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By Eleanor Counselman
Therapy in the Round
Q: I'd like to learn more about therapy groups. Can you explain their therapeutic value and what skills are required to run them that are different from those of an individual therapist?
A: After many years as a group therapist, the main distinction I see between individual and group work is that clients tend to talk about relationship problems in individual therapy, whereas they inevitably exhibit them in group therapy. In a group context, a therapist can more easily and directly see what goes wrong interpersonally for a given client. In the presence of others, clients may exhibit isolating patterns, become self-protective, or engage in off-putting behaviors, all too often without even being aware of them.
Dave was a pleasant young man who came to see me for depression and social isolation. He'd suffered several important losses—his wife divorced him and then he lost his job—and was stuck in a stressful family situation of caring for a chronically ill relative. Through individual treatment, he grieved for his losses, and his mood improved; however, he couldn't seem to develop social relationships, and he remained lonely. Friendships seemed to begin well, but never deepen. Neither he nor I was sure why, as he was bright and, when encouraged, a warm, forthcoming person.
After he joined a group that I lead, however, I began to understand what was holding him back. When other group members candidly shared their thoughts and feelings, he responded with agreeable, but entirely impersonal replies. He shifted the conversation away from any emotional engagement, making the others feel unheard and unacknowledged. For instance, he might respond to a member's painful story with "I bet things will work out in the end," or pick up on the least emotional aspect of a situation and inquire further about that.
When I shared this observation, using specific examples from group sessions, he was dumbfounded. His deflecting style was completely automatic behavior, developed years before to protect himself from intrusive and prying parents. But once he recognized it and acknowledged the old, lingering anxieties that he circumvented by not revealing anything about himself, he began to connect more directly with other group members and people outside the group.
Group therapy is a highly effective laboratory in which to practice new behavior and get honest feedback from others. The woman who consistently tells her individual therapist that she never gets her needs met in relationships may discover in group that she behaves in ways that inevitably make sure that others overlook her. The group members will let her know that if she doesn't speak up, she will be overlooked. Members will ask where she learned how to be overlooked, and will encourage her to take the risk of asking for attention. The "nice guy" who's always afraid of offending someone can express irritation with another group member and learn that the world hasn't ended, and that he's still accepted by the group.
In an effective therapy group, the majority of the work takes place in the room: although members talk about their lives "outside," the real action is the moment-by-moment back-and-forth among group members. The group leader's role is to help participants give constructive and honest feedback to each other—sometimes called the "hall of mirrors"—and avoid giving criticism or advice.
Because a well-run group offers a safe, contained space, it can help members try out new behaviors or ways of interacting that they wouldn't attempt elsewhere. A large part of the leader's role is to encourage members to try out new behaviors and responses. One group member, Susan, was the daughter of an unpredictable and intrusive mother. She'd learned to protect herself by always being in control, to the point that, in the group, she assigned herself the task of monitoring the process and drawing in silent members, as if she didn't trust me to be the group leader. In one session, I invited her to experiment with allowing herself to let me be the one in charge. After stepping back during the session, she reported that she was amazed at the level of anxiety she experienced, and the strength of her long-buried yearning to allow herself to depend on someone else. She later said that she felt safer letting me be in control in group than in an individual session, because of the perceived protection of the other "siblings."
In fact, although prospective members often imagine that the presence of the other members makes group therapy more anxiety-provoking, the opposite is often true. The group can actually support an individual member, especially when there's a conflict or another issue with the group leader.
I once made a mistake in tallying the bill of a meek, superego-burdened group member. Raised by harsh, perfectionist parents, she'd never before stood up to authority. But with the encouragement of her fellow group members, she was able to tell me that the mistake had made her mad, and that she doubted my competence as a result of my error. She wouldn't have dared stand up to me in a one-on-one session, but the group support gave her courage.
For group therapy to be effective, any new members should be up to the level of the group. A person who can't describe what he's feeling and experiences only body sensations won't do well with group members who are more fluent in speaking about their emotions, but this same person might do well among people who have difficulty articulating their feelings. The basic requirement of membership in a group is that the client must be able to uphold the particular group agreement or contract, which typically covers attendance requirements, payment, confidentiality, limits on outside contact with group members, termination procedures, and the role of the leader.