Excerpts from Must Read Books & Articles on Mental Health
Books, Part VIII
The Theory & Practice of Group Psychotherapy- Irvin Yalom
CHAPTER 2- Interpersonal Learning, pp. 17-46
THE IMPORTANCE OF INTERPERSONAL RELATIONSHIPS
From whatever perspective we study human society--whether we scan humanity's
broad evolutionary history or scrutinize the development of the single individual--we are
at all times obliged to consider the human being in the matrix of his or her interpersonal
relationships. There is convincing data from the study of primitive human cultures and
nonhuman primates that humans have always lived in groups that have been characterized by
intense and persistent relationships among members. Interpersonal behavior has clearly
been adaptive in an evolutionary sense: without deep, positive, reciprocal interpersonal
bonds, neither individual nor species survival would have been possible.
John Bowlby, from his studies of the early mother-child relationship,
concludes not only that attachment behavior is necessary for survival but that it is core,
intrinsic, genetically built in. If mother and infant are separated, both experience
marked anxiety concomitant with their search for the lost object. If the separation is
prolonged, the consequences for the infant will be profound. Goldschmidt, on the basis of
an exhaustive review of the ethnographic evidence, stated:
Man is by nature committed to social existence, and is therefore inevitably involved in
the dilemma between serving his own interests and recognizing those of the group to which
he belongs. Insofar as this dilemma can be resolved it is resolved by the fact that man's
self-interest can best be served through his commitment to his fellows.... Need for
positive affect means that each person craves response from his human environment. It may
be viewed as a hunger, not unlike that for food, but more generalized. Under
varying conditions it may be expressed as a desire for contact, for recognition and
acceptance, for approval, for esteem, or for mastery.... As we examine human behavior, we
find that persons not only universally live in social systems, which is to say they are
drawn together, but also universally act in such ways as to attain the approval of their
Similarly, a century ago the great American psychologist-philosopher, William James,
We are not only gregarious animals liking to be in sight of our fellows, but we have an
innate propensity to get ourselves noticed, and noticed favorably, by our kind. No more
fiendish punishment could be devised, were such a thing physically possible, than that one
should be turned loose in society and remain absolutely unnoticed by all the members
Indeed, James's speculations have been substantiated time and again
by contemporary research that documents the pain and the adverse consequences of
loneliness. There is, for example, persuasive evidence that the rate for virtually every
major cause of death is significantly higher for the lonely, the single, the divorced, and
All modern American schools of dynamic psychotherapy are
interpersonally based and draw heavily, though implicitly, from the American neo-Freudian
theorists Karen Horney, Erich Fromm, and, especially and most systematically, Harry Stack
Sullivan and his interpersonal theory of psychiatry.
Despite Sullivan's seminal importance, contemporary generations of
therapists rarely read him. For one thing, his language is often obscure (though there are
excellent renderings of his work into plain English); for another, his work has so
pervaded contemporary psychotherapeutic thought that his original writings seem overly
familiar or obvious. However, in the recent merging of cognitive and interpersonal
approaches in psychotherapy, there has been a resurgence of interest in his
Sullivan's formulations are exceedingly helpful for understanding the
group therapeutic process. Although a comprehensive discussion of his interpersonal theory
is beyond the scope of this book, I will describe a few key concepts here. Sullivan
contends that the personality is almost entirely the product of interaction with other
significant human beings. The need to be closely related to others is as basic as any
biological need and is, in the light of the prolonged period of helpless infancy, equally
necessary to survival. The developing child, in the quest for security, tends to
cultivate and to stress those traits and aspects of the self that meet with
approval, and will squelch or deny those that meet with disapproval. Eventually
the individual develops a concept of the self (self-dynamism) based on these
perceived appraisals of significant others.
"The self may be said to be made up of reflected appraisals. if
these were chiefly derogatory, as in the case of an unwanted child who was never loved, of
a child who has fallen into the hands of foster parents who have no real interest in him
as a child; as I say, if the self-dynamism is made up of experience which is chiefly
derogatory, it will facilitate hostile, disparaging appraisals of other people and it will
entertain disparaging and hostile appraisals of itself."
This process of constructing our self-regard on the basis of reflected
appraisals that have read in the ideas of important others continues, of course, through
the developmental cycle. In their study of adolescents, Grunebaum and Solomon have
stressed that satisfying peer relationships and self-esteem are inseparable concepts.
Sullivan used the term parataxic distortions to describe
individuals' proclivity to distort their perceptions of others. A parataxic distortion
occurs in an interpersonal situation when one person relates to another not on the
basis of the realistic attributes of the other but on the basis of a
personification existing chiefly in the former's own fantasy. Though parataxic
distortion is similar to the concept of transference, it differs in two important ways.
First, the scope is broader: it refers not only to an individual's distorted view of the
therapist but to all interpersonal relationships (including, of course, distorted
relationships among group members). Second, the theory of origin is broader: parataxic
distortion is constituted not only of the simple transferring onto contemporary
relationships of attitudes toward real-life figures of the past but also of the distortion
of interpersonal reality in response to intrapersonal needs. I will generally use the two
terms interchangeably: despite the imputed difference in origins, transference and
parataxic distortion may be considered operationally identical. Furthermore, many
therapists today use the term transference to refer to all interpersonal
distortions rather than confining its use to the patient-therapist relationship.
Interpersonal (that is, parataxic) distortions tend to be
self-perpetuating. For example, an individual with a derogatory, debased self-image may,
through selective inattention or projection, incorrectly perceive another to be a harsh,
rejecting figure. Moreover, the process compounds itself because that individual may then
gradually develop mannerisms and behavioral traits--for example, servility, defensive
antagonism, or condescension--that eventually will cause others to become, in reality,
harsh and rejecting. This sequence of circular causality, commonly referred to as the self-fulfilling
prophecy, is important and often plays a significant role in group therapy.
Parataxic distortions, in Sullivan's view, are modifiable primarily through consensual
validation--that is, through comparing one's interpersonal evaluations with those of
others. Consensual validation is also an important concept in group therapy. Not
infrequently a group member alters distortions after sampling the other members' views of
some important incident.
This brings us to Suilivan's view of the therapeutic process. He
suggests that the proper focus of research in mental health is the study of processes that
involve or go on between people. Mental disorder, or psychiatric symptomatology in all its
varied manifestations, should be translated into interpersonal terms and treated
accordingly. "Mental disorder" refers to interpersonal processes that are either
inadequate to the social situation or excessively complex because of the introduction of
illusory persons into the situations. Accordingly, psychiatric treatment should be
directed toward the correction of interpersonal distortions, thus enabling
the individual to lead a more abundant life, to participate collaboratively with
others, to obtain interpersonal satisfactions in the context of realistic, mutually
satisfying interpersonal relationships: "One achieves mental health to the extent
that one becomes aware of one's interpersonal relationships." Psychiatric cure is the
"expanding of the self to such final effect that the patient as known to himself is
much the same person as the patient behaving to others."
