The Theory and Practice of Group Psychotherapy (8 page)

During the next group meeting, the therapist, enthusiastic but professionally inexperienced and insensitive to interpersonal needs, announced that he would read aloud the results of the popularity poll. Hearing this, the group members grew agitated and fearful. They made it clear that they did not wish to know the results. Several members spoke so vehemently of the devastating possibility that they might appear at the bottom of the list that the therapist quickly and permanently abandoned his plan of reading the list aloud.

I suggested an alternative plan for the next meeting: each member would indicate whose vote he cared about most and then explain his choice. This device, also, was too threatening, and only one-third of the members ventured a choice. Nevertheless, the group shifted to an interactional level and developed a degree of tension, involvement, and exhilaration previously unknown. These men had received the ultimate message of rejection from society at large: they were imprisoned, segregated, and explicitly labeled as outcasts. To the casual observer, they seemed hardened, indifferent to the subtleties of interpersonal approval and disapproval. Yet they cared, and cared deeply.

The need for acceptance by and interaction with others is no different among people at the opposite pole of human fortunes—those who occupy the ultimate realms of power, renown, or wealth. I once worked with an enormously wealthy client for three years. The major issues revolved about the wedge that money created between herself and others. Did anyone value her for herself rather than her money? Was she continually being exploited by others? To whom could she complain of the burdens of a ninetymillion-dollar fortune? The secret of her wealth kept her isolated from others. And gifts! How could she possibly give appropriate gifts without having others feel either disappointed or awed? There is no need to belabor the point; the loneliness of the very privileged is common knowledge. (Loneliness is, incidentally, not irrelevant to the group therapist; in chapter 7, I will discuss the loneliness inherent in the role of group leader.)

Every group therapist has, I am sure, encountered group members who profess indifference to or detachment from the group. They proclaim, “I don’t care what they say or think or feel about me; they’re nothing to me; I have no respect for the other members,” or words to that effect. My experience has been that if I can keep such clients in the group long enough, their wishes for contact inevitably surface. They are concerned at a very deep level about the group. One member who maintained her indifferent posture for many months was once invited to ask the group her secret question, the one question she would like most of all to place before the group. To everyone’s astonishment, this seemingly aloof, detached woman posed this question: “How can you put up with me?”

Many clients anticipate meetings with great eagerness or with anxiety; some feel too shaken afterward to drive home or to sleep that night; many have imaginary conversations with the group during the week. Moreover, this engagement with other members is often long-lived; I have known many clients who think and dream about the group members months, even years, after the group has ended.

In short, people do not feel indifferent toward others in their group for long. And clients do not quit the therapy group because of boredom. Believe scorn, contempt, fear, discouragement, shame, panic, hatred! Believe any of these! But never believe indifference!

In summary, then, I have reviewed some aspects of personality development, mature functioning, psychopathology, and psychiatric treatment from the point of view of interpersonal theory. Many of the issues that I have raised have a vital bearing on the therapeutic process in group therapy: the concept that mental illness emanates from disturbed interpersonal relationships, the role of consensual validation in the modification of interpersonal distortions, the definition of the therapeutic process as an adaptive modification of interpersonal relationships, and the enduring nature and potency of the human being’s social needs. Let us now turn to the corrective emotional experience, the second of the three concepts necessary to understand the therapeutic factor of interpersonal learning.

THE CORRECTIVE EMOTIONAL EXPERIENCE

In 1946, Franz Alexander, when describing the mechanism of psychoanalytic cure, introduced the concept of the “corrective emotional experience.” The basic principle of treatment, he stated, “is to expose the patient, under more favorable circumstances, to emotional situations that he could not handle in the past. The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experience.”
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Alexander insisted that intellectual insight alone is insufficient: there must be an emotional component and systematic reality testing as well. Patients, while affectively interacting with their therapist in a distorted fashion because of transference, gradually must become aware of the fact that “these reactions are not appropriate to the analyst’s reactions, not only because he (the analyst) is objective, but also because he is what he is, a person in his own right. They are not suited to the situation between patient and therapist, and they are equally unsuited to the patient’s current interpersonal relationships in his daily life.”
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Although the idea of the corrective emotional experience was criticized over the years because it was misconstrued as contrived, inauthentic, or manipulative, contemporary psychotherapies view it as a cornerstone of therapeutic effectiveness. Change both at the behavioral level and at the deeper level of internalized images of past relationships does not occur primarily through interpretation and insight but through meaningful here-and-now relational experience that disconfirms the client’s pathogenic beliefs.
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When such discomfirmation occurs, change can be dramatic: clients express more emotion, recall more personally relevant and formative experiences, and show evidence of more boldness and a greater sense of self.
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These basic principles—the importance of the emotional experience in therapy and the client’s discovery, through reality testing, of the inappropriateness of his or her interpersonal reactions—are as crucial in group therapy as in individual therapy, and possibly more so because the group setting offers far more opportunities for the generation of corrective emotional experiences. In the individual setting, the corrective emotional experience, valuable as it is, may be harder to come by, because the client-therapist relationship is more insular and the client is more able to dispute the spontaneity, scope, and authenticity of that relationship. (I believe Alexander was aware of that, because at one point he suggested that the analyst may have to be an actor, may have to play a role in order to create the desired emotional atmosphere.)
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No such simulation is necessary in the therapy group, which contains many built-in tensions—tensions whose roots reach deep into primeval layers: sibling rivalry, competition for leaders’/parents’ attention, the struggle for dominance and status, sexual tensions, parataxic distortions, and differences in social class, education, and values among the members.
But the evocation and expression of raw affect is not sufficient
: it has to be transformed into a corrective emotional experience. For that to occur two conditions are required: (1) the members must experience the group as sufficiently safe and supportive so that these tensions may be openly expressed; (2) there must be sufficient engagement and honest feedback to permit effective reality testing.

