CLINICAL COMMENTARY XXXII

Clinical Commentary

CLINICAL COMMENTARY XXXII

The patient’s experience of a group, with its particular atmospheres andcomplex interactions, can be very different from that of individual therapy.The contributors here say something of starting a group and the difficultiesthat probably exist at the outset of any therapy.

Sue Robinson

CLINICAL MATERIAL

This is a description of the first session of an outpatient psychotherapy groupin a large city hospital. The first session contained all the anxieties andconcerns that the text-books predict: confusion of the relevance of the groupto their problems, search for approval, acceptance, respect or domination,questioning of the rules and structure, concerns about the type of behaviourexpected, issues around dependency (Yalom 1985). In individual therapydependency is nurtured and regression may be encouraged. In the group,dependency behaviour, one of Bion’s (1961) basic assumptions, obstructsthe work of the group. Issues of dependency, apparent in any setting, can bemore evident in the group as it is a social setting. There is an amplificationof this behaviour and the techniques of the therapist in responding to it maybe different.

There are five members of the group – Jane, Daniel, Toby, Jonathan andMelissa. I had seen each member twice before the group began. BothJonathan and Melissa had failed to attend at least two individual sessionsoffered. Members had varied histories in so far as some had been inindividual therapy whilst others were new to therapy. Melissa hadoriginally been referred for therapy six years ago but had failed to engagepreviously.

All were present at the first session, although two arrived ten minutes afterthe group had started. The arrangement for the first session was that I wouldcollect all the group members from the outpatients’ waiting area. After that,members would have to make their way to the group room themselves.

Jane, Daniel and Toby were in the waiting area. Jonathan and Melissawere not – a repetition of the pattern already established in the individualsessions I had offered? We sat down in a row – me, Toby, Daniel and Jane.

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I gave my name, and said that I was the group therapist and repeated thetime of the sessions.

There was a brief silence. Jane said, ‘Are we supposed to introduceourselves?’ I said, ‘If you would like to.’ She said her name, then Daniel andToby did the same. Silence; about four minutes. It felt much longer to me;perhaps because I was feeling a pull from the group to be more active andthus relieve them of their anxiety about the unknown. Jane addressed me,quite annoyed, ‘What’s the point in coming if no one speaks. I don’t see howthat’s supposed to help me with my problem.’ Toby said, ‘I think we’resupposed to do it for ourselves.’ I felt that my silence was experienced bythe group as cruel and unkind and yet wanted to allow some of the need forstructure and guidance to become manifest.

Jane described herself as a stay-at-home mother. Toby had problemsdealing with people. He couldn’t handle confrontation. Daniel had been inan accident, lived at home with his father, and felt depressed.

There was another silence. Jane described herself as unable to relax. Shewas visibly highly anxious. Throughout the session all members kept theircoats on, except Melissa when she arrived. Toby and Jane began to talk inquite an animated fashion about not feeling relaxed. The flow dried up.

Jane asked if anyone had been in a group before. No. Toby had hadcounselling and hypnotherapy. Jane said, ‘Oh, I’ve had counselling too, butnot hypnotherapy.’ Toby said, ‘Counselling didn’t help.’ I wondered aboutthe anxiety about whether this experience would ‘help’.

Melissa and Jonathan arrived. Toby, who had been sitting next to me, bythe door, moved to give Melissa his seat. Jonathan sat in the empty seat onmy left side. There was silence. Jane said that they had introduced them-selves. Melissa and Jonathan gave their names.

There was another silence, then Toby said, ‘It’s awkward ’cos we don’tknow each other.’ Jane agreed, ‘It’s hard, I can’t bear the silences. That’swhy I had to speak.’ Jonathan had been in a group before and he was worriedit would be the same. He felt that in the silences. When he first came intothe room, he felt it was really claustrophobic. The other group had been ina bigger room. People were too close, it was too intense. He was coming tothe group because he felt depressed. There was a discussion about depres-sion. Jonathan, Toby and Daniel described ‘breakdowns’. Toby’s counsellorhad said that it was an emotional breakdown. Jonathan had not been ableto get out of bed all day. Toby had gone through a period like that. He wastaking ‘happy pills’ to help him. Jonathan said that he refused to take pills.He had before, but he had really tried to get off them. He didn’t want tobecome dependent on them. I wonder if there was a fear of becomingdependent on the group, and let down again. There was some disagreementbetween Toby and Jonathan about taking pills. The discussion faded out.