These ideas--that therapy is broadly interpersonal, both in its goals
and in its means--are exceedingly germane to group therapy. That does not mean that all,
or even most, patients entering group therapy ask explicitly for help in their
interpersonal relationships. Yet I have observed that the therapeutic goals of patients,
somewhere between the third and the sixth months of group therapy, often undergo a shift.
Their initial goal, relief of suffering, is modified and eventually replaced by new goals,
usually interpersonal in nature. Goals may change from wanting relief from anxiety or
depression to wanting to learn to communicate with others, to be more trusting and honest
with others, to learn to love.
The goal shift from relief of suffering to change in interpersonal
functioning is an essential early step in the dynamic therapeutic process. It is important
in the thinking of the therapist as well. Therapists cannot, for example, treat depression
per se: depression offers no effective therapeutic handhold, no rationale for examining
interpersonal relationships, which, as I hope to demonstrate, is the key to the
therapeutic power of the therapy group. It is necessary, first, to translate depression
into interpersonal terms and then to treat the underlying interpersonal pathology. Thus,
the therapist translates depression into its interpersonal issues--for example, passive
dependency, isolation, obsequiousness, inability to express anger, hypersensitivity to separation--and
then addresses those interpersonal issues in therapy.
Sullivan's statement of the overall process and goals of therapy is
deeply consistent with those of interactional group therapy. However, the emphasis on the
patient's understanding of the past, of the genetic development of those maladaptive
interpersonal stances, may be less crucial in group therapy than in the individual setting
where Sullivan worked.
The theory of interpersonal relationships has become so much an
integral part of the fabric of psychiatric thought that it needs no further underscoring.
People need people--for initial and continued survival, for socialization, for the pursuit
of satisfaction. No one--not the dying, not the outcast, not the mighty--transcends the
need for human contact.
During my many years of leading groups of patients who all had some
advanced form of cancer, I was repeatedly struck by the realization that, in the face of
death, we dread not so much nonbeing or nothingness but the accompanying utter loneliness.
Dying patients may often be haunted by interpersonal concerns--at being abandoned, for
example, even shunned, by the world of the living. One patient, for example, had planned
to give a large evening social function and learned that very morning that her cancer,
heretofore believed contained, had metastasized. She kept the information secret and gave
the party, all the while dwelling on the horrible thought that the pain from her disease
would get so unbearable that she would become less human and, finally, unacceptable to
others. Another patient with severe heart disease who had had a pacemaker and a
ventricular defibrillator inserted felt severe anxiety. His greatest terror was social in
nature: he worried about going into ventricular tachycardia in public and needing a
cardiac jolt, which would humiliate him in front of his friends and associates. He lost
sight of the anxiety of the real threat--that his heart might not be revived and that
death could come capriciously, at any moment.
I agree with Elisabeth Kubler-Ross that the question is not whether,
but how to tell a patient openly and honestly about a fatal illness. The patient is
always informed covertly that he or she is dying by the demeanor, by the shrinking away,
of the living.
The isolation of the dying is often double-edged. Patients themselves
often avoid those they most cherish, fearing that they will drag their family and friends
into the quagmire of their despair. Thus they avoid morbid talk, develop an airy, cheery
facade, and keep their fears to themselves. Their friends and family contribute to the
isolation by pulling back, by not knowing how to speak to the dying, by not wanting to
upset them or themselves.
Physicians often add to the isolation by keeping patients with advanced
cancer at a considerable psychological distance--perhaps to avoid their sense of failure
and futility, perhaps also to avoid dread of their own death. They make the mistake of
concluding that, after all, there is nothing more they can do. Yet from the patient's
standpoint, this is the very time when the physician is needed the most, not for technical
aid but for sheer human presence. What the patient needs is to make contact, to be able to
touch others, to voice concerns openly, to be reminded that he or she is not only apart
from but also a part of.
The outcasts--those individuals thought to be so inured to rejection that
their interpersonal needs have become heavily calloused--have compelling social needs,
too. I once had an experience in a prison that provided me with a forceful reminder of the
ubiquitous nature of this human need. An untrained psychiatric technician consulted me
about his therapy group, composed of twelve inmates. The members of the group were all
hardened recidivists, whose offenses ranged from aggressive sexual violation of a minor to
murder. The group, he complained, was sluggish and persisted in focusing on extraneous,
extra-group material. I agreed to observe his group and suggested that first he obtain
some sociometric information by asking each member privately to rank order everyone in the
group for general popularity. (I had hoped that the discussion of this task would induce
the group to turn its attention upon itself.) Although we had planned to discuss these
results before the next group session, unexpected circumstances forced us to cancel our
During the next group meeting, the therapist, enthusiastic but
professionally inexperienced and insensitive to interpersonal needs, announced that he had
decided simply to 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
The need for acceptance by and interaction with others is no different
among people at the opposing pole of human fortunes--those who occupy the ultimate realms
of power, renown, or wealth. I once worked with an enormously wealthy patient 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 forty-million-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 patients 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
patients in the group long enough, another aspect inevitably surfaces. They are concerned
at a very deep level about the group. One patient 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
Many patients 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 patients 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 patients 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."" Alexander insisted that
intellectual insight alone is insufficient: there must be an emotional component and
systematic reality testing as well. Patients, while effectively 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." In general, this is the widely accepted position in contemporary
psychotherapy. Even among psychoanalysts--who historically tend to rely most heavily on
the mutative power of pure interpretation--there are few, since Greenson in the 1960s, who
deny that the human, personal qualities of the therapists are as important as the content
of the insight they provide.
These basic principles--the importance of the emotional experience in
therapy and the patient's discovery, through reality testing, of the inappropriateness of
his or her interpersonal reactions--are as crucial in group therapy as in individual
therapy, 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, maybe hard to come by because of the insularity
and unreality of the patient therapist 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 .)
No such simulation is necessary in the therapy group, which contains
many built-in tensions--tensions whose roots reach deeply 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 patients 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, clearly the two
are not unrelated and much may be learned from an examination of single important events.
My patients almost invariably select an incident that is highly laden emotionally and
involves some other group member, rarely the therapist.
