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Difficult Topics in Group Psychotherapy

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This book contains eleven selected papers on difficult topics group therapists encounter in their work. Based on the author's forty years in the field, these papers include the topics of shame, courage, hostility, combined individual and group therapy, money, indirect communication, difficult patients, silence, and the missed session. Written from a psychodynamic orientation with a relational emphasis, they pay special attention to countertransference. An autobiographical introduction to each paper discusses what experiences have led the author to write on each topic. These introductions honor the role that personal experience has played in the evolution of Dr Gan's therapeutic presence.

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Chapter One: Shame

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While I mentioned shame in several of my early papers, I did not write exclusively about it until much later in my career. Looking back, I realized I would hear shame discussed in a lecture or case conference and then focus on it in my psychotherapy practice. However, my focus on this emotion would be short-lived. It took a few personal experiences to drive home the vital importance of this feeling. The first personal experience that I recall, which occurred in my twenties, took me 15 years to process and had a profound effect on my clinical practice. I had just graduated from college, and wanted to go to medical school, but having majored in English Literature, I had taken only three science courses. I elected to take an extra year as a special student during which time I took quantitative and qualitative analysis, calculus, physics, and genetics. In the genetics course we, of course, studied the fruit fly. Here, I thought, was a wonderful opportunity to share with my then 65 year-old father—who had a fifth grade education and worked as a middleman in the fruit business—something that I was learning to which he could relate. My education had always been tinged with sadness, as the more I learned the further I felt from my uneducated parents. Here was a tiny opportunity to bridge the chasm. I brought my father to the genetics laboratory, sat him down, and showed him how to use the microscope under which was the slide I had prepared of a fruit fly. My father looked into the microscope—God only knows what he actually saw—and proclaimed with some disdain, “That is no fruit fly.” I felt hurt, unappreciated and impotent with rage.

 

Chapter Two: Hostility

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Somebody once said that the brain starts thinking at the moment of birth and stops functioning at the first opportunity for public speaking. A similar statement can be made about hostility: When faced with it, the group leader often stops thinking. A sudden, unexpected outburst of hostility is the psychological equivalent of a cardiac arrest; if one is not familiar with ways of handling it before it occurs, creative thinking is unlikely to take place on the spot.

Hostility results from unprocessed anger that goes underground where it festers and then gets directed at other people. It is an emotion that is difficult for most people to deal with effectively. There are several reasons why anger, a momentary reaction to a given stimulus, remains unexpressed. The person feeling anger may decide, with sufficient cause, that trying to process the hurt or disappointment with those involved is not a wise idea, that doing so will only result in further hurt. It might be that the other person, perhaps a parent, has a chronic disease; the child unconsciously wishes/fears that expressing anger will kill the parent. It may be a spouse who, through limitations of his/her own, is either unable or unwilling to take responsibility for his/her part in an upsetting situation. It may be unreasonable but powerful grievances from childhood that stand in the way of family members ever resolving accusations that continue to tear at the fabric of the family. Whatever the reasons, however, unexpressed anger goes underground and turns into simmering resentment that emerges as hostility.

 

Chapter Three: Broaching the subject of group therapy

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A few years ago, in my role as Co-Chair of the Annual Meeting of the American Group Psychotherapy Association (AGPA), I had a seemingly straightforward interaction with a member who had applied to and been accepted to present a workshop at the meeting. I say “seemingly” because the interaction was anything but simple. Three weeks before the Annual Meeting, she called to tell me that she was unable to present her workshop because she had just returned from a four-day hospital stay after suffering a heart attack. What was noteworthy about the phone conversation was how apologetic she was for not being able to keep her commitment. Her reaction seemed extreme in the moment; in retrospect, I can identify with many elements of her response—or were they my projections onto her response?

She felt extremely guilty about not being able to keep her commitment and took pains to explain that in the previous 20 years she had never missed a meeting and had never reneged on a commitment to present. Her contrition appeared to have many components, some of them probably unconscious. Although her workshop was on countertransference, a topic for which I could easily find a willing and worthy replacement, the degree of her despondency felt remarkable. She seemed unable in the moment to appreciate that while she was a very competent clinician, she was also replaceable. She was also unable to keep in perspective her caring about the Annual Meeting and her taking care of herself. At some level she felt very guilty that in taking care of herself she was neglecting her duty as a presenter and failing the organization. She seemed ashamed of her inability to keep her commitment. She stated that she hoped her decision would not be held against her in years to come when she again applied to lead an institute or present a workshop. The idea seemed to be that we would think less of her—and apparently want nothing more to do with her— for her decision to take good care of herself. Apparently it never occurred to her that AGPA could better plan for her replacement with advanced notice, or that the advanced notice she was providing would facilitate conference planning. She could not, in other words, envision that something that would be good for her would also be good for AGPA.

 

Chapter Four: Money

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It is not surprising that there are so many jokes and cartoons about money and therapy given the delicate and uncomfortable nature of the topic. In one cartoon, her husband’s surgeon, still in his operating gown, approaches an anxious spouse in the waiting room. Clearly the news he has to deliver is not good. The surgeon says, “His last wish was that all his bills be paid on time.”

