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Groups, Meetings, and Dinner Tables: What Group Therapy Offers
By Graeme Daniels, MFT
Once a client of mine, a beginning member of a therapy group, told me that it takes him at least three months before he could be truthful, with anybody . This was in response to a question as to why he had withheld from another member, concerns he harbored regarding that other member's participation. To many in the room, the question seemed moot given that other member's recent departure from the group. However, while my reticent client's statement was at least half-serious, he and others were stilled by their recollection that three months was the minimum duration of group participation requested of each member. Coincidence? He, like many others, had sought group therapy, hungry for an experience of universality, that ambivalence-inducing quality that groups offer. Group therapy, they learned, would reduce loneliness, and disconfirm uniqueness, generating a sober mix of relief and shame. My group considered anew the implications of the group rule, and it dawned upon some that they had yet to make use of the group's potential. That beginning member had himself been contemplating departure, yet he remained in the group for an additional two years.
For many, fully engaging in group therapy entails abandoning preconceptions about its purpose, and relinquishing strict adherence to social norms that inhibit a group's growth. For some, this process may constitute a surrendering of values that would otherwise cast psychotherapy as an extravagantly luxuriant exercise.
Addressing expectations is a critical part of orientation to group therapy. In one, sometimes two individual sessions, I typically meet with prospective group members, gathering information about the client's needs, gauging their previous experience of psychotherapy, and of group therapy in particular. Thereafter, I reserve time to discuss the nature of group therapy, to explain how it may meet specific demands, but also venture beyond to offer new challenges. Two such challenges lay in the area of group commitment and group identity.
It is not uncommon to new members to question-and sometimes balk at-the policy of a minimum commitment. This policy asks that members commit to a minimum period, say ninety days, in which they would regularly attend meetings. Those who bristle are clients who may wish to test the waters of group therapy more gingerly, to "try it and then see how I feel". Here there is a normal feeling of anxiety at the prospect of sharing oneself with others who, in all likelihood, are strangers; even more so, actually, if the others members of the group prove familiar. However, it is precisely this extra layer that group therapy presents-that vulnerability-that compels a special commitment. I ask these would-be members to imagine introducing themselves to a group: sharing something of their life story, their hopes for the group experience, perhaps disclosing secrets rigidly withheld elsewhere. Then I ask them to consider what it would be like for them if, at the following meeting, several fellows members were absent, having withdrawn from the group after their own "trial" attendance. That anxiety of that initial presentation would be compounded by the pain of implied rejection, and while it is unrealistic to legislate against such feelings, the notion of a group commitment provides a foundation for the development of group cohesion.
Some group members have expressed surprise at the contrast between the group experience, and that of individual therapy. With respect to both pragmatic and abstract matters, it is again important to orient new members to the nuances of group therapy. I find that cancellation policies for groups, for example, bear special explanation, and only make sense in the context of a broader discussion of group cohesion. One early experience of mine illustrates the importance of tailoring a policy with group commitment in mind. A member had called to cancel his participation in a single meeting, and later asked for a discount from his monthly charge, or-failing that-he asked if he could sit in on one of my other groups in order to make up the missed session. I was at pains to explain why neither option was possible. However, I managed somehow to assert that while a twenty four hour cancellation policy is a norm of individual therapy, the essential factors of group therapy complicate the issue. The development of trust between members, for instance, necessitates consistent attendance of an established group, and is thus prohibitive of a "drop-in" style of participation. Group members, I explained, were effectively paying for their reserved space in the group. I am aware, of course, that there are many groups-psycho-education, short-term groups, and specialized groups-that do operate and perhaps thrive with high turnover of membership, and must therefore make concessions in the area of group cohesion in favor of a problem-solving, or agenda-setting style.
At the same time, I think that much of the "drop-in" sensibility is borrowed from the 12-step community. Many of the groups I have facilitated have been specialized addictions, or recovery-oriented groups, and I've noticed amongst members some confusion between group therapy and the typical 12-step meeting format. At those meetings, members are accustomed to a structured format in which pre-selected readings are presented, and then followed by testimonial-style sharing. "Crosstalk"-defined as commenting upon another's share-is actively discouraged, replaced by a prevailing ethic in which members are urged to focus upon-and be responsible for-their own internal process. Moreover, as the movement in inherently leaderless, no official record of attendance is kept, and so drop-in attendance is both inevitable and welcomed. The development of a group identity is therefore happenstance. Contrast this with an ongoing therapy group, in which consistent attendance is expected. Meanwhile, interaction among group members within the meeting's structure is not only encouraged, but indeed seems the connective tissue of the group experience.
Initially disorienting, but ultimately accepted by those who remain in group therapy, the group identity idea owes much to Irvin Yalom's proposal that as many member problems as possible be discussed in the context of the group experience. The "here and now" technique deflects from problem solving of external matters (termed content), to a rumination of how problems manifest within the group (correspondingly termed process). Instead of questions like "how can the group address that problem" (in which case members may be invited to simply listen, or else give advice), the question becomes "how has this problem occurred in the group", with variations inviting practice in direct, authentic expression. Who in here might you be angry at? Who have you judged, or felt judged by? And how do you feel about my questions so far?