The most common type of incident my patients report (as did patients
describer by Frank and Ascher) involves a sudden expression of strong dislike or anger
toward another member. In each instance, communication was maintained, the storm was
weathered, and the patient 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 patient expressed strong negative affect.
2. This expression was a unique or novel experience for the patient.
3. The patient 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 patient realized either that the anger expressed was
inappropriate in intensity or direction, or that prior avoidance of affect
expression had been irrational. He or she may or may not have gained some insight, that
is, learned the reasons accounting either for the inappropriate affect or for his or her
prior avoidance of affect experience or expression.
5. The patient was enabled to interact more freely and to explore interpersonal
relationships more deeply.
The second most common type of critical incident described by my
patients also involved strong affect--but, in these instances, positive affect. For
example, a schizoid patient ran after and comforted a distressed patient who had bolted
out of the room; later he spoke of how profoundly he was affected by learning that he
could care for and help someone else. Others similarly spoke of discovering their
aliveness or of feeling in touch with themselves. These incidents had in common the
1. The patient expressed strong positive affect--an unusual occurrence.
2. The feared catastrophe did not occur-derision, rejection, engulfment, the
destruction of others.
3. The patient.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. Patients recalled an incident, usually involving self-disclosure, that plunged
them into greater involvement with the group. For example, a previously withdrawn,
reticent patient 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
1. A strong expression of emotion, which is interpersonally directed and is a
risk taken by the patient.
2. A group supportive enough to permit this risk taking.
3. Reality testing, which allows the patient 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 certain avoided 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.
This formulation has direct relevance to the concept of the here-and-now, a key concept of
group therapy that I will discuss in depth in chapter 6. Here I will state only this basic
premise: to the degree that 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 upon 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 chapter 5, when we discuss the
therapist's tasks, most groups have little difficulty in entering the emotional stream of
the here-and-now; it is the therapist's job to keep directing the group toward the
self-reflective aspect of that process.
The mistaken assumption that a strong emotional experience is in
itself a sufficient force for change is seductive, as well as venerable. Modern
psychotherapy was conceived in that very error: the first description of dynamic
psychotherapy (Freud and Breuer's 1895 book on hysteria) described a method of cathartic
treatment based on the conviction that hysteria is caused by a traumatic event to which
the individual has never fully responded emotionally. Since illness was supposed to be
caused by strangulated affect, treatment thus consisted of giving a voice to the stillborn
emotion. It was not long before Freud recognized their error: emotional expression, though
necessary, is not a sufficient condition for change. Freud's discarded ideas,
tossed carelessly away, have refused to die and have been the seed for a continuous fringe
of therapeutic ideologies. The Viennese fin-de-siecle cathartic treatment still
lives today in the approaches of primal scream, bioenergetics, and the many group leaders
who place an exaggerated emphasis on emotional catharsis.
My colleagues and I conducted an intensive investigation of the process
and outcome of many of the encounter techniques popular in the 1970s (see chapter 16 for a
description of this research), and our findings provide much support for the dual
emotional-intellectual components of the psychotherapeutic process. We explored, in a
number of ways, the relationship between each member's experience in the group and his or
her outcome. For example, we asked the members to reflect, retrospectively, on those
aspects of the group experience that they deemed most pertinent to their change. We also
asked them during the course of the group (at the end of each meeting) to describe which
event that meeting had had the most personal significance. When we correlated the type of
event with outcome, we obtained surprising results that disconfirmed many of the current
stereotypes about the prime ingredients of the successful encounter group experience.
Although emotional experiences (expression and experiencing of strong affect,
self-disclosure, giving and receiving feedback) were considered extremely important, they
did not distinguish successful from unsuccessful. group members. In other words, the
members who were unchanged or even had a destructive experience were as likely as
successful members to value highly the emotional incidents of the group.
What types of experiences did differentiate the successful from the
unsuccessful members? There was clear evidence that a cognitive component was
essential; some type of cognitive map was needed, some intellectual system that framed the
experience and made sense of the emotions evoked in the group. (See chapter 16 for a full
discussion of this result.) That these findings occurred in groups led by leaders who did
not attach much importance to the intellectual component speaks strongly for its being
part of the core, and not the facade, of the change process.
THE GROUP AS SOCIAL MICROCOSM
A freely interactive group, with few structural restrictions, will, in time,
develop into a social microcosm of the participant members. Given enough time, group
members will begin to be themselves: they will interact with the group members as they
interact with others in their social sphere, will create in the group the same
interpersonal universe they have always inhabited. In other words, patients will, over
time, automatically and inevitably begin to display their maladaptive interpersonal
behavior in the therapy group. There is no need for them to describe or give a detailed
history of their pathology: they will sooner or later enact it before the group
This concept is of paramount importance in group therapy and constitutes a
keystone upon which rests the entire approach to group therapy. It is widely accepted by
clinicians, although each therapist's perception and interpretation of group events and
descriptive language will be determined by his or her school of conviction. Thus,
Freudians may see patients manifesting their oral, sadistic, or masochistic needs in their
relationship to other members, object-relations theorists may focus on the patients'
manifesting the defenses of splitting, projective identification, idealization,
devaluation; correctional workers may see conning, exploitative behavior; social
psychologists may see manifold bids for dominance, affection, or inclusion; Adlerians may
speak more of feelings of inferiority and compensatory behavior and of masculine and
feminine guiding lines, and attend more carefully to birth order (youngest sister, older
brother, and so on) and the sibling relationships--both historically and how they are
played out in the group; whereas students of Horney may see the detached, resigned person
putting energies into acting noncommittal and indifferent, or the arrogant-vindictive
person struggling to prove him or herself right by proving others wrong.
The important point is that, regardless of the type of conceptual
spectacles worn by the therapist-observer, each member's interpersonal style will
eventually appear in his or her transactions in the group. Some styles result in
interpersonal friction that will be manifest early in the course of the group. Individuals
who are, for example, angry, vindictive, harshly judgmental, self-effacing, or grandly
coquettish will generate considerable interpersonal static even in the first few meetings.
Their maladaptive social patterns will come under the group's scrutiny far earlier than
will those of individuals who may be equally or more severely troubled but who, for
example, subtly exploit others or achieve intimacy to a point but then, becoming
frightened, disengage themselves.
The initial business of a group usually consists of dealing with the
members whose pathology is most interpersonally blatant. Some interpersonal styles become
crystal-clear from a single transaction; others, from a single group meeting; others
require months of observation to understand. The development of the ability to identify
and put to therapeutic advantage maladaptive interpersonal behavior as seen in the social
microcosm of the small group is one of the chief tasks of a training program for group
psychotherapists. Some clinical examples may make these principles more graphic.
