Not long ago,and at the insistence of his girlfriend who threatened to leave him if he didn’t, a young man came to my office for a psychotherapy consultation. I asked him: ” How can I help you?”.  He said his girlfriend told him that he had relationship issues. He didn’t really want to come for a consultation; he said that he didn’t need it. This was a bad sign. He was in my office under duress, which is never a good motivation to seek treatment.  I asked him, a bit sarcastically,  if he always did what his girlfriend told him to do.   After listening to his ‘defense’ of his plight with women, I recommended group treatment.   From even a brief interview, it seemed clear this young man had no idea how he came across in relationships. He took no responsibility for any part of it. He flatly refused the offer to join one of my groups.  When I asked why not, he said:” I don’t care about other people’s problems”.  To which I replied: “Exactly, that’s the problem!” He didn’t believe me and left in a huff. His girlfriend did indeed leave him soon thereafter. This bright but not very introspective young man just didn’t get it.  Had he allowed it, a group therapy experience might have  been able to help him with his ‘relationship issues’– but with one major proviso.  The treatment had to take place in a secure frame environment.

This simply means that the group leader and members are only known to each other in a clean fee-for-service relationship between patient and doctor.  And that members are only known to each other on a first name basis  and that they are otherwise anonymous to each other outside of the group.  That is, there is no  social contact apart from their roles as group members.  This is the way that I have run groups for over 30 years.  I do it this way for two reasons.  The first is to preserve confidentiality. Members must feel safe to say everything, knowing that nothing leaves the room. Second, when members have outside the group contact, at best the treatment is diluted, at worst it is contaminated. Not every group therapist practices the way that I do.  In some groups, members have all sorts of complicated outside the group contact.  In some circumstances, like small towns, rural areas, the military and group training institutes,  outside the group contact is inevitable.  This is not necessarily a bad thing, but it always has consequences for the treatment.  It is the leader’s responsibility to know when outside the group contact is potentially disruptive to the treatment or worse, when it does harm. Before giving an example, here’s a little background about group therapy.

 In recent years, group psychotherapy has emerged from its roots, as a little known and less respected  stepchild of individual therapy. It is now  a  recognized treatment modality for people with relationship problems, which to my mind covers just about everyone.  There are few people who have never experienced conflict with either personal or professional relationships. In individual psychotherapy patients tell the story of their life, their perception of who they are and why their lives are not where they want them to be.  In group therapy, it’s different.  Members re-create their relationships with significant others in their lives through their ‘as if’ relationships with the group members.  This is called– the transference. And while no one is  exactly  quite sure how this process happens, but it does. It means that members react to each other as they would react to important people in their lives, past and present. The group leader can actually see, in vivo, how members undermine themselves in relationships, rather than through the patient’s narrative.  This is something that an individual therapist can not directly observe and it is what gives group its healing power.

Popular notions of group therapy derived from TV and movies like: One Flew Over the Cuckoo’s Nest, The Bob Newhart and Anger Management, for example, have created a distorted image of what goes on in a well run therapy group.  At best,  group therapy looks silly, at worst, it looks evil.

The following stories compare to apparently similar group events that are actually quite different.  The major difference has to do with the blurring of boundaries between therapy and not therapy.  The outcomes are very disparate as a consequence of blurring this boundary in the second story.

A woman in her 20’s spent the first year of her individual treatment complaining about the harsh treatment that she was receiving at the hands of  her older sisters.  As the youngest of the three, she felt like an innocent victim of her sisters meanness.   She said that she felt like Cinderella with her wicked step sisters. I suggested group therapy because I thought that she needed support and I also had a hunch that there was more to the story than she was telling me.  It wasn’t that she was lying so much as it was that her ‘spin’ may have been self-serving. I didn’t have to wait very long to find out.

On her first night in group, and within the first half-hour of the meeting, she went around the room verbally abusing all the other female group members. I had to caution her to stop talking and listen for the rest of the group.  While there may have been an element of reality to her feelings of sibling rivalry– competitive and jealous feelings as the newcomer to the group, the intensity of her reaction was over the top. Since the group members were anonymous to each other, and she had no real life contact with any of them, I could reasonably assume that her reaction was mainly transference.  She actually had been a precocious new member by re-creating her family in the group right from the start. That was what was supposed to happen.  The ferocity of her verbal attack, however, alerted me to the possibility that she wasn’t necessarily her sisters’ victim but that she played a part in her own family discord.  I learned more about this dynamic of hers in that  first group session than in a year of individual therapy.  And although it took her awhile to see the connection between her own behavior and other members’ response to her, she learned that she could say that she felt competitive and jealous without acting those feelings out in the group.  Subsequently, her relationships with her sisters improved. In the next story, the outcome wasn’t as sanguine.

In a  group at a psychoanalytic group training  institute, under the direction of  a brilliant, authoritarian and charismatic figure, a member complained about the unfair distribution of perks of the organization that the leader’s inner circle was afforded. Loyalty to the leader was rewarded with such benefits as patient referrals, supervisory and teaching positions in the organization and so on.  The group knew her history of sibling rivalry with brothers and sisters in her family of origin.  Her real-life father played favorites and she wasn’t one of them. The group reminded her of this and characterized her grousing as transference, a relic from the past.  There was no validation that perhaps the group leader did indeed have an inner circle .  That is, the was some measure of truth to her assertion that members curried favor with him.  This phenomenon is known as “gaslighting”.  It is a term that is derived from the classic movie of the 1940’s, GASLIGHT, where the husband (Charles Boyer) attempts to drive the wife (Ingrid Bergman) mad by invalidating her perception of reality.  She is saved from ruin at the end of the movie by a handsome stranger (Joseph Cotton) who had been watching her slow deterioration from a distance.  The stranger saved the day by providing evidence, that the husband had been attempting to get rid of her,to drive her crazy and to place her in a mental hospital.  The woman in the group wasn’t so lucky.   In a personal communication to me, the member let me know that she left that meeting feeling anxious and depressed.

This story is different from the first one because she had complicated outside the group relationships with other members and with the leader.  She suffered when her view of reality was questioned.  The famous psychiatrist, R.D. Laing, was known to have said;” The fastest way to drive  someone mad is to undermine their perception of reality”.