Whom BY
to Refer
HENRY
for
GRUNEBAUM,
Group M.D.,
AND
Psychotherapy WILLIAM
KATES,
M.D.
the clinic conclusive.
The authors believe that group psychotherapy is a useful modality in terms ofboth economic use of resources and manpower and effective treatment for many common problems. Three major indications for group therapy are inappropriate patterns of interpersonal relationships, the tendency to act immediately onfeelings, and the potential or existence ofa transference that impedes individual therapy. Patients in these categories who are also in crisis or have a neuroticproblemfor which the development of a transference neurosis is indicated may require individual therapy instead ofor in addition to group therapy. The attitude ofthe referring physician is crucial; he/she must provide support during the transition and must believe that group therapy can substantially benefit the patient.
How, In answer
setting
PAPER
will
present
a clinical
perspective
clinical guidelines that scepticism of scientific
vides
economic
use
of staff
time
it is an appropriate and of common problems.
Discussion
of referrals
for
and
energy,
effective
necessary.
group
but
for
is
often clouded by strong ideological opinions-typically, the feeling that group therapy is “second-rate treatment.” Such a position is often reinforced by clinicians having had rewarding personal experiences in individual psychotherapy or analysis but no such experiences in group psychotherapy. However, a review of the literature on the effectiveness of group and individual psychotherapy (1) suggested that there is no scien-
tific reason to believe that individual therapy is superior to group therapy. The most carefully controlled study (2) was of discharged but previously hospitalized schizophrenics and found that group therapy was more effective than individual therapy carried out by the same therapists. Other studies of treatment outcome in
The authors Cambridge,
are with the Mass. 02138,
Cambridge
Hospital,
1493
Cambridge
St.,
where Dr. Grunebaum is Director of Family and Group Psychotherapy Training and Dr. Kates is Staff Psychiatrist. Dr. Grunebaum is also Associate Clinical Professor of Psychiatry and Dr. Kates is Clinical Instructor of Psychiatry, Harvard Medical School.
130
Am J Psychiatry
134:2,
February
1977
or
Individual
in-
modalities to be chosen? we have arrived at a set of
reflect a position outcome studies
between and the
treatment
is conceived
the con-
of mdiseems
of as is.
also
psychotherapy
designed
sue-focused, insight-oriented psychotherapy This therapy is long-term and involves considerable activity by the therapist, with careful attention to the transference, and has been well described by Malan (3), Balint and associates (4), and Balsam and Balsam (5). Group treatment is also seen as long-term, occurring in a stable group of peers where the members are provided opportunities for demonstrating habitual difficulties in
on the
treatment
poorly
viction of preference and ideology. At this point, a brief description of the kinds vidual and group treatment we are discussing
frequently asked question, How do you decide whether to refer a patient for group or for individual psychotherapy? We believe that group therapy is a useful treatment modality for many patients seeking help in an outpatient clinic setting, not only because it probecause a number
been
then, are treatment to that question,
relationships THIS
have
(being)
and
for trying
out
new
styles
of
relating (becoming). The leader’s task is to foster mature peer relations and growing intimacy while keeping the focus not on himself and the transference but on the group members and their feelings about each other. Yalom (6) has presented a similar perspective on group therapy. The patient population with whom we are concerned
is the broad range of adults who come to the outpatient department of a mental health center or general hospital. These adults (excluding addicts, alcoholics, delinquents, psychotics, and older people, who ferent problems in choice of treatment have neurotic, characterological, borderline,
tional having cellent
problems. They are perceived the potential to benefit from candidates
for
psychotherapy.
present difmodalities) and situa-
as treatable, as insight, and as exChoice
of treat-
ment modality becomes an urgent question as the clinic year progresses and all individual therapy time is filled. Group therapy referrals are then made because “nothing else is available,” and many therapists feel that they are referring first-class patients fo secondclass treatment. The clinic is forced to consider the question as it is usually phrased: “Whom shall we refer to group or individual therapy?” Our clinical experience suggests a more effective formulation of this question that can help clinicians to use therapeutic resources more rationally as well as provide more flexible opportunities for patient growth. In this view, one particular kind of patient is not assigned to one kind of treatment; rather, over time the patient
is referred flexibly ful for the pattern
to the treatment modality of action that he/she
most usewishes to
HENRY
change.