The Grand Dame
Valerie, a twenty-seven-year-old musician, sought therapy with me primarily
because of severe marital discord of several years' standing. She had had considerable,
unrewarding individual and hypnotic uncovering therapy. Her husband, she reported, was an
alcoholic who was reluctant to engage her socially, intellectually, or sexually. Now the
group could have, as some groups do, investigated her marriage interminably. The members
might have taken a complete history of the courtship, of the evolution of the discord, of
her husband's pathology, of her reasons for marrying him, of her role in the conflict;
they might have given advice for new behavior or for a trial or permanent separation.
But all this historical, problem-solving activity would have been in
vain: this entire line of inquiry not only disregards the unique potential of therapy
groups but is also based on the highly questionable premise that a patient's account of a
marriage is even reasonably accurate. Groups that function in this manner fail to help the
protagonist and also suffer demoralization because of the ineffectiveness of a
problem-solving, historical group therapy approach. Let us instead observe Valerie's
behavior as it unfolds in the here-and-now of the group. .
Valerie's group behavior was flamboyant. First, there was her grand
entrance, always five or ten minutes late. Bedecked in fashionable but flashy garb, she
would sweep in, sometimes throwing kisses, and immediately begin talking, oblivious to
whether some other member was in the midst of a sentence. Here was narcissism in the raw.
Her world view was so solipsistic that it did not take in the possibility that life could
have been going on in the group before her arrival.
After very few meetings, Valerie began to give gifts: to an obese
female member, a copy of a new diet book; to a woman with strabismus, the name of a good
ophthalmologist; to an effeminate gay patient, a subscription to Field and
Stream magazine (to masculinize him); to a twenty-four-year-old virginal male, an
introduction to a promiscuous divorced friend of hers. Gradually it became apparent that
the gifts were not duty-free. For example, she pried into the relationship between the
young man and her divorced friend and insisted on serving as a go-between, thus exerting
considerable control over both individuals.
Her efforts to dominate soon colored all of her interactions in the
group. I became a challenge to her, and she made various efforts to control me. By sheer
chance, a few months previously I had seen her sister in consultation and referred her to
a competent therapist, a clinical psychologist. In the group Valerie congratulated me for
the brilliant tactic of sending her sister to a psychologist; I must have divined her
deep-seated aversion to psychiatrists. Similarly, on another occasion, she responded to a
comment from me, "How perceptive you were to have noticed my hands trembling."
The trap was set! In fact, I had neither "divined" her
sister's alleged aversion to psychiatrists (I had simply referred her to the best
therapist I knew), nor noted Valerie's trembling hands. If I silently accepted her
undeserved tribute, then I would enter into a dishonest collusion with Valerie; if, on the
other hand, I admitted my insensitivity either to the trembling of the hands or to the
sister's aversion, then in a sense I would also be bested. She would control me either
way! In such situations, the therapist has only one real option: to change the frame and
to comment upon the process--the nature and the meaning of the entrapment.
(I will have a great deal more to say about relevant therapist technique in chapter 6.)
Valerie vied with me in many other ways. Intuitive and intellectually
gifted, she became the group expert on dream and fantasy interpretation. On one occasion
she saw me between group sessions to ask whether she could use my name to take a book out
of the medical library. On one level the request was reasonable: the book (on music
therapy) was related to her profession; furthermore, having no university affiliation, she
was not permitted to use the library.
However, in the context of the group process, the request was complex
in that she was testing limits; granting her request would have signaled to the group that
she had a special and unique relationship with me. I clarified these considerations to her
and suggested further discussion in the next session. Following this perceived rebuttal,
however, she called the three male members of the group at home and, after swearing them
to secrecy, arranged to see them. She engaged in sexual relations with two; the third, a
gay man, was not interested in her sexual advances but she launched a mighty seduction
The following group meeting was horrific. Extraordinarily tense and
unproductive, it demonstrated the axiom (to be discussed later) that if something important
in the group is being actively avoided, then nothing else of import gets talked
about either. Two days later Valerie, overcome with anxiety and guilt, asked for an
individual session with me and made a full confession. It was agreed that the whole matter
should be discussed in the next group meeting.
Valerie opened the next meeting with the words: "This is
confession day! Go ahead, Charles!" and then later, "Your turn, Louis."
Each man performed as she bade him and, later in the meeting, received from her a critical
evaluation of his sexual performance. A few weeks later, Valerie let her estranged husband
know what had happened, and he sent threatening messages to all three men. That was the
last straw! The members decided they could no longer trust her and, in the only such
instance I have known, voted her out of the group (She continued her therapy by joining
another group.) The saga does not end here, but perhaps I have gone far enough to
illustrate the concept of the group as social microcosm.
Let us summarize. The first step was that Valerie clearly displayed
her interpersonal pathology in the group. Her narcissism, her need for adulation, her
need to control, her sadistic relationship with men--the entire tragic behavioral
scroll--unrolled in the here-and-now of therapy. The next step was reaction and
feedback. The men expressed their deep humiliation and anger at having to "jump
through a hoop" for her and at receiving "grades" for their sexual
performance. They drew away from her. They began to reflect: "I don't want a report
card every time I have sex. It's controlling, like sleeping with my mother! I'm beginning
to understand more about your husband moving out!" and so on. The others in the
group, the female members and the therapists, shared the men's feelings about the wantonly
destructive course of Valerie's behavior--destructive for the group as well as for
Most important of all, she had to deal with this fact: she had joined a
group of troubled individuals who were eager to help each other and whom she grew to like
and respect; yet, in the course of several weeks, she had so poisoned her environment
that, against her conscious wishes, she became a pariah, an outcast from a group that had
had the potential of being very helpful to her. Facing and working through these issues in
her subsequent therapy group enabled her to make substantial personal changes and to
employ much of her considerable potential constructively in her later relationships and
The Man Who Liked Robin Hood
Ron, a forty-eight-year-old attorney who was separated from his wife, entered therapy
because of depression, anxiety, and intense feelings of loneliness. His relationships,
with both men and women, were highly problematic. He yearned for a close male friend but
had not had one since high school. His current relationships with men assumed one of two
forms: either he and the other man related in a highly competitive, antagonistic fashion,
which veered dangerously close to combativeness, or he assumed an exceedingly dominant
role and soon found the relationship empty and dull.
His relationships with women had always followed a predictable
sequence: instant attraction, a crescendo of passion, a rapid withering. His love for his
wife had decayed years ago and he was currently in the midst of a painful divorce.