The group began to discuss the dark. It was more comfortable in the dark.Jonathan and Jane said that they didn’t like to go out, because people could

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see them. Toby didn’t care about people seeing him, but he slept all day, andwas up at night. Like a vampire. Daniel asked if depression was genetic.There seemed to be some agreement that it was. He said that he thoughtthat he was over-sensitive.

Jonathan suddenly responded, ‘I hate that ‘over-sensitive’ label, as if mencan’t be sensitive. I was labelled over-sensitive in my family. I really hatethat.’ Daniel said that he meant that his brother had a thicker skin than him.Conflict threatened but was immediately smoothed over, both by Danielappearing to apologize and Melissa interjecting: ‘Happy Valentine’s Day.’

Toby said that today was his anniversary with his girl-friend. They hadbeen together eight years. He had given her her present last night. She wasthe one that insisted that he come to the group. She was really pleased thathe had come. Jane said that she was doing it for herself; ‘I don’t like the wayI am.’ She had been this way for 15 years, since her son was born. Jane neverfelt loved by her mother. She never showed her any affection. She didn’twant to be like her mother, but she found that she was that way with herkids. She was really critical. She began to cry. Was this in response to thematerial she was sharing or the anxiety provoked by so immediatelyconfronting her defences? Jane and Toby were talking together, as if no oneelse was in the room. Were they pretending they were alone, having a‘normal’ conversation or was the group looking to them for direction?Jonathan interrupted. He could identify with that as he hated his mother.She was really unsupportive and never said ‘well done’. He never felt recog-nized by his mother. Toby said his father was very critical. ‘When he died Ionly cried for about 30 seconds. Then I found out he’d told other people thathe was proud of me, but he never told me. I always felt like he didn’t seeme, ’cos I was so different.’

I said that Valentine’s Day had been mentioned and then the discussionhad turned to critical and rejecting parents. I wondered if the group wasasking if there would be recognition and approval in the group. Did riskinglove mean rejection? Daniel said that he had been very moved when Janewas crying (he had had tears in his eyes). ‘Sometimes I can’t breathe.Things get stuck in my throat. If I get too conscious of what I’m eating Ican’t swallow.’ Jane said, ‘Me too.’ Toby said that he found it hard tobreathe sometimes. Jane said, ‘Me too.’ Would it be difficult to swallow thegroup?

Melissa asked Daniel if his brother had been treated differently. Danielsaid that when they were younger his brother had behavioural problems, butnot now. Melissa said, ‘I meant, did he get preferential treatment?’ Danielsaid, ‘Not really.’ I wondered if Melissa was questioning whether there wouldbe preferential treatment here? Who would be my favourite?

Jonathan wanted some confrontation, he wanted his views to be chal-lenged. Toby couldn’t handle confrontation; he backed down. One of hisformer bosses was always blaming him for mistakes that his boss had made.

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Daniel talked about walking away from confrontation. Jane asked Jonathan,if he was confronted by someone, didn’t he think he was right. Jonathan said,yes, on some things he was very clear about what he thought. Jane said thatshe was too. Toby said that he only found men confrontational. He got onwell with women. I was aware that the group members were anxious aboutconflict but I was reluctant to address it at this stage. Perhaps this was myown anxiety about wanting the first session to be ‘successful’1 rather thanthe idea that at the first session the group needed some ‘safety’ in order toreturn. Instead, I asked Toby if it felt confrontational to be in a group withmen. He looked at both men, and he said, ‘No. This is OK. Well, I don’tknow when the first row will be.’ I had told him before that the group mightbe difficult, and he had been warned. He asked Jane if she had been warnedthat the group might be difficult. She said, hesitantly, ‘I guess I have been.But if we all come back then it will be OK. I’m going to come back nextweek. If we don’t come back then it won’t work.’ Jonathan said that he wasglad he had come as it was good to find out that other people had problemsas well.

