The Theory and Practice of Group Psychotherapy (7 page)

Recognizing the primacy of relatedness and attachment, contemporary models of dynamic psychotherapy have evolved from a drive-based, one-person Freudian psychology to a two-person relational psychology that places the client’s interpersonal experience at the center of effective psychotherapy. †
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Contemporary psychotherapy employs “a relational model in which mind is envisioned as built out of interactional configurations of self in relation to others.”
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Building on the earlier contributions of Harry Stack Sullivan and his interpersonal theory of psychiatry,
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interpersonal models of psychotherapy have become prominent.
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Although Sullivan’s work was seminally important, contemporary generations of therapists rarely read him. For one thing, his language is often obscure (though there are excellent renderings of his work into plain English);
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for another, his work has so pervaded contemporary psychotherapeutic thought that his original writings seem overly familiar or obvious. However, with the recent focus on integrating cognitive and interpersonal approaches in individual therapy and in group therapy, interest in his contributions have resurged.
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Kiesler argues in fact that the interpersonal frame is the most appropriate model within which therapists can meaningfully synthesize cognitive, behavioral, and psychodynamic approaches—it is the most comprehensive of the integrative psychotherapies.†
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Sullivan’s formulations are exceedingly helpful for understanding the group therapeutic process. Although a comprehensive discussion of interpersonal theory is beyond the scope of this book, I will describe a few key concepts here. Sullivan contends that the personality is almost entirely the product of interaction with other significant human beings. The need to be closely related to others is as basic as any biological need and is, in the light of the prolonged period of helpless infancy, equally necessary to survival. The developing child, in the quest for security, tends to cultivate and to emphasize those traits and aspects of the self that meet with approval and to squelch or deny those that meet with disapproval. Eventually the individual develops a concept of the self based on these perceived appraisals of significant others.

The self may be said to be made up of reflected appraisals. If these were chiefly derogatory, as in the case of an unwanted child who was never loved, of a child who has fallen into the hands of foster parents who have no real interest in him as a child; as I say, if the self-dynamism is made up of experience which is chiefly derogatory, it will facilitate hostile, disparaging appraisals of other people and it will entertain disparaging and hostile appraisals of itself.
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This process of constructing our self-regard on the basis of reflected appraisals that we read in the eyes of important others continues, of course, through the developmental cycle. Grunebaum and Solomon, in their study of adolescents, have stressed that satisfying peer relationships and self-esteem are inseparable concepts.
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The same is true for the elderly—we never outgrow the need for meaningful relatedness.
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Sullivan used the term “parataxic distortions” to describe individuals’ proclivity to distort their perceptions of others. A parataxic distortion occurs in an interpersonal situation when one person relates to another not on the basis of the realistic attributes of the other but on the basis of a personification existing chiefly in the former’s own fantasy. Although parataxic distortion is similar to the concept of transference, it differs in two important ways. First, the scope is broader: it refers not only to an individual’s distorted view of the therapist but to all interpersonal relationships (including, of course, distorted relationships among group members). Second, the theory of origin is broader: parataxic distortion is constituted not only of the simple transferring onto contemporary relationships of attitudes toward real-life figures of the past but also of the distortion of interpersonal reality in response to intrapersonal needs. I will generally use the two terms interchangeably; despite the imputed difference in origins, transference and parataxic distortion may be considered operationally identical. Furthermore, many therapists today use the term transference to refer to all interpersonal distortions rather than confining its use to the client-therapist relationship (see chapter 7).

The transference distortions emerge from a set of deeply stored memories of early interactional experiences.
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These memories contribute to the construction of an internal working model that shapes the individual’s attachment patterns throughout life.
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This internal working model also known as a schema
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consists of the individual’s beliefs about himself, the way he makes sense of relationship cues, and the ensuing interpersonal behavior—not only his own but the type of behavior he draws from others.
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For instance, a young woman who grows up with depressed and overburdened parents is likely to feel that if she is to stay connected and attached to others, she must make no demands, suppress her independence, and subordinate herself to the emotional needs of others.† Psychotherapy may present her first opportunity to disconfirm her rigid and limiting interpersonal road map.

Interpersonal (that is, parataxic) distortions tend to be self-perpetuating. For example, an individual with a derogatory, debased self-image may, through selective inattention or projection, incorrectly perceive another to be harsh and rejecting. Moreover, the process compounds itself because that individual may then gradually develop mannerisms and behavioral traits—for example, servility, defensive antagonism, or condescension—that eventually will cause others to become, in reality, harsh and rejecting. This sequence is commonly referred to as a “self-fulfilling prophecy”—the individual anticipates that others will respond in a certain manner and then unwittingly behaves in a manner that brings that to pass. In other words, causality in relationships is circular and not linear. Interpersonal research supports this thesis by demonstrating that one’s interpersonal beliefs express themselves in behaviors that have a predictable impact on others.
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Interpersonal distortions, in Sullivan’s view, are modifiable primarily through consensual validation—that is, through comparing one’s interpersonal evaluations with those of others. Consensual validation is a particularly important concept in group therapy. Not infrequently a group member alters distortions after checking out the other members’ views of some important incident.