I think it important to note that many of the norms of group therapy, and in particular the "here and now", or process-oriented approach, violate social rules with which many of us-clients and therapists alike-were raised. It was some time before I determined that many of the interventions that comprised my training were, for lack of a better work, rude! So I empathize with members who, when asked to comment on another's share, complain "It's not my place to say". As I write these thoughts on the eve of the holiday season, I wonder what would happen if, at the extended family dinner table, I put on my therapist hat and asked, "would anyone like to give uncle some feedback as to how he has shared at the table tonight?" Minding one's own business was as important a value as any other in my upbringing. So it has been for many others. The 12-step philosophy, manifest in its format and norms, presents more conservatively in this regard. The movement protects members' privacy via its well known principle of anonymity; but more quietly, embedded within the aforementioned "no crosstalk" structure, there also exists a safeguard against intrusiveness. Group therapy-practiced in the manner Yalom suggests, offers no such safeguard, and so proceeds with more risk.
When people say, "you're talking like a therapist", they mean to say, "you ask questions only therapists ask". It suggests a deliberate design for psychotherapy, and in particular group therapy: to gently subvert the manner in which people ordinarily communicate. I use the word gently because I think it is the experience of many that the continuum of feedback that group therapy offers, from questions, to advice, criticism, encouragement, or even compliments, have so often in the past entailed embarrassment-if not abuse-so that normative social prohibitions against such exchanges seem well founded. Safety first, as some might say.
I have also found that group therapy attempts an awkward balance between a hierarchical structure, and egalitarianism. The issue of therapist self-disclosure is a good example of this strain. A facilitator invites self disclosure from individual members, encourages interaction within the group. A "here and now" approach furthers the intimacy and risk by encouraging spontaneous comment on the process as it unfolds. As this occurs repeatedly, there comes a time when individuals' socialization calls for the therapist to self disclose. For some this is about the need for leadership. The therapist/expert models his or her experience, becomes a teacher of direct expression, or a "wounded healer", informing a group with the details of his or her background. For others, therapist self disclosure presents dubious trappings, the opportunity to fuse with and ideal, at the expense of their own self-activation. Above all, I think for most there is a normal expectation of reciprocity, perhaps even what Martin Buber termed the "I-thou", or fully present, mutually caring relationship.
Generally speaking, the "I-thou" experience is not what prospective group members request-at least not with the therapist-when initially seeking group therapy. As I have mulled over opportunities to self disclose in groups, to reveal myself or else deflect onto clients' process, I note the ambivalence with which members experience my participation. Furthermore, though some make reference to what ostensibly are goals of achieving connectedness with others-seeking fellowship, learning others' perspectives, etc.-most enter and participate in groups with a host of defenses, undoubtedly nurtured over a lifetime, for a considerable period thereafter. It is a sporting axiom that "the best defense is a good offense", and the ethos is readily transferable to a group therapy setting. It is no longer any surprise to me that newcomers, despite the best of intentions, bring to group what they otherwise bring to their daily lives, so that blaming, venting, and other subtler types of projection-such as advice-giving-form the character of an early developing, or "young" group.
The goals of group therapy are therefore variable. There's a place in group for those who-to paraphrase Scott Peck-seek relief from life's pain. They expect of therapy, roughly, what we ordinarily expect of doctors and psychiatrists: to simply reduce the symptoms of distress. The point at which members' goals may transform into something more abstract-interpersonal or perhaps spiritual-is a mystery to me (I know it isn't ninety days). The germination of this moment is, however, well depicted in a passage from Yalom's latest novel, The Shopenhauer Cure. In a story that follows, among other things, the process of an ongoing therapy group, a schizoid-like group member who aspires to become a therapist, compares his outlook to that of the therapist/protagonist: "I don't offer an emotional relationship-I'm not here to love my client. Instead I am an intellectual guide", he states. He then adds, "I'm beginning to understand what you're aiming for-a Buber-like I-thou encounter". At first it seems ironic that this character is the one who challenges the therapist to reciprocate self disclosure. At the same time, he is drawn to consider how his challenge reflects his relatedness to the group, and to its facilitator. He concedes that his attempt to elicit that disclosure was as much intended to usurp the leadership as it was to establish closeness. The authenticity and intimacy of his sharing appears to grow thereafter.
Yalom introduces this character, who initially seems so incompatible with the process-oriented approach, so as to illustrate the transformative potential of group therapy. It needn't compete with, much less be interchangeable with, other means of fellowship, but may indeed offer more than what clients bargain for.
* This article has been accepted for possible print in an upcoming issue of The Therapist, the publication of the California Association of Marriage and Family Therapists (CAMFT), headquartered in San Diego, California. This article is copyrighted and been reprinted with the permission of CAMFT.
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