The Changing Face of Group Psychotherapy: Adventures in Fifty Years of Practice
By Marvin N. Kaphan, Licensed Clinical Social Worker
GPASC 53rd Annual Conference: Keynote address
In the interest of full disclosure, I must begin by admitting that while it’s true that I have been in practice for over fifty years, I have only maintained my six groups for forty-five years.
That said, I want to begin this memoir with an observation that I’ve made over the years: that many of the people who seem happiest in their careers, had followed what is called in mathematics a “Random Walk” or a “Drunkard’s Walk”, where they seem to shift direction again and again by what appears to be pure chance. Strangely enough, when they arrive at their destinations and look back at the path they’ve followed, they perceive that each of the tangents they’ve pursued has contributed to the happy result, as if by some unconscious plan.
My path to the profession of psychotherapy began oddly enough with a love for the fields of physics and mathematics. I had almost completed my bachelor’s degree when I left for the war. Years later, I was to realize that my work as a physicist gave me an intuitive understanding of psychodynamics that I might not of achieved in any other way.
The Army Air Corps decided to make me a psychologist, developing and administering psychomotor tests. That experience taught me that I preferred working with people to working with things, and led me to the decision to combine those interests and become a teacher of physics. Returning to school after the war, I learned that the requirements for a teaching credential involved seven education courses, each prerequisite for the next. I therefore found myself in the enviable position of receiving a truly broad education --- able to fill my time with courses in novels, music, theatricals, and singing (which, incidentally, led me to the wonderful woman who later became my wife). When I graduated, I had 256 credits, exactly twice the number ordinarily required for graduation. I am convinced that my wide education provided a valuable contribution to my future career.
In a graduate school of education, I found myself turning more and more to courses labeled “Guidance and Counseling”. One of my courses was with a disciple of Carl Rogers’ newly developed “Clientcentered therapy” . Rogers’ theories were based on the idea that clients were better able to identify their needs than we outsiders were. Extremists, which included my instructor, carried this to the point that the therapist should say no word that the client hadn’t uttered first. In fact, he bragged of a case where a client came to him and was completely silent. My instructor responded with complete silence. The client kept making weekly appointments through the therapist’s secretary for six months, without ever saying a word in session. At the end of the six months, the client said: “Thank you very much. This has been very helpful.” My instructor was absolutely certain of the benefit his patient had received. I was not completely convinced.
A contemporary joke involved a client coming to a Rogerian therapist and announcing that he was going to kill himself.
The therapist responds: “You’re going to kill yourself”.
The Client: “I’m going to jump out that window”.
The Therapist: “You’re going to jump out that window”.
The Client runs to the window and jumps out. The therapist goes to the window, looks down and says: “Splat!”
When I began teaching, by great good fortune, my first real position was in an outstanding residential treatment school for adolescents. Over the years, I became more and more involved in the treatment program, and when I told the Director that I wanted to learn to be a psychotherapist, he urged me to go to a graduate school of Social Work.
It was during my training at Columbia University that I first heard rumbling about the developing field of group psychotherapy. I was in a field placement at Manhattan State Hospital, when a poster appeared announcing a series of lectures by a pioneer of this new movement (I believe it was S. R. Slavson). By the day of the first lecture, the largest auditorium on the hospital grounds was packed. A small man shuffled across the stage to the lectern, opened a book, and started reading to us about the birds and the bees. By the end of the time period, members of the audience were shuffling their feet, showing other signs of restlessness, and muttering to each other. At the second lecture, the audience was noticeably smaller. The presenter went to the lectern, opened his book and continued to read where he had left off the week before. Now the restlessness was much more dramatic. By the end, people were shouting out exclamations like: “What’s going on here?” and “What’s this all about?”. My schedule changed at that point, and I was unable to attend the next lecture, but I heard that the group was even smaller and more intense. Some time later, I realized that a group process was being demonstrated.
