients who develop powerful negative transference reactions are able to continue working in the group because they so often develop opposite, balancing feelings toward the co-therapist or toward other members of the group—which is why many clinicians strongly advise a co-therapy format in the group treatment of borderline clients.
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It is also possible for a client to rest temporarily, to withdraw, or to participate in a less intensified fashion in the therapy group. Such respites from intensity are rarely possible in the one-to-one format.

The work ethic of psychotherapy is often more readily apparent in a group. Individual therapy with borderline clients may be marked by the absence of a therapeutic alliance.
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Some clients lose sight of the goal of personal change and instead expend their energy in therapy seeking revenge for inflicted pain or demanding gratification from therapist. Witnessing other members working on therapy goals in the group often supplies an important corrective to derailed therapy.

Since the borderline individuals’ core problems lie in the sphere of intimacy, the therapeutic factor of cohesiveness is often of decisive import. If these clients are able to accept the reality testing offered by the group, and if their behavior is not so disruptive as to cast them in a deviant or scapegoat role, then the group may become a holding environment—an enormously important, supportive refuge from the stresses borderline clients experience in everyday life. The borderline clients’ sense of belongingness is augmented by the fact that they are often a great asset to the therapy group. These individuals have great access to affect, unconscious needs, fantasies, and fears, and they may loosen up a group and facilitate the therapeutic work, especially the therapy of schizoid, inhibited, constricted individuals. Of course, this can be a double-edged sword. Some group members may be negatively affected by the borderline client’s intense rages and negativity, which can undermine the work of comembers who are victims of abuse or trauma.
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The borderline client’s vulnerability and tendency to distort are so extreme that concurrent or combined individual therapy is required. Many therapists suggest that the most common reason for treatment failure of borderline clients in therapy groups is the omission of adjunctive individual therapy.
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If conjoint therapy is used, it is particularly important for the group and the individual therapists to be in ongoing communication. The dangers of splitting are real, and it is important that the client experience the therapists as a solid, coherent team.

Despite the heroic efforts of DSM-IV-TR, the borderline personality disorder does not represent a homogeneous diagnostic category. One borderline client may be markedly dissimilar clinically to another. The frequently hospitalized chaotic individual is grossly different (and has a very different course of therapy) from the less severely disabled individual with an unanchored self.
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Thus, the decision to include a borderline client in a group depends on the characteristics of the particular individual being screened rather than on the broad diagnostic category. The therapist has to assess not only a client’s ability to tolerate the intensity of the therapy group but also the group’s ability to tolerate the demands of that particular client at that point. Most heterogeneous ambulatory groups can, at best, tolerate only one or possibly two borderline individuals. The major considerations influencing the selection process are the same as those described in chapter 8. It is particularly important to assess the possibility of the client’s becoming a deviant in the group. Rigidity of behavioral patterns, especially patterns that antagonize other people, should be carefully scrutinized. Clients who are markedly grandiose, contemptuous, and disdainful are unlikely to have a bright future in a group. It is necessary for a client to have the capacity to tolerate minimal amounts of frustration or criticism without serious acting out. A client with an erratic work record, a history of transitory relationships, or a history of quickly moving on to a new situation when slightly frustrated in an old one is likely to respond in the same way in the therapy group.

The Narcissistic Client

The term
narcissistic
may be used in different ways. It is useful to think about narcissistic clients representing a range and dimension of concerns rather than a narrow diagnostic category.
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Although there is a formal diagnosis of narcissistic personality disorder, there are many more individuals with narcissistic traits who create characteristic interpersonal problems in the course of group therapy.

The nature of the narcissistic individual’s difficulties is captured comprehensively in the DSM-IV-TR diagnostic criteria for the personality disorder. A diagnosis of the personality disorder requires that at least five of nine criteria be met: grandiose sense of self-importance; preoccupation with fantasies of unlimited success, power, love, or brilliance; a belief that he or she is special and can be understood only by other special, high-status people; a need for excessive admiration; a sense of entitlement; interpersonally exploitative behavior; lack of empathy; often envious of others; arrogant, haughty behaviors or attitudes.
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