This brings us to Sullivan’s view of the therapeutic process. He suggests that the proper focus of research in mental health is the study of processes that involve or go on between people.
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Mental disorder, or psychiatric symptomatology in all its varied manifestations, should be translated into interpersonal terms and treated accordingly.
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Current psychotherapies for many disorders emphasize this principle.† “Mental disorder” also consists of interpersonal processes that are either inadequate to the social situation or excessively complex because the individual is relating to others not only as they are but also in terms of distorted images based on who they represent from the past. Maladaptive interpersonal behavior can be further defined by its rigidity, extremism, distortion, circularity, and its seeming inescapability.
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Accordingly, psychiatric treatment should be directed toward the correction of interpersonal distortions, thus enabling the individual to lead a more abundant life, to participate collaboratively with others, to obtain interpersonal satisfactions in the context of realistic, mutually satisfying interpersonal relationships: “One achieves mental health to the extent that one becomes aware of one’s interpersonal relationships.”
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Psychiatric cure is the “expanding of the self to such final effect that the patient as known to himself is much the same person as the patient behaving to others.”
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Although core negative beliefs about oneself do not disappear totally with treatment, effective treatment generates a capacity for interpersonal mastery
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such that the client can respond with a broadened, flexible, empathetic, and more adaptive repertoire of behaviors, replacing vicious cycles with constructive ones.

Improving interpersonal communication is the focus of a range of parent and child group psychotherapy interventions that address childhood conduct disorders and antisocial behavior. Poor communication of children’s needs and of parental expectations generates feelings of personal helplessness and ineffectiveness in both children and parents. These lead to the children’s acting-out behaviors as well as to parental responses that are often hostile, devaluing, and inadvertently inflammatory.
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In these groups, parents and children learn to recognize and correct maladaptive interpersonal cycles through the use of psychoeducation, problem solving, interpersonal skills training, role-playing, and feedback.

These ideas—that therapy is broadly interpersonal, both in its goals and in its means—are exceedingly germane to group therapy. That does not mean that all, or even most, clients entering group therapy ask
explicitly
for help in their interpersonal relationships. Yet I have observed that the therapeutic goals of clients often undergo a shift after a number of sessions. Their initial goal, relief of suffering, is modified and eventually replaced by new goals, usually interpersonal in nature. For example, goals may change from wanting relief from anxiety or depression to wanting to learn to communicate with others, to be more trusting and honest with others, to learn to love. In the brief group therapies, this translation of client concerns and aspirations into interpersonal ones may need to take place earlier, at the assessment and preparation phase (see chapter 10).
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The goal shift from relief of suffering to change in interpersonal functioning is an essential early step in the dynamic therapeutic process. It is important in the thinking of the therapist as well. Therapists cannot, for example, treat depression per se: depression offers no effective therapeutic handhold, no rationale for examining interpersonal relationships, which, as I hope to demonstrate, is the key to the therapeutic power of the therapy group.
It is necessary, first, to translate depression into interpersonal terms and then to treat the underlying interpersonal pathology.
Thus, the therapist translates depression into its interpersonal issues—for example, passive dependency, isolation, obsequiousness, inability to express anger, hypersensitivity to separation—and then addresses those interpersonal issues in therapy.

Sullivan’s statement of the overall process and goals of individual therapy is deeply consistent with those of interactional group therapy. This interpersonal and relational focus is a defining strength of group therapy.† The emphasis on the client’s understanding of the past, of the genetic development of those maladaptive interpersonal stances, may be less crucial in group therapy than in the individual setting where Sullivan worked (see chapter 6).

The theory of interpersonal relationships has become so much an integral part of the fabric of psychiatric thought that it needs no further underscoring. People need people—for initial and continued survival, for socialization, for the pursuit of satisfaction. No one—not the dying, not the outcast, not the mighty—transcends the need for human contact.

During my many years of leading groups of individuals who all had some advanced form of cancer,
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I was repeatedly struck by the realization that, in the face of death, we dread not so much nonbeing or nothingness but the accompanying utter loneliness. Dying patients may be haunted by interpersonal concerns—about being abandoned, for example, even shunned, by the world of the living. One woman, for example, had planned to give a large evening social function and learned that very morning that her cancer, heretofore believed contained, had metastasized. She kept the information secret and gave the party, all the while dwelling on the horrible thought that the pain from her disease would eventually grow so unbearable that she would become less human and, finally, unacceptable to others.

The isolation of the dying is often double-edged. Patients themselves often avoid those they most cherish, fearing that they will drag their family and friends into the quagmire of their despair. Thus they avoid morbid talk, develop an airy, cheery facade, and keep their fears to themselves. Their friends and family contribute to the isolation by pulling back, by not knowing how to speak to the dying, by not wanting to upset them or themselves. I agree with Elisabeth Kübler-Ross that the question is not whether but
how
to tell a patient openly and honestly about a fatal illness. The patient is always informed covertly that he or she is dying by the demeanor, by the shrinking away, of the living.
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Physicians often add to the isolation by keeping patients with advanced cancer at a considerable psychological distance—perhaps to avoid their sense of failure and futility, perhaps also to avoid dread of their own death. They make the mistake of concluding that, after all, there is nothing more they can do. Yet from the patient’s standpoint, this is the very time when the physician is needed the most, not for technical aid but for sheer human presence. What the patient needs is to make contact, to be able to touch others, to voice concerns openly, to be reminded that he or she is not only apart from but also a part of. Psychotherapeutic approaches are beginning to address these specific concerns of the terminally ill—their fear of isolation and their desire to retain dignity within their relationships.† Consider the outcasts—those individuals thought to be so inured to rejection that their interpersonal needs have become heavily calloused. The outcasts, too, have compelling social needs. I once had an experience in a prison that provided me with a forceful reminder of the ubiquitous nature of this human need. An untrained psychiatric technician consulted me about his therapy group, composed of twelve inmates. The members of the group were all hardened recidivists, whose offenses ranged from aggressive sexual violation of a minor to murder. The group, he complained, was sluggish and persisted in focusing on extraneous, extragroup material. I agreed to observe his group and suggested that first he obtain some sociometric information by asking each member privately to rank-order everyone in the group for general popularity. (I had hoped that the discussion of this task would induce the group to turn its attention upon itself.) Although we had planned to discuss these results before the next group session, unexpected circumstances forced us to cancel our presession consultation.