|
A problem of misunderstanding? In some settings I've heard
the term "process" used with at least three different meanings, two of which are
clinical. The first meaning is administrative, and systemic, as in process of
a business-model. Process as in procedure, I've observed, is what one colleague
(with tongue firmly in cheek) called 'a molasses-like movement of ideas or action
within a hierarchical system like, say, a hospital, or an agency'. That's what
people meant when they referred to a "process" unfolding. The second meaning refers
to the internal work of an individual's therapy, with therapeutic assistance being
that of a catalyst: the client is "processing" material, as in a working-through
of disclosures, as drawn out by a probing facilitator. The last meaning, that
which is most relevant to any discussion of a system's communication, or certainly
to any discussion of group therapy, is one which carries the least shared understanding,
and incurs the most resistance.
Perhaps it's an issue of application. The process
of group therapy that I'm referring to is the relational information that passes
between group members, versus the content-that is, the explicit words spoken,
the substantive issues, and the arguments advanced (Yalom, 1995). In this context,
process refers to a meta-communication between members, sometimes conveyed non-verbally.
In my role as group therapist, I am constantly on alert for these moments of multi-layered
communication, and as a supervisor, I am frequently urging other therapists-in-training
to observe patterns of process, and to orient their groups-in plainspoken terms--
to the value of learning from such exchanges. Reflecting upon these roles, group
therapist and supervisor (of, predominantly, group therapy), I begin to notice
an interesting array of resistances to the process-orientation. It calls to mind
an article by a Murray Bowen acolyte, Michael Kerr, entitled: "An Obstacle to
'hearing' Bowen Theory". In it, he wrote of the negative reactions of students
when observing the Bowen theory in practical application. Likewise, I repeatedly
observe the squirming in chairs, and the quiet sniff of distaste, when faced with
the prospect of making process comments in groups. Thinking
more broadly, maybe the issue is one of assimilation into systems. When speaking
of the contrast between outpatient groups with members of equal circumstances,
and those wherein one member of a family is admitted to an inpatient unit and
another participates on an outpatient basis, I draw attention to the relative
intensity of the latter groups. They don't go home together, I succinctly conclude;
there's no shared drive home in which individuals might recriminate one another
for things said in the just finished group meeting. The difference is important,
I assert. And so, there is a system beyond the present system to be concerned
with. Group therapy, especially of a process-oriented approach, contends with
this vast exterior system on a constant basis. I'm referring to social norms,
family norms, the norms that state, for example, that commenting upon the manner
of communication (especially of strangers), is rude, or at least disorienting. Consider
the following question, posed by a therapist to a new group with a homogenous
set of problems, composed of psychologically-minded members: "Does anyone in the
group have any feedback for what's happening between John and Sarah?" (I shall
deliberately exclude the content) Such a statement may be calling for group members
to comment upon how the exchange illuminates the relationship, though the question's
open-ended nature easily allows group members to choose a content-oriented response
instead. More than likely, members would select from the following options: a
review of the information provided by the two members, giving advice or otherwise
attempting to problem-solve for one or the other; offering acceptance, mirroring,
or a declaration of shared experience. Even in groups of motivated members, who
have been screened for group therapy, and oriented to the norms of the group process,
comments upon meta-communication are often withheld, or else left to the group
therapist to reveal. That's our job, I once heard a group member say. That
terse reply suggests clues to the resistance to process, a matter expanded upon
in Mathew Miles' essay, "On naming the Here & Now". In it, he writes that "here
& now" comments, those references to immediate events in a group that form the
nuts and bolts of the process orientation, recall the childhood experience of
being controlled and criticized. We remember being told to look at people when
we're speaking to them, to stop interrupting, and to take our hands out of our
pockets. If group therapy is to recreate this old experience, or even to just
provide echoes of it, then it would be infantilizing. Furthermore, Miles writes,
such a focus would intensify self-consciousness, and render a discussion of communication
more complex, if not overwhelming. A content focus is, therefore, safer and easier.
Of course, group therapy is intended to do more than merely draw attention to,
or even correct, all manner of verbal and non-verbal behaviors. What distinguishes
the here & now focus from this disconcerting social template, is what Yalom refers
to as the second tier of the here & now focus, that of process illumination.