Over many years of clinical work, I have made it a practice to interview clients after they have completed group therapy. I always inquire about some critical incident, a turning point, or the most helpful single event in therapy. Although “critical incident” is not synonymous with therapeutic factor, the two are not unrelated, and much may be learned from an examination of single important events. My clients almost invariably cite an incident that is highly laden emotionally and involves some other group member, rarely the therapist.

The most common type of incident my clients report (as did clients described by Frank and Ascher)
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involves a sudden expression of strong dislike or anger toward another member. In each instance, communication was maintained, the storm was weathered, and the client experienced a sense of liberation from inner restraints as well as an enhanced ability to explore more deeply his or her interpersonal relationships.

The important characteristics of such critical incidents were:

1. The client expressed strong negative affect.

2. This expression was a unique or novel experience for the client.

3. The client had always dreaded the expression of anger. Yet no catastrophe ensued: no one left or died; the roof did not collapse.

4. Reality testing ensued. The client realized either that the anger expressed was inappropriate in intensity or direction or that prior avoidance of affect expression had been irrational. The client may or may not have gained some insight, that is, learned the reasons accounting either for the inappropriate affect or for the prior avoidance of affect experience or expression.

5. The client was enabled to interact more freely and to explore interpersonal relationships more deeply.

Thus, when I see two group members in conflict with one another, I believe there is an excellent chance that they will be particularly important to one another in the course of therapy. In fact, if the conflict is particularly uncomfortable, I may attempt to ameliorate some of the discomfort by expressing that hunch aloud.

The second most common type of critical incident my clients describe also involves strong affect—but, in these instances, positive affect. For example, a schizoid client described an incident in which he ran after and comforted a distressed group member who had bolted from the room; later he spoke of how profoundly he was affected by learning that he could care for and help someone else. Others spoke of discovering their aliveness or of feeling in touch with themselves. These incidents had in common the following characteristics:

1. The client expressed strong positive affect—an unusual occurrence.

2. The feared catastrophe did not occur—derision, rejection, engulfment, the destruction of others.

3. The client discovered a previously unknown part of the self and thus was enabled to relate to others in a new fashion.

The third most common category of critical incident is similar to the second. Clients recall an incident, usually involving self-disclosure, that plunged them into greater involvement with the group. For example, a previously withdrawn, reticent man who had missed a couple of meetings disclosed to the group how desperately he wanted to hear the group members say that they had missed him during his absence. Others, too, in one fashion or another, openly asked the group for help.

To summarize, the corrective emotional experience in group therapy has several components:

1. A strong expression of emotion, which is interpersonally directed and constitutes a risk taken by the client.

2. A group supportive enough to permit this risk taking.

3. Reality testing, which allows the individual to examine the incident with the aid of consensual validation from the other members.

4. A recognition of the inappropriateness of certain interpersonal feelings and behavior or of the inappropriateness of avoiding certain interpersonal behavior.

5. The ultimate facilitation of the individual’s ability to interact with others more deeply and honestly.

Therapy is an emotional
and
a corrective experience. This dual nature of the therapeutic process is of elemental significance, and I will return to it again and again in this text. We must experience something strongly; but we must also, through our faculty of reason, understand the implications of that emotional experience.† Over time, the client’s deeply held beliefs will change—and these changes will be reinforced if the client’s new interpersonal behaviors evoke constructive interpersonal responses. Even subtle interpersonal shifts can reflect a profound change and need to be acknowledged and reinforced by the therapist and group members.

Barbara, a depressed young woman, vividly described her isolation and alienation to the group and then turned to Alice, who had been silent. Barbara and Alice had often sparred because Barbara would accuse Alice of ignoring and rejecting her. In this meeting, however, Barbara used a more gentle tone and asked Alice about the meaning of her silence. Alice responded that she was listening carefully and thinking about how much they had in common. She then added that Barbara’s more gentle inquiry allowed her to give voice to her thoughts rather than defend herself against the charge of not caring, a sequence that had ended badly for them both in earlier sessions. The seemingly small but vitally important shift in Barbara’s capacity to approach Alice empathically created an opportunity for repair rather than repetition.

This formulation has direct relevance to a key concept of group therapy, the here-and-now, which I will discuss in depth in chapter 6. Here I will state only this basic premise:
When the therapy group focuses on the here-and-now, it increases in power and effectiveness.

But if the here-and-now focus (that is, a focus on what is happening in this room in the immediate present) is to be therapeutic, it must have two components: the group members must experience one another with as much spontaneity and honesty as possible, and they must also reflect back on that experience. This reflecting back, this
self-reflective loop,
is crucial if an emotional experience is to be transformed into a therapeutic one. As we shall see in the discussion of the therapist’s tasks in chapter 5, most groups have little difficulty in entering the emotional stream of the here-and-now; but generally it is the therapist’s job to keep directing the group toward the self-reflective aspect of that process.