GROUP PSYCHOTHERAPY

Human beings are social animals. We are born and raised in a group (the family), are socialized in groups (day care, schools, sports teams, faith communities, social media, friendship networks) and spend our lives working in groups (career groups, professional organizations). The initial experience of our primary family group often contributes to the development of thinking, feeling and behavior habits that in later life can prevent the individual from fully realizing their potential and in creating meaningful, intimate relationships. This can lead to difficulties negotiating satisfying relationships throughout our lives in all the various groups we live in whether it is managing difficult work place politics, establishing a supportive friendship network or making our romantic partnerships and marriages truly nourishing and growth sustaining.

Group Psychotherapy is one of the most powerful ways to help people increase their insight and awareness about their interpersonal behavior and to help them create the kind of change needed to more fully get their needs met.

Irvin Yalom has been a leading advocate, practitioner, researcher and educator on group therapy. His book “The Theory and Practice of Group Psychotherapy” is in its fifth edition and has been used as a primary source for teaching the art of group since it’s first release in 1970. In it, he outlines 11 therapeutic factors found within the experience of group therapy. I would like to offer a brief overview of his first 6 factors as a way of explaining how group works to help people heal and grow.

Instillation of Hope

Whether clients are excited about the opportunity to grow or on their last leg of hope, it is a crucial part of the therapist’s job to instill faith that the therapeutic process can help them. In group the therapist can rely on the aide of fellow group members to further instill and nurture a growing sense of hope and optimism that change is possible. Older group members can role model hope through their willingness to struggle with their own issues as well as having worked through similar issues that have just brought new members to the group. In two different groups for LGBT young people, one in the Midwest and another in New York City, I have witnessed scared and confused youth who are struggling with issues of sexual orientation or gender identity find solace in other young people who have successfully negotiated the coming out process.

Universality

Almost without exception, clients come to therapy with some fear that they alone face certain issues that make them feel uniquely broken and hopeless. In individual work, therapists can sometimes struggle in vain to help a client understand that they are not alone. Group can provide powerful help in the establishment of a sense of universality, or what Yalom calls a sort of “welcome to the human race” experience. I lead a psychotherapy group for 5 couples all experiencing difficulty working through conflict in their relationships.

In our culture, we are all, to some degree, under the influence of the rather pernicious myth that “perfect love” leads to being a ”happy loving couple.” Pervasive throughout television and film is the romantic notion that finding your “soul mate” leads to a life together without conflict. Countless couples I have seen alone in marital therapy have expressed shame and dismay at the amount of conflict they must work through and fear that this means they are not “right for each other.” One recent couple even expressed pride in never having had an argument, only to find them selves now engaged in a conspiracy of silence. Over the years they had avoided conflict and brick by brick thereby built a wall between each other. They wonder where their love has gone.

Couples group therapy confounds these destructive myths by showing the members not only that all couples experience conflict, but also that engaging in healthy conflict can build real muscle in their love affair. Member couples demonstrate to each other that engaging in healthy, problem solving oriented conflict can help them build greater intimacy and a sense of well-being. Marriage and family therapy research has consistently shown that learning the necessary skills to argue toward win-win solutions leads to a greater sense of safety in their relationships and a stronger sense of security in life in general.

Imparting information

Whether through didactic instruction by the therapist or through direct advice shared between members, the imparting of helpful and healing information occurs in every type of group psychotherapy. Over the years I have run a variety of groups for people struggling with persistent mental illness. In each case, providing the members with accurate information about the nature and treatment of their disorders helps them to better understand and cope with their illnesses. Additionally, group members’ role model for each other various day-to-day ways to cope with their conditions.

Altruism

Yalom points out that the act of giving to others has intrinsic value in and of itself for group members. Clients often have the experience of being “stuck” and ineffective in dealing with their own issues. Like sinking in a tar pit, the more they obsess on their own “stuckedness,” the deeper they sink into a hopeless sense of self-absorption. Finding that they can be instrumental in helping others successfully deal with issues boosts their own self-esteem. It takes them out of their heads and allows them to feel effective. And this new sense of self-efficacy empowers them anew to address their own problems.

I had a client whose wife divorced him due to his abusive, chronic anger. He came to therapy bitter and even more depressed. The world to him was a dark place and he found my attempts to instill hope Pollyannaish and absurdly optimistic. When I placed him in a mixed adult group, he was immediately labeled “the angry guy.” Over time, however, members began to see him as an intelligent problem solver and, ironically enough, very empathic towards others. His advice always came from a place of personal experience. For example, he would say, “I know how you feel John, when I would take my anger out on my wife, it never made me feel good, only more powerless.” As he took in how others positively viewed him, he not only started to take more responsibility for his anger, his world-view gradually started to brighten. Being of use to other group members allowed him to connect more intimately with them. And the more he started to care about others, the more he started to care about himself.

The Corrective Recapitulation of the Primary Family Group

The concept of transference is a long honored one in psychodynamic psychotherapy. It occurs when we experience the therapist as we once experienced one or both of our parents. Our earliest child-parent relationships are so deeply ingrained that we go through life recreating them with our friends, romantic partners and work place colleagues. Early relationship dysfunction therefore can cause us difficulties in our here-and-now interpersonal relationships. Yalom’s “Corrective Recapitulation of the Primary Family Group” is transference writ large. Instead of having a one-on-one transference with a therapist, in group therapy we may interact with therapist and the group members as we may have interacted with our family, parents and siblings. This gives us a chance to become aware of these ingrained interpersonal patterns and a “new” family willing to help us work through old family baggage and develop more adaptive and healthy relationship skills.