During the next few years, as I worked in clinics, I kept hearing of the exciting work going on in groups. Early steps had been taken long before. A half century before, Joseph Pratt was using Group techniques with his tuberculosis patients at Massachusetts General Hospital. Before the 1940’s J. L. Moreno had labeled the technique “Group Psychotherapy”, Slavson had been working with the Jewish Board of Guardians and Paul Schilder established psychoanalytic groups at Bellevue Hospital, both in New York. In 1940, S. H. Foulkes and E. James Anthony organized the Group Analytic Society in England, but it was the widening use of Group Therapy techniques in military hospitals and veterans’ hospitals during and after the Second World War that led to the real explosion of experimentation, imagination and creativity that I consider a ”Golden Age”.
It was right after the war that J. D. Sutherland , Foulkes and H. Ezriel applied psychoanalysis to groups at the Tavistock Clinic in London and Nathan Ackerman wrote about using group methods in dealing with families.
By the time I was ready to set up my private practice, It seemed that many of the greatest minds in our field were beginning to explore group therapy. To name just a few, there were Martin Grotjahn, Hyman Spotnitz, Jerome Frank, Florence Powdermaker, Clifford Sager, Helen Papaneck, Max Rosenbaum, Helen Durkin, Haim Ginott, Gisela Konopka and Fritz Redl. In many ways even the schools of business were on the cutting edge with their T-groups and Sensitivity groups.
In spite of all this excitement and activity, there was practically nowhere to turn to seek training in this new technique. The only way to learn was to volunteer to work free as a co-therapist at some clinic where someone with slightly more experience was already doing groups. I found a tiny church clinic where I became co-therapist to a bright young psychoanalyst. It was a terrifying ordeal. I sat as quietly as I could, afraid of doing something wrong, and tried to study what was going on, while not quite sure what I was looking for. When I met with the therapist after my first session, his first question was: “Well, what did you see?” When I told him I had noticed some sort of interaction between two of the group members, his response was a gruff: “Big deal, you spotted some eye contact”. Happily, our communication and relationship became much better as time went on.
Think of the upheavals going on in the 50’s and the 60’s. Psychoanalysis was changing before our eyes.
There was a growing interest in the interpersonal and the concept of a benign core in humanity. It was the day of flower children and free love. Experimentation was going on all around us. At Esalen , in Northern California, the “Human Potential Movement” was being born. Carl Rogers and Abraham Maslow helped found the Association for Humanistic Psychology, which they termed the “Third force” as apposed to the “First Force”, Behaviorism, and the “Second force”, psychoanalysis.
Our initial focus was on breaking down the barriers between people. We tried techniques from everywhere including the business schools’ sensitivity groups. We used “encounter bats” better know as “Batacas”. These foam clubs were expected to bring out buried angers --- and sometimes they did. We used the exercise of punching a pillow for the same purpose. I remember one scene of a very tall man holding a cushion in front of him with one hand while he held his other hand on the forehead of a tiny woman who swung futilely, completely unable to reach him. Many of those early exercises seemed designed to provoke conflict. They included asking the group to line up at the door in the order of their importance, or having the group form a circle and one member try to get in or out of the circle. Although this sometimes produced some interesting results, like noticing who tried to force his way through the circle and who went limp and waited for the members in the circle to get bored and dissolve the circle, It became clear very quickly that these borrowed techniques were not producing the kind of group experience I was hoping for.
I did continue to use devices to produce various results in groups. One of the most productive was the marathon session. The theory was that if a group continued long enough, and patients were sufficiently exhausted, their defenses would collapse and they would be much more open and unguarded. The traditional marathon lasted an entire weekend without sleep or interruption. I was not willing to devote a whole weekend and I didn’t think my patients could afford paying for that many hours of my time, so I would ask the participants to spend their Saturdays in the usual way without resting or sleep, then we would begin at midnight and continue until 8:00 AM Sunday morning. I had even more success with this technique than my colleagues did. I believe this was the result of the fact that they were usually filling their marathons with people unknown to each other, hoping to achieve some of the results that we were accomplishing with on-going groups. I am convinced that the results I got were because of closeness, intimacy, love, and trust that had developed over time among the members of my groups.