This is the dimension that provides examination, and understanding. Ultimately,
it calls on members to follow the track of their exchanges, reflect upon them,
and draw a non-judgemental learning experience as to how they relate to others. All
of which becomes more fascinating when thinking of groups with adolescents, or
groups with so-called "low functioning" populations. Consider some of the terms
or ideas already used or referenced in this article: hierarchy, self-consciousness,
infantilizing, problem-solving, group safety. The reader can begin to gain an
idea as to why certain populations would resist process-orientation, or else why
mental health professionals would resist it on their behalf. Recall Wilfed Bion's
three basic assumptions of group life. The first basic assumption is one he called
dependence. In a basic dependent group, one notices the group searching for an
oracle or a deity, from which all security, nourishment, and direction come (Bion,
1961). Especially in hospitals, where little, if any, orientation is provided
as to group therapy, we can imagine why adolescents would readily adhere to hierarchies
and depend upon a leader, but why they might also bristle at a therapist that
constantly drew attention to their mannerisms, or syntax, assuming a critical
intent on the part of the therapist. We can also understand why highly anxious
individuals, accessing treatment in order, primarily, to relieve symptoms, might
be disoriented by a therapeutic approach that, for example, re-directs questions
away from the facilitator, but rather towards the group, and which constantly
seeks to decentralize the group tasks. This approach places implicit responsibility
upon the group to self-activate. This question of client/patient, or group responsibility
for change versus therapist responsibility for the process (here, as in procedure)
of change, is one which all therapists must address, repeatedly. The meaning of
the That's your job rebuke is to resist shared responsibility. And
yet moments of spontaneity and individuation do occur, even if they are cast as
indicators of a resistant pathology. This is particularly true in adolescent groups,
and there is some irony here, as it is adult facilitators who, as often as not,
resist the process orientation. Consider the following brief exchange: Client:
(upon receiving a series of facilitator questions) "I feel like you're cross-examining
me!" Therapist:
"But do you see the point I was trying to make?" Client:
"I don't care. These questions are stupid" Therapist:
"Remember, this process is not about me" |
| |
The
adolescent client in this instance has made, in effect, a process comment, one
which the therapist has ignored. In speaking to many group therapists about this
kind of exchange, I've come across a few interesting pretexts for why the therapist
would choose this tact. First of all, that the group's primary task may have been
that of addressing problem behaviors, with special attention to attendant defensive
thinking. The process comment in the above scenario was deemed a deflection, a
defensive maneuver by the group member, and so a process exploration, one that
was interpretative, but not directive, would have been misguided. Secondly, many
group therapists rightfully concern themselves with group safety, and so err on
the side of containment of affect. Indulging process may lead to an escalation,
a stirring of high anxiety, or scapegoating, with problematic implications for
the later stability of the hospital unit, or else that previously indicated ride
home. "I was concerned that the group may become overwhelmed", said one facilitator,
explaining why she consistently deferred on making process interventions. She'd
actually begun the group with the glib pronouncement that the group's main purpose
was to explore patterns of communication, but as the group progressed, the term
"communication skills" replaced 'explore", and so a more didactic intent became
apparent. This was perhaps recognized by the assembled adolescents, whose largely
passive participation betrayed an unconvinced air.
Perhaps it's a question of priorities, or of assessment. It's
undoubtedly true that some clients are sufficiently dysfunctional (either in terms
of ego boundaries, or else cognitive ability), that the process-oriented approach
is too disorienting. Imagine a highly anxious group member, whose internalization
of even the most carefully neutral of interpretations evokes a panicked inference
of criticism, if not accusation. Although, one might argue that even this individual
might benefit, ultimately, from hearing different perspectives upon communication.
Furthermore, group dynamics take place within a broader context, no matter how
hard they try to create self-containment (no outside relationships as a group
rule, for example). Groups in hospital settings cannot realistically contain contact
outside of group meetings, they cannot eliminate the lack of cohesion borne of
high turnover, or ignore that destabilizing consequences of group disorientation;
and they cannot easily take neutral stances towards the varying types of self-destructive
behaviors that are often the presenting reasons for therapy. I
think it's really a matter of integrating the process-oriented approach, rather
than dismissing it as contrary to the priorities of, say, behavior modification,
or symptom reduction. In my work with adolescents, in particular, I observe a
strain of conservatism that leads to a quasi-parental dynamic between client and
clinician. It's been interesting to notice that in certain modalities (art therapy,
and drama therapy) some of the inhibiting qualities of regular talk therapy are
diminished. Self-consciousness is often reduced, for example, if disguised in
a character. Furthermore, I've noticed the symbolic disguise of art, and drama
allows for a practice of process illumination that might otherwise feel too intense,
too real. The explicit disclosure of true thoughts and feelings is often perceived
as too threatening by adolescents. When loss of esteem, or rejection, is at stake,
truth is a risk, and its disclosure requires a sensitive development of trust.