Intelligent and highly articulate, Ron immediately assumed a position of great influence
in the group. He offered a continuous stream of useful and thoughtful observations to the
other members, yet kept his own pain and his own needs well concealed. He requested
nothing and accepted nothing from me or my co-therapist. In fact, each time I set out to
interact with Ron, I felt myself bracing for battle. His antagonistic resistance was so
great that for months my major interaction with him consisted of repeatedly requesting him
to examine his reluctance to experience me as someone who could offer help.
"Ron," I asked, giving it my best shot, "let's
understand what's happening. You have many areas of unhappiness in your life. I'm an
experienced therapist, and you come to me for help. You come regularly, you never miss a
meeting, you pay me for my services, yet you systematically prevent me from helping.
Either you so hide your pain that I find little to offer you, or when I do extend some
help, you reject it in one fashion or another. Reason dictates that we should be allies,
working together to help you. How does it come about that we are adversaries?"
But even that failed to alter our relationship. Ron seemed bemused and
skillfully and convincingly speculated that I might be identifying one of my problems
rather than his. His relationship with the other group members was characterized by his
insistence on seeing them outside the group. He systematically arranged for some
extragroup activity with each of the members. He was a pilot and took some members flying,
others sailing, others to lavish dinners; he gave legal advice to some and became
romantically involved with one of the female members; and (the final straw) he invited my
co-therapist, a female psychiatric resident, for a skiing weekend.
Furthermore, he refused to examine his behavior or to discuss these
extragroup meetings in the group, even though the pregroup preparation (see chapter 12)
had emphasized to all the members that such unexamined, undiscussed extragroup meetings
generally sabotage therapy.
After one meeting when we pressured him unbearably to examine the
meaning of the extragroup invitations, especially the skiing invitation to my
co-therapist, he left the session confused and shaken. On his way home, Ron unaccountably
began to think of Robin Hood, his favorite childhood story but something he had not
thought about for decades. Following an impulse, he drove directly to the children's
section of the nearest public library to sit in a small child's chair and read the story
one more time. In a flash, the meaning of his behavior was illuminated! Why had the Robin
Hood legend always fascinated and delighted him? Because Robin Hood rescued people,
especially women, from tyrants! That motif had played a powerful role in his interior life
beginning with the Oedipal struggles in his own family. Later, in early adulthood, he
built up a successful law firm by first assisting in a partnership and then enticing his
boss's employees to work for him. He had often been most attracted to women who were
attached to some powerful man. Even his motives for marrying were blurred: he could not
distinguish between love for his wife and desire to rescue her from a tyrannical father.
The first stage of interpersonal learning is pathology display. Ron's
characteristic modes of relating to both men and women unfolded vividly in the microcosm
of the group. His major interpersonal motif was to struggle with and to vanquish other
men. He competed openly and, because of his intelligence and his great verbal skills, soon
procured the dominant role in the group. He then began to mobilize the other members in
the final conspiracy: the unseating of the therapist. He formed close alliances through
extragroup meetings and through placing other members in his debt by offering favors. Next
he endeavored to capture "my women"--first the most attractive female member and
then my co-therapist.
Not only was Ron's interpersonal pathology displayed in the group, but
so also were its adverse, self-defeating consequences. His struggles with men resulted in
the undermining of the very reason he had come to therapy: to obtain help. In fact, the
competitive struggle was so powerful that any help I extended him was experienced not as
help but as defeat, a sign of weakness.
Furthermore, the microcosm of the group revealed the consequences of
his actions on the texture of his relationship with his peers. In time the other members
became aware that Ron did not really relate to them. He only appeared to relate
but, in actuality, was using them as a way of relating to me, the powerful and feared male
in the group. The others soon felt used, felt the absence of a genuine desire in Ron to
know them, and gradually began to distance themselves from him. Only after Ron was able to
understand and to alter his intense and distorted ways of relating to me was he able to
turn to and relate in good faith to the other members of the group.
"Those Damn Men"
Linda, forty-six years old and thrice divorced, entered the group because of anxiety and
severe functional gastrointestinal distress. Her major interpersonal issue was her
tormented, self-destructive relationship with her current boyfriend. In fact, throughout
her life she had encountered a long series of men (father, brothers, bosses, lovers, and
husbands) who had abused her both physically and psychologically. Her accounts of the
abuse that she had suffered, and suffered still, at the hands of men were harrowing.
The group could do little to help her, aside from applying balm to her
wounds and listening empathically to her accounts of continuing mistreatment by her
current boss and boyfriend. Then one day an unusual incident occurred, which graphically
illuminated her dynamics. She called me one morning in great distress. She had had an
extremely unsettling altercation with her boyfriend and felt panicky and suicidal. She
felt she could not possibly wait for the next group meeting, still four days off, and
pleaded for an immediate individual session. Although it was greatly inconvenient, I
rearranged my appointments that afternoon and scheduled time to meet her. Approximately
thirty minutes before our meeting, she called and left word with my secretary that she
would not be coming in after all.
When, in the next group meeting, I inquired what had happened, Linda
stated that she had decided to cancel the emergency session because she was feeling
slightly better by the afternoon, and that she knew I had a rule that I would see a
patient only one time in an emergency during the whole course of group therapy. She
therefore thought it might be best to save that time until some future point when she
might be even more in crisis.
I found her response bewildering. I had never made such a rule, I never
refuse to see someone in real crisis. Nor did any of the other members of the group recall
my having issued such a dictum. But Linda stuck to her guns: she insisted that she had
heard me say it, and was dissuaded neither by my denial nor by the unanimous consensus of
the other group members. The discussion became circular, defensive, and acrimonious.
This incident, unfolding in the social microcosm of the group, was
highly informative and allowed us to obtain an important perspective on Linda's
responsibility for some of her problematic relationships with men. Up until that point,
the group had had to rely entirely on her portrayal of these relationships. Linda's
accounts were convincing, and the group had come to accept her vision of herself as victim
of "all those damn men out there." An examination of the here-and-now incident
indicated that Linda had distorted her perceptions of at least one important man in her
life: her therapist. Moreover, and this is extremely important, she had distorted the
incident in a highly predictable fashion: she experienced me as far more
uncaring, insensitive, and authoritarian than I really was.
This was new data. And it was extremely convincing data--data that was
displayed before the eyes of all the members. For the first time, the group began to
wonder about the accuracy of Linda's accounts of her relationships with men. Undoubtedly,
she accurately portrayed her feelings, but it became apparent that there were perceptual
distortions at work: because of her expectations of men and her highly conflicted
relationships with them, she misperceived their actions toward her.
