GROUP THERAPY WITH ADULTS* JAMES MA”, M.D.

Director, Briggs Clinic, Boston State Hospital, Boston, Massachusetts

ERE is a mounting interest in group psychotherapy as an addition T to the means available for helping people in distress. Such interest inevitably has the salutary effect of forcing us to examine more and more critically what we are doing, how we are doing it, and what we expect to achieve. I have had no experience with groups constituted exclusively for mothers. However, I shall draw upon my experience with groups of varied composition, ranging from the psychotic to the normal; male, female, and mixed in sex. It is my feeling that the special composition of a group does not alter, in any way, the basic group processes that occur although, in some instances, homogeneity, whether it be with regard to sex, diagnosis or problem, may serve to ameliorate certain tensions but will not wholly re- move them.

Clarification of the term group therapy as i t is employed in this paper is in order since there are many varieties of group therapy. In this paper, all references are to psychoanalytic group therapy. By this is meant that the analytic technique of gaining access to both conscious and unconscious men- tal mechanisms and productions, and the analytical understanding of them, are the critical tools employed. An analytically oriented group, therefore, is not simply a discussion group, and it is never a didactic exercise. An analyt- ically oriented group therapy revolves about the basic understanding that in all groups the prerequisite for mature individual satisfaction and group attainment of a goal lies in the ability of each member to establish a suffi- ciently gratifying relationship with the group leader and through that leader, with all other members of the group. The use of analytic principles by the leader best serves to preserve his role as the medium through which the group can move to its goal most constructively.

In actual practice, one sees a good deal of confusion with regard to the differences between group therapy and individual therapy. Supervision of group therapists reveals that they are often doing individual psychotherapy in a group. This happens particularly when the therapist loses sight of the nature of intragroup relationships. Individual therapy is a one-to-one situa- tion in which the therapist’s attention is devoted exclusively to the one pa- tient while the patient’s primary concern is his relationship with the thera- pist. The therapist explores the nature of the patient’s feelings to the thera- pist as well as to other important figures in the life of the patient. In the group, a multiple situation exists in which the therapist’s attention is now

Presented at the 1952 Annual Meeting.

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directed to all patients or group members while the group members are con- cerned not only with their relationship to the leader but also to each and every member of the group. A variety of pressures now exists. The group therapist explores the nature of the members' feelings to each other as well as to himself. The situation, then, is one much more diffuse than that in in- dividual therapy, and most important, it is one in which no single member can become the chief focus of the leader's attention without threatening the integrity of the group. In every group there will be found someone who seeks personal attention from the leader and, too often, the leader succumbs to this demand. It can be avoided so long as the group leader is aware that the attention seeker is responding to conflicts stimulated by being in a group and that all other members of the group must have special feelings and reac- tions to this kind of rivalrous situation. The group leader must treat what goes on before him as manifestations of group reaction and not as the reac- tion of one individual to one other individual whether the other be the leader or another group member.

From this, I would like to propose a working definition of group therapy for your consideration: Group therapy is a method of psychotherapy in which the emotional reactions of members of the group to each other and to the leader are understood as being reflections of interpersonal conflicts of the individuals comprising the group. The collection of individuals into a group provides a setting in which these conflicts are intensified and even exag- gerated because of the number and variety of pressures exerted by the pres- ence of a group of people. The leader of the group exploits the setting and the emotional reactions for the direct general benefit of the group as a whole, indirectly for the individual members of the group.

We may be able to examine this definition more closely by a consideration of the goals of group therapy. In terms of group processes, the immediate reasons for bringing a group together for group therapy must be relegated to a secondary position. In other words, whether the aim of the group is to help mothers with the problems of their children, or to help obese people become thin, or to help neurotic or psychotic patients with their intimate conflicts, or to help prospective group therapists learn group therapy-all these are secondary to the goal of helping each member see the nature of his relationships to all other members of the group and to the leader. Each mem- ber is to learn how he feels toward everyone else present, how he reacts to them, and why he feels and does so. The primary goal then becomes the at- tainment of group unity for purposes of mutual exploration, analysis, and synthesis. This kind of group unity can be achieved only with the active management of conscious and preconscious emotional reactions within the group. Ideally, the leader should be prepared to manage unconscious emo- tional reactions as well. It is only after the intragroup tensions have been

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resolved that the manifest reasons for organizing the group can be tackled. On the other hand, a good deal of this latter work is already in process since the conflicts with which the members enter the group operate to prevent group unity and therefore operate to prevent achievement of the very goal which the leader and group have already decided upon. For example, a mother may, in all earnestness, enter a group dealing with the problems of children. She is prepared for wholehearted cooperation on her part. Before she can participate, someone else in the group dominates conversation. The mother feels annoyed and begins to react to the other member with the goal now of winning out over that one while her original well-meant purpose is completely forgotten. Now, multiply this reaction, since the group may have anywhere from three to fifteen people, and one may see how the original con- scious purpose can be easily cast aside.