Then there is the joke about Mr. Jones, a man with a rare eye disease who consults a famous ophthalmologist. It turns out to be the best of all possible worlds for the patient as Dr. Smith correctly diagnoses and successful treats Mr. Jones’s rare disorder. Dr. Smith successively tells Mr. Jones his bill will be $600, $400, $200 and then $100 only to find out that Mr. Jones has no money. Pulling himself up in his chair, Dr. Smith asks his patient, “Where do you get off coming to a world famous ophthalmologist when you have no money?” Mr. Jones replies, “When it is a matter of my health, money is of no concern!” The caretaker’s self interest and the patient who is a big spender with other people’s money are just two of the many issues that come up in group psychotherapy.

 

Chapter Five: Indirect communication

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During the second year of my psychiatric residency, a supervisor, observing one of my psychotherapy sessions with a paranoid patient, commented on what he considered my lack of eye contact with the patient. Such supervisory comments, especially early in one’s training, can have a chilling effect on self-confidence and independent thinking. In retrospect, my training would have been better served by supervisory curiosity: “Dr. Gans, I noticed that you limited your eye contact with your patient. Do you have any thoughts about why?”

Years later, while reading Leston Haven’s book (1976) Participant Observation, which dealt with Harry Stack Sullivan’s ideas and technique, especially an approach employing counterprojec-tion, I was excited to encounter creative thinking about eye contact. Havens developed the idea that projection follows attention and that attention is often secured through eye contact. He described how in clinical encounters with certain patients or in particular situ-ations—a paranoid patient or a strongly negative transference—it is counterproductive or even destructive to the therapy to encourage the patient to look at the therapist. Since people tend to believe their projections, encouraging eye contact can result in patients believing that their own hostility actually resides in the therapist, a development that only serves to exacerbate an already tenuous therapeutic alliance. Could it be that my revered supervisor’s comments were not only unhelpful but also incorrect to boot!

 

Chapter Six: Difficult patients

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Early in my training, despite some attention to counter-transference, there was a tendency to see the patient in objective terms. The pathology resided “out there” in the patient, and my job was to work on it. My seeming objectivity, without my being aware of it, provided me protection from the patient’s pathology and defended against the possibility of contagion. I resided in the illusory, protective bubble of my sterile objectivity. To give this approach some credit, there are patients from whom we do need some protection. Patients with malignant narcissism or an overpowering need for Oedipal victory devote impressive amounts of energy to destroying the therapeutic enterprise rather than to working with and benefiting from it. Even in the best of clinical hands, it may not be possible to stop or even to limit such intent. Paradoxically, trying hard to reverse the destruc-tiveness of such “difficult patients” often serves only to encourage it. As someone once noted: “Never wrestle with a pig; you just get full of mud and, furthermore, the pig loves it.”

 

Chapter Seven: Silence

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A grounding in the basic tenets of psychodynamic psychotherapy equips the therapist to deal in depth with a wide range of emotional difficulties. The importance of the therapeutic alliance, ability to work in the transference, using countertransference for therapeutic purposes, detecting and interpreting enactments, and containing and metabolizing projective identifications are some of the skills involved. Like any teaching, however, when adhered to inflexibly, the concepts can impede the therapy and, sometimes, even do damage to the patient.

Therapists trained in the psychodynamic model, in the main, follow patients’ productions rather than elicit them with questions. Thus, I explain to new patients that I usually do not begin sessions by speaking first in order to insure that what we talk about is what is on the patient’s mind, not what I imagine is on the patient’s mind. Since many of us believe in the superiority of in-depth therapy to more behaviorally oriented or exclusively supportive therapies, we tend not to rely on their methods, even though such methods may help a particular patient at a given phase of the therapy. The following example illustrates a mistake I made regarding the approach to silence in the therapeutic hour.

 

Chapter Eight: The missed session

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As psychiatric residents, we ran our first therapy group in the second year of residency training. Halfway through the first year of running my own group, I was confronted with a situation for which I was totally unprepared. I arrived, as usual, five minutes early to set up the chairs and did not find it unusual that none of my group members were yet present. Nor did it seem totally strange when at the 5:00 P.M. start time none of the six members of my group of chronically ill patients had arrived. When, however, 15, 30 and then 45 minutes later, still no group member had arrived, I was flooded with a wide range of feelings: annoyance, concern, frustration, abandonment, self-doubt, powerlessness, and shame. I also began to have fantasies of retaliation that alternated with wondering just how long I should continue to sit there. Perhaps I should just leave, as in, “The hell with them; why should I be interested in them if they are not interested in me and our group?”

This line of thinking in turn stimulated the positive side of my powerful superego: to be a good therapist I had to stay the full one and one-half hours that the group met. I tried to picture all the group members in my mind and began to conduct a fantasized version of the group proceedings had all the members been present. I kept track of my countertransference feelings. I medicated my feelings of worthlessness by imagining that my supervisor would be totally impressed with my creative efforts.

 

Chapter Nine: Courage

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Change and growth in a psychotherapy group depend on the willingness of its members and leader to display courage from time to time. How do I know this? Where did this knowledge come from?

One morning, I descended the stairs to my home office after having had a very upsetting and disorienting fight with my wife. The fight resulted from the tremendous stress caused by having two adolescents at home, recent parental deaths, and financial constraints. Stretched to the limit and probably feeling unappreciated by one another, we managed to escalate a trivial misunderstanding into a hurtful argument. In this state of mind, I entered my office where all seven members of my Wednesday morning group were already assembled. I could hardly listen to the interchanges between members during the first 20 minutes of the group. I felt more disturbed than many of the group members I was there to help. I sensed tears welling up in my eyes, wondered if my distress would be perceived, and how I would handle the situation if it were commented upon.

 

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