But there was more yet to be learned from the social microcosm. An
important piece of data was the tone of the discussion: the defensiveness, the irritation,
the anger. In time I, too, became irritated by the thankless inconvenience I had
suffered by changing my schedule to meet with Linda. I was further irritated by her
insistence that I had proclaimed a certain insensitive rule when I (and the rest of the
group) knew I had not. I fell into a reverie in which I asked myself, "What would it
be like to live with Linda all the time instead of an hour and a half a week?" If
there were many such incidents, I could imagine myself often becoming angry, exasperated,
and uncaring toward her. This is a particularly clear example of the concept of the
self-fulfilling prophecy described on page 20. Linda predicted that men would behave
toward her in a certain way and then, unconsciously, operated so as to bring this
prediction to pass.
Men Who Could Not Feel
Allen, a thirty-year-old unmarried scientist, sought therapy for a single,
sharply delineated problem: he wanted to be able to feel sexually stimulated by a woman.
Intrigued by this conundrum, the group searched for an answer. They investigated his early
life, sexual habits, and fantasies. Finally, baffled, they turned to other issues in the
group. As the sessions continued, Allen seemed impassive and insensitive to his own and
others' pain. On one occasion, for example, an unmarried member in great distress
announced in sobs that she was pregnant and was planning to have an abortion. During her
account she also mentioned that she had had a bad PCP trip. Allen, seemingly unmoved by
her tears, persisted in questioning her intellectually about the effects of "angel
dust" and was puzzled when the group turned on him because of his insensitivity.
So many similar incidents occurred that the group came to expect no
emotion from him. When directly queried about his feelings, he responded as if he had been
addressed in Sanskrit or Aramaic. After some months the group formulated an answer to his
oft-repeated question, "Why can't I have sexual feelings toward a woman?" They
asked him to consider instead why he couldn't have any feelings toward anybody.
Changes in his behavior occurred very gradually. He learned to spot and
identify feelings by pursuing telltale autonomic signs: facial flushing, gastric
tightness, sweating palms. On one occasion a volatile woman in the group threatened to
leave the group because she was exasperated trying to relate to a psychologically deaf and
dumb goddamned robot." Allen again remained impassive, responding only, "I'm not
going to get down to your level."
However, the next week when he was asked about the feelings he had
taken home from the group, he said that after the meeting he had gone home and cried like
a baby. (When he left the group a year later and looked back at the course of his therapy,
he identified this incident as a critical turning point.) Over the ensuing months he was
more able to feel and to express his feelings to the other members. His role within the
group changed from that of tolerated mascot to that of accepted compeer, and his
self-esteem rose in accordance with his awareness of the members' increased respect for
In another group, Ed, a forty-seven-year-old engineer, sought therapy
because of loneliness and his inability to find a suitable mate. Ed's pattern of social
relationships was barren: he had never had close male friends and had only sexualized,
unsatisfying, short-lived relationships with women who ultimately and invariably rejected
him. His good social skills and lively sense of humor resulted in his being highly valued
by other members in the early stages of the group.
As time went on and members deepened their relationships with one
another, however, Ed was left behind: soon his experience in the group resembled closely
his social life outside the group. The most obvious aspect of his behavior was his limited
and offensive approach to women. His gaze was directed primarily toward their breasts or
crotch; his attention was voyeuristically directed toward their sexual lives; his comments
to them were typically simplistic and sexual in nature. Ed considered the men in the group
unwelcome competitors; for months he did not initiate a single transaction with a man.
With so little appreciation for attachments, he, for the most part,
considered people interchangeable. For example, when a member described her obsessive
fantasy that her boyfriend, who was often late, would be killed in an automobile accident,
Ed's response was to assure her that she was young, charming, and attractive and would
have little trouble finding another man of at least equal quality. To take another
example, Ed was always puzzled when other members appeared troubled by the temporary
absence of one of the co-therapists or, later, by the impending permanent departure of a
therapist. Doubtless, he suggested, there was, even among the students, a therapist of
equal competence. (In fact, he had seen in the hall a bosomy psychologist, whom he would
particularly welcome as therapist.)
He put it most succinctly when he described his MDR (minimum daily
requirement) for affection; in time it became clear to the group that the identity of the
MDR supplier was incidental to Ed--far less relevant than its dependability. Thus evolved
the first phase of the group therapy process: the display of interpersonal pathology. Ed
did not relate to others so much as he used them as equipment, as objects to
supply his life needs. It was not long before he had recreated in the group his
habitual--and desolate--interpersonal universe: he was cut off from everyone. Men
reciprocated his total indifference; women, in general, were disinclined to service his
MDR, and those women he especially craved were repulsed by his narrowly sexualized
THE SOCIAL MICROCOSM: A DYNAMIC INTERACTION
There is a rich and subtle dynamic interplay between the group member and the
group environment. Members shape their own microcosm, which in turn pulls characteristic
defensive behavior from each. The more spontaneous interaction there is, the more rapid
and authentic will be the development of the social microcosm. And that in turn increases
the likelihood that the central problematic issues of all the members will be evoked and
For example, Nancy, a young borderline patient, entered the group
because of a disabling depression, a subjective state of disintegration, and a
tendency to develop panic when left alone. All of Nancy's symptoms had been intensified by
the threatened breakup of the small commune in which she lived. She had long been
sensitized to the breakup of nuclear units; as a child she had felt it was her task to
keep her volatile family together, and now as an adult she nurtured the fantasy that when
she married, the various factions among her relations would be permanently reconciled.
How were Nancy's dynamics evoked and worked through in the social
microcosm of the group? Slowly! It took time for these concerns to manifest themselves. At
first, sometimes for weeks on end, Nancy would work comfortably on important but minor
conflict areas. But then, certain events in the group would fan her major, smoldering
concerns into anxious conflagration. For example, the absence of a member would unsettle
her. In fact, much later, in a debriefing interview at the termination of therapy, Nancy
remarked that she often felt so stunned by the absence of any member that she was unable
to participate for the entire session.
Even tardiness troubled her and she would chide members who were not
punctual. When a member thought about leaving the group, Nancy grew deeply concerned and
could be counted on to exert maximal pressure upon the member to continue, regardless of
the person's best interests. When members arranged contacts outside the group meeting,
Nancy became anxious at the threat to the integrity of the group. Sometimes members felt
smothered by Nancy. They drew away and expressed their objections to her phoning them at
home to check on their absence or lateness. Their insistence that she lighten her demands
on them simply aggravated Nancy's anxiety, causing her to increase her protective efforts.