Decisions
made
several
ment
at the
MAJOR
about
times
treatment
in the
alternatives
course
of a patient’s
may
be
treat-
clinic.
INDICATIONS
FOR
GROUP
PSYCHOTHERAPY
Faulty
Interpersonal
First, group treatment seems stand and change patterns of relationships, particularly with sex (although we have also seen mosexual
relationships).
The
to help patients underdifficult interpersonal people of the opposite these difficulties in ho-
difficulties
are often
man-
ifested in one of three ways: 1) withdrawal from relationships, 2) multiple transient relationships, and 3) very sticky and overdependent relationships, often with inappropriate partners. Ms. A, a 22-year-old secretary, had been terrified of men since adolescence, when her aunt was raped. She was referred to group therapy because her individual therapist was concerned that she knew nothing about sex and sexuality. It was suggested that she learn to talk to men before becoming sexually involved. Gradually, over the course of a year in group treatment, she reported that she was talking to men at work and having lunch with them for the first time.
Mr. B, a 37-year-old architect, had had long periods in his life when he lived alone and saw only a few old friends. However, there were also periods when he became sexually involved with women who were usually uneducated but quite motherly. As he became increasingly involved and they began to care for him, his feelings ofdesire gradually turned to contempt. In the group, his need to look down on people was brought forcefully to his attention and this behavior slowly changed. Concurrently, his efforts to relate warmly were rewarded by the group’s increasing enjoyment of his intelligent and witty assessments of situations. The group provided both ofthese a chance to get to know members
gradually and safely. patient often is unable other sex since he/she sient, uncaring, casual
fearful of the
people opposite
with sex
Similarly, the promiscuous to get to know members of the relates predominantly in a tranway.
Mr. C was a businessman who made ing which he conducted both business
frequent trips durand sex. When he in the group, it was
became attached to one of the women not possible for him to deal with her casually as had been his pattern in the past. He had to deal with her as a whole person week after week, which provided him an opportunity to study his conflicts regarding intimacy. He gradually came to see that intimacy was possible and more rewarding than his previous patterns.
The interpersonal ples are manifestations
patterns described of the patient’s
defined as the ego-syntonic personality (as opposed
aspects to neurotic
in these character,
examhere
of an individual’s or ego-alien fea-
AND
WILLIAM
KATES
tures). Guttmacher (7) has also written about the efficacy of group psychotherapy in the treatment of character problems. Confronting aspects of a patient’s character in individual therapy is often hazardousconfrontation may be experienced as rejection rather than as help. Commenting on a patient’s boring tone of voice, provocative or seductive behavior, or sense of entitlement
Patterns
GRUNEBAUM
may
sound
to the
patient
like
a statement
of the therapist’s personal feelings and opinions rather than factual observation. In group therapy, character patterns such as those in the examples above are not described
but
are
instead
experienced
in the
actual
in-
teractions in the group. Since reactions to the patient are multiple, confrontations are modulated and made possible by the simultaneous offer of support and empathic identification. The skillful leader can, if necessary, regulate the force and sadism of the confrontation. Confrontation more readily mon “sibship” more friendly
see their
by a that of the and less
than
own
experience
characterological both
ously. The participation
A man from man who was have difficulty
‘
same
‘Of course,’
support
One
need
not
and vicari-
for silent to par-
always
be
in the
a grouse hunting family was told by another also to the manor born that he seemed to accepting his ‘ ‘aristocratic roots. ‘ ‘ When
in anger,
the
in others
and
focus in the group allows the patient is too threatened
ticipate more directly. “hot seat” in a group.
from
problems
confrontation
shifting when
he replied
peer is received and accepted offered by a “parent.” The commembers makes the experience rejecting. Finally, members can
‘
‘
‘You
only
know
sort of family, ‘ defused the anger
‘
that
because
you are
the soft-spoken and demanded
rejoinder, an honest
interfere
patients’
self-scrutiny.