One of my esteemed colleagues, the late Paul Bindrim , who was later to become President of the Group Psychotherapy Association of Southern California, developed an approach that became quite famous. Time Magazine described the movement Paul started with an article entitled “Stripping Body & Mind“ that began:
“Group-psychotherapy marathons lasting 24 to 48 hours are being staged by many psychologists in the Los Angeles area. At the end of these, Psychotherapist Paul Bindrim noticed that when the sessions had gone well, group members tended to shed some of their clothes. Could it be, Bindrim wondered, that what he calls a man's "tower of clothes" is not only a safeguard for his privacy, but also a self-imposed constraint to keep out people he fears? If so, a man who disrobed physically might be better able to disrobe emotionally.”
Paul developed a weekend workshop using nudity and swimming pools, which was recorded as a beautiful and sensitive film entitled “Out of Touch” by the Canadian Film Board. Paul was very concerned about confidentiality, and produced a lengthy comprehensive contract that every participant was required to sign. When a writer joined one of his groups under false pretenses, and then wrote a thinly veiled novel about the experience, Paul sued and finally won a landmark court decision that now gives us more confidentiality protection.
From time to time, someone in one of my groups would say: “You say we can do anything we want. Suppose we want to take our clothes off, would that be OK?” I would tell the questioner: “You’d be welcome to do it, but I think it might add to the uptightness if you add embarrassment about being naked”. That always discouraged it, but since I had always encouraged risk taking, one common discussion in my groups was: “What is the hardest, most difficult or scariest thing to get myself to say or do”.
One evening, when a group was discussing this subject, one woman said:
“The scariest thing for me would be to take my clothes off.” When asked why, she said: “You guys treat me as if I’m beautiful, but I know I’m fat and ugly. I’m afraid if I took my clothes off you’d see that I’m fat and ugly, and treat me differently.” The group couldn’t understand how her clothes could be bigger on the inside than on the outside, but went on to the next person, a man who said: “The scariest thing for me would be if she took her clothes off.” When asked why that would be, he replied: “I’m picturing that she would take her clothes off, she’d look fat and ugly, and she’d look at me and say: “Well?” and I wouldn’t know what to say.” At that point the woman said: “If that’s what scares him, that’s what I’m going to do.” She stood up pulled off her clothes, looked at him and said: “Well?” He wiped his forehead, and said: “Whew! You look wonderful.”
To my great surprise, there was very little self-consciousness. In fact, the group became more and more close and more open, and less conscious of their nakedness. As I stopped being resistant, all of my groups began to experiment with nudity on occasion with similar results. I believe that the difference from the reaction I expected was due to the long period that the groups had been together and the closeness and trust they had developed. It seemed strange to me that the most reluctance I saw was from some of the men. They eventually revealed that their fear was that they might get erections. The women reacted to the men’s concern with: “That would be nice.” I interpreted this fear as a fear of revealing emotion. In actuality, I never saw any indication of sexual arousal. The situation always felt completely un-erotic.
Although the occasions when a group would return to nudity were relatively rare, in one of my groups, one woman decided that when the group was moving too slowly, she could get a reaction by suddenly pulling her clothes off. Undressing typically wouldn’t happen when a relatively new person was in a group, except one time. A new man joined the group and the woman I just mentioned was very frustrated that she couldn’t get a reaction out of him. In desperation, she pulled off all her clothes except her knee-high boots, picked up a Bataca and began to beat him with it. To the day he left the group some years later, he kept marveling about the scene in his first group session, where this naked booted woman stood over him beating him.