Adolescents often defend against this risk by projecting the dilemma onto adults,
particularly parents: "I want to gain their trust". A
more thorough depiction of group dynamics with adolescents is provided by Pressman,
Kymissis, and Hauben's 2001 article: "Group Psychotherapy for Adolescents Comorbid
for Substance Abuse and Psychiatric Problems: A Relational Constructionist Approach"
In this description of a combined day treatment and high school program, the authors
posit several observations about adolescents in treatment: that adolescents construct
acceptance and personal meaning through role-defined, non-hierarchical relations;
that conflict resolution involves the emergence of overwhelming feelings that
comorbid adolescents cannot control; that they may require extended orientation
to group therapy, and may initially engage groups in a rebellious fashion; that
the primary challenge for the patients is to learn self-control and trust of others;
finally, and most crucially, that negative countertransference can be avoided
when staff members do not feel intense responsibility and need for control. The
program structure and pattern of interventions reflect many of these baseline
assumptions. The hierarchy of the program is decentralized, for example, de-emphasizing
a "charismatic" leader, and instead implementing a multidisciplinary team. This
tended to mitigate rebellious action. Empathy as a leading intervention, is emphasized,
allowing space to de-pathologize patient behavior. Staff would empathize with
the adolesents' resistance to treatment, rather than coaching a premature cohesiveness.
Empathy with parents' distress replaced collusion with the need for punitive,
rigid responses designed to influence negative behaviors. In the article, examples
are given of aggressive gestures, horseplay, sexual innuendos between patients
and staff, that are met with largely interpretive response (only the example of
the aggressive gesture led to a patient being removed from group); ultimately,
that example, also was treated with an interpretive response, rather than a strictly
directive intervention. Above all, while not strictly identical to a process-orientation,
the above-described model presents two provocative challenges that speak directly
to what is, perhaps, a systemic resistance to process: 1.) That the ability for
adolescents to express angry feelings is more important than maintaining strict
unit order, and 2.) That a lack of strict adherence to subject matter of the group
allows staff to keep abreast of the adolescents' thoughts and feelings. The
first time someone walked out of a group I was facilitating, I felt in my heart
that I'd done something wrong. That action, combined with the group's subsequent
blaming of the departed individual (I was briefly relieved, but ultimately confused),
seemed to violate some ill-defined notion of leadership. In this article, I've
reviewed what I've observed as the resistance to a process-orientation, within
a variety of different types of groups, but with particular attention to group
therapy with adolescents. I've implicitly advocated for a style of group facilitation
that challenges order, hierarchy, even what some may term safety, and in doing
so entered that ambiguous space wherein client/patient and therapist responsibility
is negotiated. Once again. REFERENCES
Kerr,
Michael E., MD (1991) "An Obstacle to 'Hearing' Bowen". Family Center Report,
Volume 12, No. 4. Pressman,
Mary A., MD, Kymiss, Paul, MD, Hauben, Richard, C.A.C (2001) "Group Psychotherapy
for Adolescents Comorbid for Substance Abuse and Psychiatric Problems: A Relational
Constructionist Approach". International Journal of Group Psychotherapy,
51(2) Yalom,
Irvin (1995) The Theory and Practice of Group Psychotherapy. Fourth Edition.
Basic books Miles,
Mathew (1970) "On Naming the Here and Now" unpublished essay, Colombia University.
The Theory and Practice of Group Psychotherapy. Fourth Edition. Basic books Bion,
Wilfred (1961) "Experiences in groups and other papers" New York: Basic books.
Disorders of Self, New Therapeutic Horizons (1995) Edited by James F. Masterson,
MD, and Ralph Klein, MD. Brunner/Mazel, Inc.
|