In speaking of goals decided upon by group and leader, we are led to a dis- cussion of the working agreement that must be decided upon in the first meeting. In brief, the working agreement settles the questions of what will be expected of the group and of the leader. In addition, other details such as frequency, duration and place of meetings, regularity of attendance, and re- cording of meetings should be dealt with. Of importance, too, is the agree- ment on confidentiality of what goes on in the meetings. What is expected of the group is essentially for the group to determine what use it wishes to make of the meetings, i.e., what goal or goals are anticipated. On the part of the leader, he will expect the group to speak as freely as possible and yet to reveal of themselves only what they would feel comfortable in revealing. For himself, he makes i t clear that he will observe, listen, record mentally, and clarify what he feels seems to be going on at a given moment. He will not lecture nor make it a practice to answer questions nor be judgmental. There is much more to be said with regard to the intricacies of the working agreement and to the reasoning that enters into each point of the agreement. It is not my intent to enter into such details in this paper.

However, as we examine more closely the question of goals in group therapy, then i t becomes apparent that the process of establishing group unity, to the end that the originally stated goals may be reached, is one of constant analysis by the group leader of deviations from the working agree- ment by the group. The example already given of the mother who runs into a dominating group member and responds to that member can now be fur- ther seen as an example of deviation from the working agreement.

Some therapists have had the experience of seeing group unity attained without going through the process noted above. There is a kind of group unity that results from regular proximity along with the sharing of mutual problems. In my experience, however, this unity is deceptive in that each member has managed to hide his special feelings with regard to the group

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members and to the leader; he has usually done so under group pressure and the fear of opposing the group. The result is that original goals may be dis- cussed, but only with many private reservations which often take prece- dence once the group is ended, or between group meetings.

The intragroup reactions that militate against group cohesion and achieve- ment of the group goal are reactions that each member brings from his own individual sphere of interpersonal conflict in his life apart from the group. Thus, one member may experience immediate antagonism to the leader, a figure of authority; another may form a bond with a younger, helpless- looking member. Whatever the case, the feelings of each member and his defenses against anxiety are not newly created in the group. As in any psy- chotherapy, negative or group disruptive feelings cut out most of the leader's work.

We have found it convenient to divide the active group process into four stages. None of these stages stand apart from the others since each appears and reappears time and again. The first stage is a working through of hos- tility; the second, a working through of the anxieties activated by the close- ness of group relationships; the third is one of personal mutual analysis; and the fourth, one of personal mutual synthesis. As the group makes progress, the latter two stages predominate so that the stage of synthesis has minimal hostility. I t could not be otherwise. I t is in the stages of working through hostility and the anxieties activated by closeness that the success of the group hangs in the balance. Group hostility may be expressed first toward the leader or it may be expressed among the members toward each other be- fore turning upon the leader, or both may occur simultaneously. Where hostility is absent, then either the group has quickly erected a special de- fense against it (very often, polite conversation) or the leader is permitting himself to be blind to it. I t would seem that in group therapy we have a laboratory demonstration of the disruptive forces operating to prevent use- ful work. The disruptive forces are the hostilities among the group members. At some points there appear to be much less incentive toward unity and much more incentive toward successful hostile fragmentation. In some groups, the hostility is so subtle as to make itself known only in unconscious gestures and associations. However it may appear, it must be ferreted out, brought into the open, examined, and necessary clarification made as to its sources and connections within the group. In this regard, it is often felt that the exposure and clarification of intragroup hostilities should not be per- mitted to develop into extensive personal confessions since this may create more anxiety than can be handled without losing some or all of the group. The awareness of the hostile feelings of one to the other in the group serves to bind the group now on the basis of mutuality of feelings rather than only on the basis of mutuality of problems or goals. An illustration may help:

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A group of psychiatric residents who voluntarily submitted themselves to group therapy soon began to attack the group leader. As their attitudes toward the leader were clarified they began to attack each other. All of the rankling antagonisms that they had hidden from each other in their daily contacts on the wards came to light. The leader observed their reactions to each other, recorded them mentally, and then made judicious interpreta- tions. Soon it became apparent that rivalry with each other for recognition with the leader, who, in turn, represented the director of resident training, was the source of the antagonisms. When they were confronted with this mutual awareness of feelings, constructive energy could be mobilized in re- solving the bitter antagonisms while leaving intact healthy competition as good psychiatrists.

To emphasize the point, progress in a group seems to be proportional to its success in resolving intragroup hostilities. These are the hostilities brought into every group, consciously or otherwise, from the realm of the personal conflicts of each member. Hostility and anxiety experienced as the result of closeness in the group are closely related, and working out one always in- volves the other. To recognize these first two stages is the responsibility of the leader. Failure to do so may often result in the degeneration of the group into a glib discussion group wherein no one has any intention of making any changes for himself.

How shall the group leader operate in this tremendous exchange of emo- tional reaction? Group processes evolve with the leader as the primary source of stimulus for progressive change. Not to forget, too, that he may serve as a stimulus for regressive change. I t is necessary for the group members to be the active participants rather than for the leader to take the lead. The more actively the leader participates, the more thoroughly do group reaction and interaction diminish. Too much inactivity by the leader, however, would also render the group process impossible. The delicate in-between position of activity is assumed by the leader in clarifying the presenting is- sues and emotional trends of the group. As a clarifier of feelings, the leader promulgates no judgments, issues no final decisions, and does not permit himself or the group to find and keep a scapegoat for hostility within the group. The leader seeks to prevent any situation from arising which will prevent the group from working through to understunding the nature of the hostility involved. The further aim of the leader is to work through to understanding the current emotional problems of the group. As more and more of the inappropriate emotional reactions are subjected to scrutiny, the use of positive attitudes for constructive work begins to take precedence. Positive group transference to the leader is essential for growth and this transference is made possible not only by the constant examination of nega- tive attitudes and feelings, but also by the special character of the role that

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the leader assumes. The group leader will be the only member present who will maintain at all times a neutral yet helpful collaborative position. Around him emotional storms will batter, and through him solution and relief may result. He cannot himself participate in the storms and remain helpful to the group. In this connection, the chief contribution of the group leader rests in the maturity of his personality.

Perhaps I have made the role of the group leader sound inordinately diffi- cult. I believe it is that difficult. I t is the price attached to doing good group therapy. Experience in individual therapy does not make o’ne a group therapist automatically. Neither can a host of good intentions, sincerity of purpose, or stubborn tenacity accomplish that end. To be a group therapist takes training, guidance and experience. Participation as a “patient” in a group of prospective therapists is an excellent means of learning both sides of the problem, i.e., the emotional reactions one endures in a group and the role of the leader. Concurrently, the dynamics of group processes become more vivid. Supervision and consultation with an experienced group thera- pist should also be available. Lastly, there is the need for mature group leaders. The term mature would include an understanding by the leader of the nature of his own unconscious responses and of his ways of dealing with people. The emotional demands on the therapist are very heavy and the most desirable kind of training for a group leader should probably include a personal analysis.

In conclusion, it may appear to you that in a paper supposedly covering general observations, too much emphasis has been placed on one special facet, intragroup hostility. The intention was deliberate since it is my thesis that the success or failure of a group hangs on the degree to which intragroup hostility, both conscious and unconscious, is resolved.

SUMMARY This paper attempts to clarify the interpersonal processes occurring as

part and parcel of group therapy. A definition of group therapy is offered to serve as a basis for understanding the roles of the group members and of the leader in a setting of analytically oriented group therapy. The goals of group therapy are regarded as terminating in crystallization of group unity which can then be used productively in mutual solutions of problems. The role of the group leader and the understanding of his task are critical in this proc ess. Group unity cannot be achieved without knowledge of the intragroup reactions that sabotage unity. Essentially, this means the successful anal- ysis of intragroup hostilities by leader and group. The complexities of group therapy and the intensity of the emotional processes are such as to suggest certain preparatory requirements of a group leader.