Of course, that was many decades ago. In the modern world, patients don’t ask for nudity. We wouldn’t use it anyway, among other reasons, because it’s doubtful that our malpractice carriers would stand for it. In our early experiments, we used many different techniques. I would bring in body movement specialists, or use group hypnosis. In group hypnosis, I would suggest that the group was a single organism, with each member a part of the whole. As I had them move farther from each other, I had them feel the hunger to be close together, and as I had them move closer, I had them feel the warmth and relief of the closeness. After about 10 years of doing group, Yalom’s book came out, and it was a thrill to find that he confirmed many of the things I had been finding in my own groups.
As I look back, some scenes from the past come to mind. Some that illustrate how group interaction exposes psychodynamics so that the other members are educated about dynamics even if the person struggling with them isn’t yet ready to see through them. For example, the day a woman brought up a compulsion that she had to search through food that she had prepared for her children, to make sure she hadn’t dropped any needles or pins into it.
A man said (very gently): “You know, sometimes a fear masks a wish.”
The Woman: “I don’t know what you’re talking about.”
The man (still very carefully): “I mean that perhaps somewhere in your unconscious, where you don’t know about it and are not responsible for it, there’s some little urge to harm your children, and this compulsion is a defense against that.”
The Woman: “Funny, I can understand each word you’ve said, but I can’t make sense out of what you’re saying.”
The Man (making strangling motions, shouts): “You want to kill your kids, you want to murder them.”
The woman: “Everything’s getting foggy, I don’t understand what’s going on.”
Or the Man who said: I see I’m afraid to let my marriage get too good.
Group member: Why is that.
The Man: Then I might not feel like leaving.
Group Member: What’s wrong with that, you’d be staying because you want to.
The Man: I know and it doesn’t make sense, but I feel as if I’d be losing my options.
Or the Woman who had been talking about how terribly abusive her husband was to her and the children.
Group Member: “Why do you stay with him?”
The Woman: “Oh, for the children”
Group Member: “But you say he’s cruel to them.”
The Woman: “Yes, but he can discipline them, and I can’t.”
Group Member: “What do you mean by ‘discipline’?”
The Woman: “Discipline is forcing children to do ridiculous things.”
Or those wonderful moments of perception like the one where a group member discovered: “I see. If the same thing happens to me in several places, the only common factor is me.” Or the one who said: “I feel like someone who walks around carrying two steel bars that he holds in front of him wherever he looks, while shouting: “let me out of this cage”
In this conference, you are hearing from faculty members of four Universities about the latest methods being used, taught, and refined today. I have, therefore, focused this presentation on my reminiscences about the early days.
So what have I learned in all these years? There are three things the group seems to need from me. One is an environment of safety. If patients are to be encouraged to be open and vulnerable in group, they must be sure that nothing they say or do in group can impact jobs, marriages or friendships in their outside life, and they must develop trust in the therapist and their fellow group members. Second, they need my utmost care in selection of group members. Each of my groups seems to have a different personality, and deciding which group to place someone in seems crucial. Finally, they need my services as a moderator, interpreter and traffic cop.
I’ve talked a lot today about devices and techniques, but when I received a letter recently from a new group therapist requesting advice about techniques to use when a group becomes dull, I realized that the main thing I have learned is to trust the group process. Over the years, as I have eliminated almost all the devices and rituals of the past, I’ve seen groups accomplish amazing things when we trust the process.
QUESTION 1: Are any of your groups focus groups?
ANSWER: No. I believe that groups that are formed by matching participants by symptoms tend to focus all their attention on handling symptoms, and tend to avoid underlying issues. They sometimes actually reinforce the symptoms. Even without symptoms in common, patients can find many psychodynamic parallels on a deeper level.
QUESTION 2: How would you characterize your groups?
ANSWER: I would describe them as long-term open-end heterogeneous psychodynamic groups. As much as possible, I try to include in each group younger men, older men, younger women, and older women, so that in some ways they replicate a family.
QUESTION 3: You speak of the care necessary in placement of patients into groups. Why is this necessary, and how do you do it?