Though she longed for comfort and safety in the group, it was, in fact, the very
appearance of these unsettling vicissitudes that made it possible for her major conflict
areas to become exposed and to enter the stream of the therapeutic work.
Not only does the small group provide a social microcosm in which the
maladaptive behavior of members is clearly displayed but it also becomes a laboratory in
which is demonstrated, often with great clarity, the meaning and the dynamics of the
behavior. The therapist sees not only the behavior but also the events triggering it and
sometimes, more important, the anticipated and real responses of others.
Leonard, for example, entered the group with a major problem of
procrastination. In Leonard's view, procrastination was not only a problem but an
explanation. It explained his failures, both professionally and socially; it explained his
discouragement, depression, and alcoholism. And yet it was an explanation that obscured
In the group we became well acquainted with Leonard's procrastination.
It served as his supreme mode of resistance to therapy when all other resistance had
failed. When members worked hard with Leonard, and when it appeared that part of his
neurotic character was about to be uprooted, he found ways to delay the group work.
"I don't want to be upset by the group today," he would say, "this new job
is make or break for me." "I'm just hanging on by my fingernails";
"Give me a break--don't rock the boat"; "I'd been sober for three months
until the last meeting caused me to stop at the bar on my way home." The variations
were many, but the theme was consistent.
One day Leonard announced a major development, one for which he had
long labored: he had quit his job and obtained a position as a teacher. Only a single step
remained: getting a teaching certificate, a matter of filling out an application requiring
approximately two hours' labor. Only two hours, and yet he could not do it! He delayed
until the allowed time had practically expired and, with only one day remaining, informed
the group about the deadline and lamented the cruelty of his personal demon,
procrastination. Everyone in the group, including the therapists, experienced a strong
desire to sit Leonard down, possibly even in one's lap, place a pen between his fingers,
and guide his hand along the application form. One patient, the most mothering member of
the group, did exactly that: she took him home, fed him, and schoolmarmed him through the
As we began to review what had happened, we could now see his
procrastination for what it was: a plaintive, anachronistic plea for a lost mother. Many
things then fell into place, including the dynamics behind Leonard's depressions (another
even more desperate plea for love), alcoholism, and compulsive overeating.
The idea of the social microcosm is, I believe, sufficiently clear: if
the group is so conducted that the members can behave in an unguarded,
unself-conscious manner, they will, most vividly, recreate and display their pathology in
the group. Furthermore, in the in vivo drama of the group meeting, the trained
observer has a unique opportunity to understand the dynamics of each patient's behavior.
RECOGNITION OF BEHAVIORAL PATTERNS IN THE SOCIAL MICROCOSM
If therapists are to turn the social microcosm to therapeutic use, they must first learn
to identify the patients' recurrent maladaptive interpersonal patterns. In the incident
involving Leonard, the therapist's vital clue was the emotional response of members and
leaders to Leonard's behavior. These emotional responses are valid and indispensable data:
they should not be overlooked or underestimated. The therapist or other group members may
feel angry toward a member, or exploited, or sucked dry, or steamrollered, or intimidated,
or bored, or tearful, or any of the infinite number of ways one person can feel toward
These feelings represent data--a bit of the truth about the other
person and should be taken seriously by the therapist. If the feelings elicited in others
are highly discordant with the feelings that the patient would like to engender in others,
or if the feelings aroused are desired, yet inhibit growth (as in the case of Leonard),
then therein lies an important part of the patient's problem. It is to this phenomenon
that the therapist should direct attention.
There are many complications inherent in this thesis. Some critics
might say that a strong emotional response is often due to pathology not of the subject
but of the respondent. If, for example, a self-confident, assertive man evokes strong
feelings of fear, intense envy, or bitter resentment in another man, we can hardly
conclude that the response is reflective of the former's pathology.
Thus the emotional response of another member is not sufficient;
therapists need confirmatory evidence. They look for repetitive patterns over time and for
multiple responses--that is, the reactions of several other members (referred to as
consensual validation) to the individual. And most of all, therapists rely on the most
valuable evidence of all: their own emotional responses.
But, the same critics might say, "How can we be sure the
therapists' reactions are 'objective'? Surely therapists also have their blind spots,
their own areas of interpersonal conflict and distortion." I will address this issue
fully in later chapters on training and on the therapist's tasks and techniques, but for
now note only that this argument is a powerful reason for therapists to know themselves as
fully as possible. Thus it is incumbent that the neophyte group therapist embark on a
lifelong journey of self-exploration, a journey that includes both individual and group
None of this is meant to imply that therapists should not take
seriously the responses and feedback of all patients, including those who are
highly disturbed. Even the most exaggerated, irrational responses contain a core of
reality. Furthermore, the disturbed patient may be a valuable, accurate source of feedback
at other times (no individual is highly conflicted in every area). Lastly, of course, an
idiosyncratic response contains much information about the respondent.
This final point constitutes a basic axiom for the group therapist. Not
infrequently, members of a group respond very differently to the same stimuli. An incident
may occur in the group that each of seven or eight members perceives, observes, and
interprets differently. One common incident and eight different responses--how can
that be? There seems only one plausible explanation: there are eight different inner
worlds. Splendid! After all, the aim of therapy is to help patients understand and
alter their inner worlds. Thus, analysis of these differing responses is a royal road-a
via regia-into the inner world of the group member.
For example, consider the first illustration offered in this chapter, the
group containing Valerie, a flamboyant, controlling member. According to their inner
worlds, the group members responded very differently to her, ranging from obsequious
acquiescence to lust and gratitude to impotent fury or effective confrontation. Or,
again, consider certain structural aspects of the group meeting: members have markedly
differing responses to sharing the group's or the therapist's attention, to disclosing
themselves, to asking for help or helping others. Nowhere are such differences more
apparent than in the transference--the members' responses to the leader: the same
therapist will be experienced by different members as warm, cold, rejecting, accepting,
competent, or bumbling.
THE SOCIAL MICROCOSM-IS IT REAL?
I have often heard group members challenge the veracity of the social microcosm. They may
claim that their behavior in this particular group is atypical, not at all representative
of their normal behavior. Or that this is a group of troubled individuals who have
difficulty perceiving them accurately. Or even that group therapy is not real; it is an
artificial, contrived experience that distorts rather than reflects one's real behavior.