When I was a Graduate student studying to become a psychotherapist, I myself entered a mixed adult therapy group for professional training and my own personal growth. I grew up with an angry, overly critical father who constantly loomed over me in a threatening way. I can remember that this oppressive relationship seemed so unfair! I was not allowed to express my anger at him directly, as that would merely incur his wrath. So instead, I developed a passive-aggressive pattern of dealing with my anger and a fear of my own bottled up rage. My mother and brother, being equally cowed by my father, were unable to come to my defense and so seemed at times to side with my father. When I entered the therapy group I had no idea that I would soon come face-to-face with this early family dynamic.

As is standard in most groups, the weekly fee was prefixed. One is expected to pay for their spot whether or not they could attend every session. It was this classic financial boundary that triggered my family transference when I had to miss two sessions in order to attend a conference out of town. That old sense of unfairness riled me, as the male group leader appropriately would not budge on our fee agreement. The old rage I had for my father boiled inside me at my new oppressor! I remember sitting in group furious but terrified. On one hand I was pissed that the fee I agreed to now seemed so unfair, but I also had a powerful sense that this group leader could really help me. If I expressed the rage I risked incurring his wrath, being punished and never getting to work through this enduring pattern. I felt hopelessly stuck between my old baggage and taking what seemed like a huge risk.

I announced at the start of the next group that I had something to say to the leader. Now I had done it. I was stuck. Now I had to say something. The group stared at me in silence, waiting for me to speak and appearing to me as useless as my mother and brother once seemed. The leader sat expressionless looking at me, but I could not speak. Even though the rage grew inside me, it was like I was encaged in a psychic membrane through which I could not emerge. The pressure of the moment grew as I steeled myself, psychically clawing through the membrane until suddenly I screamed “FUUUUUUCK YOOOOOU!” at the leader. Silence. More Silence. I was now deeply self-conscious and embarrassed. I literally cannot remember what the leader said, if anything. But I do remember he did not punish me. He could take my rage and still care about me. Anger did not kill love! And then the other members that had seemed so useless mere moments before actively congratulated me. One member who reminded me of my brother and whom I had great fondness for said, “that was the best “fuck you” we have heard in a long time.” Others said they didn’t know if they could have been so strong. My embarrassment vanished, replaced with pride. I could breath again.

This was not the end of my work in group, but it was the beginning of my efforts to break out of my passive-aggressive pattern. In time, I learned how to directly and appropriately express anger at the people closest to me in my life. My relationships in and outside of the group deepened.

Development of Socializing Techniques

Most clients come to therapy with unconscious social habits that work to undercut or even sabotage their interpersonal relationships. Others merely have gaps in their social skills set that leave them unprepared to deal with specific life and relational situations. These social habits or skill deficits often do not come fully alive in individual therapy, but place a client in a group and suddenly they are on full display. A client may even make tremendous progress in individual therapy, but once joining a group exhibit a lack of assertiveness, an inability to effectively resolve conflict, poor active listening skills, or a lack of an empathic understanding of others. Group therapy can offer clients a safe space to gain awareness of their relational difficulties through feedback from others and an opportunity to learn and practice new, more adaptive social skills.

A woman in one of my mixed groups, and a psychotherapist herself, came to therapy to understand why she was unable to meet men who would really care about her. She demonstrated great skill at empathic listening and provided useful feedback to others. However, she never seemed to make any headway on her own issue. One session a male member remarked that he didn’t think of her as an actual group member, but as just a “nice lady here to assist the group.” This feedback stirred up long buried resentment in the woman. It created a new awareness that she was over-identified with being a good helper to the detriment of getting her own needs met. Further exploration revealed that, as the eldest child of seven, she was expected by her mother to take a parenting role towards her younger siblings and her own autonomous strivings were punished.

With the group as her experimental laboratory, she gradually learned and practiced new assertiveness skills. She demonstrated this by feeling free to ask the group for what she needed and by engaging in conflict with other members when they upset her. In time the group came to see her as a more fully fleshed out human being. They were surprised as her extraordinary, even edgy sense of humor began to emerge. One day a male member remarked that he found her very sexy! It was not long after that she met a man who she eventually married. She realized that by being a constant caretaker in the past, she only attracted needy men. Now she was able to meet a man who could be a full partner to her in a mutually satisfying relationship.

In Conclusion

Interpersonal group psychotherapy is widely recognized as a powerful modality for therapeutic change. Over the 30 years of my psychotherapy practice, I have found it to be extraordinarily useful to my clients. Group can also work even more effectively as an adjunct to individual therapy. Individual work can feel safe for some clients, but group often reveals issues that remain hidden in individual work. By observing clients interpersonal behavior in group, we both discover new issues to deal with in individual sessions. Clients may then process their group experiences in one-on-one with me, and then return to group ready to try a new social skill or engage another group member in a new, more effective way.