ANSWER: Fortunately, I have little need to worry about the biggest concern of therapists who have patients self refer for groups: that the patient may be totally unsuited for, or damaging to, their groups. Most of my group patients have been individual patients of mine for a considerable period of time, so that I know them quite well. Those that have not been my patients, have been referred by individual therapists who know them quite well and feel that the patient needs a group experience. They can usually assure me that the patient is ready for the group. I interview these referred patients very carefully, but I have noticed that when I have made mistakes, they have only been among this group of patients, and usually result from relying too confidently upon the referring therapist’s evaluation.
Although the composition of all the groups seems the same on paper, over the years each group has developed a completely different personality, which has remained consistent over decades. I believe that if the patient, the group and its members are to get the most benefit from the group experience, it is my responsibility to be especially careful in choosing the group they will attend. While other colleagues, including the current GPASC President, Dr. Irene Harwood, have been working on formalized processes for selecting group members, the method I have used has been much more subjective. I use a fantasy process. I try to imagine how each member of the group will affect this patient, and how this patient will affect each of the members and the functioning of the group as a whole.
QUESTION 4: Regarding nudity: Have any of your patients resisted undressing?
ANSWER: One of the principal assurances I give every patient who enters my groups is that they would never be forced to do or say anything they’re not willing to do or say. The first time someone in a group chose to undress there was always someone who chose not to. However, by the second time, almost everyone joined in, usually saying something like: “I saw how relaxed and easy everyone felt, and I found myself feeling clunky and clumsy in my clothes.”
One woman who delayed a lot longer than the others, said when she decided to undress: “I may take off my clothes, but you’ll never see me without my makeup.” It was months before she got up the courage to take off her makeup. When she did, no one could detect any difference in her appearance.
Just about always, people who had doubts about their appearance discovered that others found them much more attractive than they believed themselves to be. One woman who was extremely obese and had always said she would never consider undressing in group, after more than year of sadly watching others undress, said at the end of a very intense marathon: “Oh, what the hell!”, and took her clothes off. Instead of the usual rather positive reaction, one woman who had become quite close to her screamed: ”My God, How could you do that to yourself!”. The obese woman began to cry and spoke in detail for the first time about the verbal abuse she taken from her father throughout her childhood. The abuse had centered on her weight. The session ended with the two women crying in each other’s arms. That session became a turning point for the obese woman. For the first time she began taking off weight. Although she has been out of treatment for many years, I have had occasion to have contact with her every few years, and she is now quite slim and graceful.
QUESTION 5: In those days, did you ever take your clothes off in a group?
ANSWER: From time to time one or another of the women would ask if I would take my clothes off. I would answer that if they were sure they wanted me to, I would. Almost always, they would react by covering their eyes with their hands, looking away, giggling and saying: “No, not really.” One time, in one group, one person stuck to her guns, so I did it. This brings into focus how much boundary considerations have changed and crystallized over the years. Now we have a very different view of what is appropriate and what is not in many fields. In some ways, this has been valuable in forging professionalism and providing guides to neophytes trying to find their way, but sometimes something is lost. For example, it wasn’t many years ago that a teacher could feel free to hug a child without the slightest hesitation or concern about appropriateness.
Fifty years ago, our field, and in fact the world around us, was in ferment. There was a feeling of adventurousness and creativity. We were infused with courage and confidence that we could accomplish anything. On the other hand, there was no one to guide us; no one to teach us. As I have watched the changes that have developed in our practice, I am awed by the great minds that have honed our theoretical concepts. In fact, as I look around at this conference, I see a collection of fine teachers insuring that the next generations of group therapists will have a solid professional basis as they begin their careers. It makes one proud to see the knowledge and structure that we’ve built, but I can’t help hoping that we never lose that adventurous, explorative spark that has led to so many past achievements.
Marvin N. Kaphan, MSW
(LCS 181) and (MFT 717)
Diplomate, American Board of
Examiners in Clinical Social Work
12520 Magnolia Boulevard, Suite 210
Valley Village, CA 91607
Fax: (310) 454-0700
Tel: (818) 766 - 9540
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