To the neophyte therapist, these arguments may seem formidable, even persuasive, but they
are in fact truth distorting. In one sense, the group is artificial: members do not choose
their friends from the group; they are not central to one another; they do not live, work,
or eat together; though they relate in a personal manner, their entire relationship
consists of meetings in a professional's office once or twice a week; and the
relationships are transient-the end of the relationship is built into the social contract
at the very beginning.
When faced with these arguments, I often think of Earl and Marguerite,
two patients in a group I led long ago. Earl had been a member of the group for four
months when Marguerite was introduced. They both blushed to see each other since, by
chance, they had only a month previously gone on a Sierra Club camping trip together for a
night and been "intimate." Neither wanted to be in the group with the other. To
Earl, Marguerite was a foolish, empty girl, "a mindless piece of ass," as he was
to put it later in the group. To Marguerite, Earl was a dull nonentity, whose penis she
had made use of as a means of retaliation against her husband.
They worked together in the group once a week for about a year. During
that time, they came to know each other intimately in a fuller sense of the word: they
shared their deepest feelings; they weathered fierce, vicious battles; they helped each
other through suicidal depressions; and, on more than one occasion, they wept for each
other. Which was the real world and which the artificial?
The point is that the group can be far more real than the world out
there. The group attempts to identify and eliminate social, prestige, or sexual games;
members go through vital life experiences together; the reality-distorting facades are
doffed as members try hard to be honest with one another. How many times have I heard a
group member say, "This is the first time I have ever told this to anyone"?
These people are not strangers. Quite the contrary: they know one another deeply and
fully. Yes, it is true that members spend only a small fraction of their lives together.
But psychological reality is not equivalent to physical reality. Psychologically, group
members spend infinitely more time together than the one or two meetings a week when they
physically occupy the same office.
TRANSFERENCE AND INSIGHT
Before concluding the examination of interpersonal learning as a mediator of change, I
wish to call attention to two concepts that deserve further discussion. Transference and
insight play too central a role in most formulations of the therapeutic process to be
passed over lightly. I rely heavily on both of these concepts in my therapeutic work and
do not mean to slight them. What I have done in this chapter is to embed them both into
the factor of interpersonal learning.
Transference is a specific form of interpersonal perceptual
distortion. In individual psychotherapy, the recognition and the working through of this
distortion is of paramount importance. In group therapy, working through interpersonal
distortions is, as we have seen, of no less importance; however, the range and
variety of distortions are considerably greater. Working through the
transference--that is, the distortion in the relationship to the therapist--now becomes
only one of a series of distortions to be examined in the therapy process.
For many patients, perhaps for the majority, it is the most important
relationship to work through since the therapist is the personification of parental
images, of teachers, of authority, of established tradition, of incorporated values. But
most patients are also conflicted in other interpersonal domains: for example, power,
assertiveness, anger, competitiveness with peers, intimacy, sexuality, generosity, greed,
Considerable research emphasizes the importance many members place on
working through relationships with other members rather than with the leader. To take one
example, a team of researchers asked members, in a twelve-month follow-up of a short-term
crisis group, to indicate the source of the help each had received. Forty-two percent felt
that the group members and not the therapist had been helpful, and 28 percent responded
that both had been of aid. Only 5 percent stated that the therapist alone was a major
contributor to change .28
This corpus of research has important implications for the technique of
the group therapist: rather than focusing exclusively on the patient-therapist
relationship, therapists must facilitate the development and working-through of
interactions among members. I will have much more to say about these issues in chapters 6
Insight defies precise description; it is not a unitary concept. I
prefer to employ it in the general sense of "sighting inward"--a process
encompassing clarification, explanation, and derepression. Insight occurs when one
discovers something important about oneself--about one's behavior, one's motivational
system, or one's unconscious.
In the group therapy process, patients may obtain insight on at least
four different levels:
1 . Patients may gain a more objective perspective on their interpersonal
presentation. They may for the first time learn how they are seen by other people: as
tense, warm, aloof, seductive, bitter, arrogant, pompous, obsequious, and so on.
2. Patients may gain some understanding into their more complex interactional
patterns of behavior. Any of a vast number of patterns may become clear to them: for
example, that they exploit others, court constant admiration, seduce and then reject or
withdraw, relentlessly compete, plead for love, or relate only to the therapist or to the
men or the women members.
3. The third level may be termed motivational insight. Patients may learn why
they do what they do to and with other people. A common form this type of insight assumes
is learning that one behaves in certain ways because of the belief that different behavior
would bring about some catastrophe: one might be humiliated, scorned, destroyed, or
abandoned. Aloof, detached patients, for example, may understand that they shun closeness
because of fears of being engulfed and losing themselves; competitive, vindictive,
controlling patients may understand that they are frightened of their deep, insatiable
cravings for nurturance; timid, obsequious individuals may dread the eruption of their
repressed, destructive rage.
4 A fourth level of insight, genetic insight, attempts to help patients
understand how they got to be the way they are. Through an exploration of personal
developmental history, the patient understands the genesis of current patterns of
behavior. The theoretical framework and the language in which the genetic explanation is
couched are, of course, largely dependent on the therapist's school of conviction.
I have listed these four levels in the order of degree of inference.
An unfortunate and long-standing conceptual error has resulted, in part, from the tendency
to equate a "superficial-deep" sequence with this "degree of
inference" sequence. Furthermore, deep has become equated with "profound"
or "good," and superficial with "trivial," "obvious," or
"inconsequential." Psychoanalysts have disseminated the belief that the more
profound the therapist, the deeper the interpretation (from a genetic perspective), and
the more complete the treatment. There is, however, not a single shred of evidence to
support this contention.
Every therapist has encountered patients who have achieved considerable
genetic insight based on some accepted theory of child development-be it that of Freud,
Klein, Winnicott, Kernberg, Kohut, or another-and yet made no therapeutic progress. On the
other hand, it is commonplace for significant clinical change to occur in the absence of
genetic insight. Nor is there a demonstrated relationship between the acquisition of
genetic insight and the persistence of change. In fact, there is much reason to
question the validity of our most revered assumptions about the relationship between types
of early experience and adult behavior and character structures
A fuller discussion of causality would take us too far afield from
interpersonal learning, but I will return in depth to the issue in chapters 5 and 6. For
now, it is sufficient to emphasize that there is little doubt that intellectual
understanding lubricates the machinery of change. It is important that
insight-"sighting in"--occur, but in its generic, not its genetic, sense.
And psychotherapists need to disengage the concept of "profound" or
"significant" intellectual understanding from temporal considerations. Something
that is deeply felt or has deep meaning for a patient may or-as is usually the case may
not be related to the unraveling of the early genesis of behavior.