Many
of
the
patterns
that
with
relationships with others do not reflect regression in the face ofunconscious conflict but seem instead to result from early deprivation and fixation. Uncovering and interpretation of conflict do not seem useful for these kinds ofproblems. Balint (8)labeled the predicament
ofthe
her
need py, with tionships, emotional
modes Impulsive
patient
“the
for “healing, its supportive can often experience
of relating
basic
that
and
fault”
and
described
his/
not explaining.” Group theraatthosphere and multiple relaprovide some of the corrective move
allows
people
beyond
to try
fixated
out
new
patterns.
Behavior
A considerable number of young adults find it difficult to control the need to act immediately on their feelings. The unique advantage of group therapy is that some members of the group become participants in the patient’s characteristic pattern of action while others serve as the chorus to the drama, commenting on the behavior. The psychotherapist conducting individual therapy often finds it more difficult to be both participant and observer. The temporal simultaneity or conAmfPsychiatry
134:2,
February
1977
131
WHOM
TO
REFER
FOR
GROUP
PSYCHOTHERAPY
tiguity of action and commentary tend to force the patient to examine feelings underlying the action. Commentary from other group members is experienced, as noted earlier, as less threatening than that from the therapist. The actual data of the patient’s behavior are available to the therapist, and his/her comments can take
into
account
all parties
in the
interaction,
focusing
attention on initiators, recipients, and witnesses. For instance, he/she can say: “It appears that Tom gets himself attacked, something Steven is only too happy to engage in, while Mary says, ‘Let’s you and him fight’.” The therapist can see first-hand how the patient gets himself attacked. These data are much harder The
to come problem
within
the
leading
by in individual for the therapist
group,
to intimate
i.e.,
therapy. is to contain
to prevent
subgroups,
sexual or anger
the
feelings
action
from
to fragmenta-
tion. Responsibility for group boundaries and rules are shared by the leader and members. The more disturbed and fragmented the members, the more responsibility the leader must take for group rules. With healthier patients, responsibility for group rules is given to members. In discussing these rules and their infringements, group members can learn about the feelings that underlie action. It is our belief that the group leader should strive to make the group a setting in which interpersonal relationships and personal expression can be approached playfully. Like play, the expression of real feelings and reactions need not have weighty consequences in action but instead can be an opportunity for learning.
feelings about the leader. Peers view of the therapist as a human and idiosyncracies. Mr. E joined
the group
despite
can present being with
a realistic limitations
the fact that he believed
the therapist was insufficiently experienced to help him. A referral by the group therapist to an individual therapist was unsuccessful. The patient could not find the right therapist and derogated the efforts of the group leader. The group repeatedly pointed out to him that he wanted a god, not a human being, as a therapist. They also told him that he talked down to the therapist as though he thought of himself as superior. He was eventually able to accept a referral-this time to a woman, even though he believed “no woman could know enough to help me.” He was able to agree with the group therapist that seeing a woman therapist would enable him to detour his need to expect too much of certain men and his disappointment with their failures. The new therapist and patient were able to begin productve work within a short time.