I said that I wondered if it was going to be OK to be confrontational inthe group. Jonathan hoped that there would be confrontation, otherwise itwould be very dry. Toby went back to talking about his father being reallycritical. It was as if nothing he did was right.

I was aware that Melissa had been silent (and Daniel hadn’t said much).‘I wonder if the group is concerned about the rules here, and if they willget them right.’ Melissa nodded. ‘Yes.’ The group became much moreanimated. Daniel, talking over Melissa, said, ‘Do you mean like lateness.’Melissa said that, when she came into the group she thought maybe I hadtold them what to do, as there was silence. ‘When I’ve been to seminars,the group leader says talk a bit about yourself, or why you are here. Maybeyou told everyone to just sit and relax for a bit. I thought that there wouldbe more structure.’

Jonathan said that he was glad there was no structure and people couldsay what they wanted. Then there was no pressure. Like Jane talking abouther mother. People could come in when they wanted. He didn’t want struc-ture. Melissa said, ‘I didn’t say I wanted structure, just that there didn’t seemto be any.’ There was a brief silence and then Jane said, ‘Everyone has saidsomething about themselves, except you. Do you want to say somethingabout yourself?’

Melissa said that she had been interested in people talking about criticalparents and she wanted to ask Jane, was there anything she thought wasgood about her mother. ‘Everyone is focusing on the negative. If you wantme to tell you everything that’s wrong with me, we’ll be here all night andyou’ll all fall asleep.’

Jonathan said, ‘That’s very interesting. I can see that there are somepositive things about my mother.’

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Melissa said that it seemed that everyone was finding out what they hadin common. She had a really critical parent as well. Her father. She didn’twant to be like her father. She doesn’t want to be that way, but she is reallyhard on herself. Perfectionist. She wants to get it right. Melissa said, to Jane,‘You said about being right, and I have to admit, that I know I’m right. Ithink that my way is the best way.’

It was time to end.

Note

1. My hesitation in addressing the conflict in the first session may have set a patternfor avoiding conflict which took many sessions to redress.

ReferencesBion, W.R. (1961) Experiences in Groups. London: Routledge.Yalom, I. (1985) The Theory and Practice of Group Psychotherapy. New York: Basic

Books.

COMMENTARY FROM A GROUP AND JUNGIAN ANALYST

The group therapist has to be a dynamic administrator responsible forcreating and maintaining the setting, monitoring and protecting the bound-aries and, simultaneously, has to undertake a therapeutic role, leadership,analysis, interpretation. The first session is a critical time in any group. Theearly developmental or formative process, dealing with issues of beingtogether, who’s who, what resources are there, what is the task, what are therules, and so on, is uppermost in the group therapist’s mind. The task at thisstage is to observe members’ entry into the group, to establish ground-rulesand boundaries and to provide a good container for whatever feelings maysurface, at the same time allowing room for movement and flexibility whilstmaintaining boundaries. This is the time to listen carefully, to learn, to wait,to hold and to let things emerge whilst learning the group language (andeach group has its own). Containing one’s own anxiety, always there at thebeginning of a new group, and dealing with the new group’s anxiety is aformidable and exacting task.

It is good preparation to see each member a few times before the start.Although we have little detail about the background of the individuals andeven less about the therapist’s own feelings before and during the session,early anxiety is evident. For example, the therapist stating his/her name andthe group times presumably is an indication of this as the patients have alreadymet the therapist. I have always found Foulkes’ dictum of ‘go in, sit down andkeep quiet’ very useful. The therapist’s comments start off the group and setit on a similar route: ‘Are we supposed to introduce ourselves?’ Might thegroup evolve in another direction if the therapist had said nothing?

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CLINICAL COMMENTARY XXXII