Finally,
the
acceptance
by the
patient
of the
limita-
of the transference object is greatly enhanced by the real gratification provided by the multiple relationships offered in the group. All demands for gratification are not focused on one limited being (the therapist). When life or death is dependent upon the vicissitudes of an untestable transference, as is often the case with some suicidal patients, the addition of group therapy multiplies the possibilities of gratification and reduces the all-or-none impact of the individual transference. tions
Transference SUMMARY
Group therapy is extremely useful when predicted or existing transference cannot be placed in perspective by the patient who insists on the “reality” of feelings. Szasz (9) has emphasized that transference interpretations always involve reality testing and that the patient must be able to experience certain feelings as being inappropriate to the therapeutic relationship. If the patient is unable to do this, therapist and patient have a difference of opinion rather than an opportunity for understanding. Dealing with such problems is easier in the group, which offers the patient several unique opportunities. The reality-testing clarifications are offered by peers rather than by the object of the transference distortions; thus they can be more readily accepted by the patient. Ms. D was a waif-like young woman who had almost no relations with her family and required constant support from her therapist. Moreover, she sought a second therapist on whom she also made demands. In the group she felt that
the
rejecting not only worried
her. The other group members did she get her share of attention that she was the leader’s favorite.
Members sharing the 132
Am
therapist,
by
not
gratifying
her
of the group can support the perspective they have gained
J Psychiatry
134:2,
February
1977
wishes,
was
pointed out that but they were
AND
There
are
uniquely
three
types
of
problems,
then,
the
the power
necessary
support
of transference and if the patient
is over three major
from
in group of interpersonal
that
individual
problem
areas
to group of group
the patient is extremely trustful of others. This populations and among
that
therapy: relationships
are
1) unsatisfying patterns 2) tendencies to put feelings immediately into action, and 3) the potential to develop a transference that will be difficult to interpret and study. Although these problems are often associated with one another, the presence of any one of them is sufficient to suggest referral to a group. This referral may require modification if, for example, the patient is also in crisis. Patients in crisis require immediate help and intervention that is best supplied by individual therapy. Unless the group is organized around a shared common crisis (e.g., natural groups like mourners or arranged groups like heart attack victims), group cohesion does not take place rapidly enough to provide the new member with
approachable
Modification
patient by on similar
CONCLUSIONS
individual
can provide. wants help we have
therapy referral
therapy
,
and
After the crisis with one of the
described,
referral
is indicated. is also
required
when
paranoid and severely misis often the case in inpatient drug addicts, and techniques
HENRY
and goals of group therapy must be modified accordingly. Examples of such modifications are mandatory treatment, introduction of co-leaders, and increased frequency of group meetings. The leader may need to focus his/her expectations on helping group members to tolerate being in each other’s presence, with confrontations
kept
The third tion of group ic problems ence best
to a minimum.
set of circumstances referral is the existence
requiring modificaof specific neurot-
for
which the development of a transferneurosis and its analysis are indicated. This can be achieved in individual therapy or analysis,
growth, patients.
2.
Int J Group
O’Brien
CP,
478,
person that groups have much her ongoing support during therapy and often for some
Groups
must
this
type
of patient.
be seen
as useful
to offer patients and his/ the transition to group time after its beginning.
places
for change
and
with
WILLIAM
KATES
for second
-class
DH:
Charles
RM,
9.
et al: Group
Arch
of Brief
Gen
vs individual
on psy-
Psychiatry
Basic
Brown
and
Books,
J: The
therapy.
27:474-
Springfield,
Ill,
Focal Psychotherapy: Philadelphia, JB
concept
a Psychotherapist:
& Co.
Practice
A Clinical
1974
of Group
Psychotherapy.
of character, character Psychiatry 14:513-522,
Fault-Therapeutic Publications,
Szasz T: The communication ent. BrJ Psychol 32:161-170,
J Psychiatry
An ExLippincott
1970
Compr
M: The Basic Tavistock
E:
A: Becoming
Little,
Am
Psychotherapy.
PH, Balint Psychoanalysis.
ID: The Theory York,
Guttmacher Balint London,
BA,
research
1975
1963
Balsam
Boston,
and group 8.
A Study
Balint M, Ornstein ample of Applied Co, 1972
New
Ray
schizophrenics.
C Thomas,
Primer.
7.
KB,
of hard-nosed
25:185-197,
1972
3. Malan 4.
review
Psychother
Hamm
chotherapy
6. Yalom
for
by the patient of a referral to group on both the conviction of the referring
treatment
H: A soft-hearted
groups.
supplement
to treatment
not as second-class
1. Grunebaum
5. Balsam
acceptance depends
AND
REFERENCES
where the search for an answer to the question, “How did I get to be this way” is also best pursued. Concurrent or subsequent group therapy may be a useful The therapy
GRUNEBAUM
problems, 1973
Aspects
of Regression.
between
child
1968
of distress 1959
134:2,
February
1977
and
par-
133
to Refer
HENRY
for
GRUNEBAUM,
Group M.D.,
AND
Psychotherapy WILLIAM
KATES,
M.D.
the clinic conclusive.
The authors believe that group psychotherapy is a useful modality in terms ofboth economic use of resources and manpower and effective treatment for many common problems. Three major indications for group therapy are inappropriate patterns of interpersonal relationships, the tendency to act immediately onfeelings, and the potential or existence ofa transference that impedes individual therapy. Patients in these categories who are also in crisis or have a neuroticproblemfor which the development of a transference neurosis is indicated may require individual therapy instead ofor in addition to group therapy. The attitude ofthe referring physician is crucial; he/she must provide support during the transition and must believe that group therapy can substantially benefit the patient.
How, In answer
setting
PAPER
will
present
a clinical
perspective
clinical guidelines that scepticism of scientific
vides
economic
use
of staff
time
it is an appropriate and of common problems.
Discussion
of referrals
for
and
energy,
effective
necessary.
group
but
for
is
often clouded by strong ideological opinions-typically, the feeling that group therapy is “second-rate treatment.” Such a position is often reinforced by clinicians having had rewarding personal experiences in individual psychotherapy or analysis but no such experiences in group psychotherapy. However, a review of the literature on the effectiveness of group and individual psychotherapy (1) suggested that there is no scien-
tific reason to believe that individual therapy is superior to group therapy. The most carefully controlled study (2) was of discharged but previously hospitalized schizophrenics and found that group therapy was more effective than individual therapy carried out by the same therapists. Other studies of treatment outcome in
The authors Cambridge,
are with the Mass. 02138,
Cambridge
Hospital,
1493
Cambridge
St.,
where Dr. Grunebaum is Director of Family and Group Psychotherapy Training and Dr. Kates is Staff Psychiatrist. Dr. Grunebaum is also Associate Clinical Professor of Psychiatry and Dr. Kates is Clinical Instructor of Psychiatry, Harvard Medical School.
130
Am J Psychiatry
134:2,
February
1977
or
Individual
in-
modalities to be chosen? we have arrived at a set of
reflect a position outcome studies
between and the
treatment
is conceived
the con-
of mdiseems
of as is.
also
psychotherapy
designed
sue-focused, insight-oriented psychotherapy This therapy is long-term and involves considerable activity by the therapist, with careful attention to the transference, and has been well described by Malan (3), Balint and associates (4), and Balsam and Balsam (5). Group treatment is also seen as long-term, occurring in a stable group of peers where the members are provided opportunities for demonstrating habitual difficulties in
on the
treatment
poorly
viction of preference and ideology. At this point, a brief description of the kinds vidual and group treatment we are discussing
frequently asked question, How do you decide whether to refer a patient for group or for individual psychotherapy? We believe that group therapy is a useful treatment modality for many patients seeking help in an outpatient clinic setting, not only because it probecause a number
been
then, are treatment to that question,
relationships THIS
have
(being)
and
for trying
out
new
styles
of
relating (becoming). The leader’s task is to foster mature peer relations and growing intimacy while keeping the focus not on himself and the transference but on the group members and their feelings about each other. Yalom (6) has presented a similar perspective on group therapy. The patient population with whom we are concerned
is the broad range of adults who come to the outpatient department of a mental health center or general hospital. These adults (excluding addicts, alcoholics, delinquents, psychotics, and older people, who ferent problems in choice of treatment have neurotic, characterological, borderline,
tional having cellent
problems. They are perceived the potential to benefit from candidates
for
psychotherapy.
present difmodalities) and situa-
as treatable, as insight, and as exChoice
of treat-
ment modality becomes an urgent question as the clinic year progresses and all individual therapy time is filled. Group therapy referrals are then made because “nothing else is available,” and many therapists feel that they are referring first-class patients fo secondclass treatment. The clinic is forced to consider the question as it is usually phrased: “Whom shall we refer to group or individual therapy?” Our clinical experience suggests a more effective formulation of this question that can help clinicians to use therapeutic resources more rationally as well as provide more flexible opportunities for patient growth. In this view, one particular kind of patient is not assigned to one kind of treatment; rather, over time the patient
is referred flexibly ful for the pattern
to the treatment modality of action that he/she
most usewishes to
HENRY
change.
Decisions
made
several
ment
at the
MAJOR
about
times
treatment
in the
alternatives
course
of a patient’s
may
be
treat-
clinic.
INDICATIONS
FOR
GROUP
PSYCHOTHERAPY
Faulty
Interpersonal
First, group treatment seems stand and change patterns of relationships, particularly with sex (although we have also seen mosexual
relationships).
The
to help patients underdifficult interpersonal people of the opposite these difficulties in ho-
difficulties
are often
man-
ifested in one of three ways: 1) withdrawal from relationships, 2) multiple transient relationships, and 3) very sticky and overdependent relationships, often with inappropriate partners. Ms. A, a 22-year-old secretary, had been terrified of men since adolescence, when her aunt was raped. She was referred to group therapy because her individual therapist was concerned that she knew nothing about sex and sexuality. It was suggested that she learn to talk to men before becoming sexually involved. Gradually, over the course of a year in group treatment, she reported that she was talking to men at work and having lunch with them for the first time.
Mr. B, a 37-year-old architect, had had long periods in his life when he lived alone and saw only a few old friends. However, there were also periods when he became sexually involved with women who were usually uneducated but quite motherly. As he became increasingly involved and they began to care for him, his feelings ofdesire gradually turned to contempt. In the group, his need to look down on people was brought forcefully to his attention and this behavior slowly changed. Concurrently, his efforts to relate warmly were rewarded by the group’s increasing enjoyment of his intelligent and witty assessments of situations. The group provided both ofthese a chance to get to know members
gradually and safely. patient often is unable other sex since he/she sient, uncaring, casual
fearful of the
people opposite
with sex
Similarly, the promiscuous to get to know members of the relates predominantly in a tranway.
Mr. C was a businessman who made ing which he conducted both business
frequent trips durand sex. When he in the group, it was
became attached to one of the women not possible for him to deal with her casually as had been his pattern in the past. He had to deal with her as a whole person week after week, which provided him an opportunity to study his conflicts regarding intimacy. He gradually came to see that intimacy was possible and more rewarding than his previous patterns.
The interpersonal ples are manifestations
patterns described of the patient’s
defined as the ego-syntonic personality (as opposed
aspects to neurotic
in these character,
examhere
of an individual’s or ego-alien fea-
AND
WILLIAM
KATES
tures). Guttmacher (7) has also written about the efficacy of group psychotherapy in the treatment of character problems. Confronting aspects of a patient’s character in individual therapy is often hazardousconfrontation may be experienced as rejection rather than as help. Commenting on a patient’s boring tone of voice, provocative or seductive behavior, or sense of entitlement
Patterns
GRUNEBAUM
may
sound
to the
patient
like
a statement
of the therapist’s personal feelings and opinions rather than factual observation. In group therapy, character patterns such as those in the examples above are not described
but
are
instead
experienced
in the
actual
in-
teractions in the group. Since reactions to the patient are multiple, confrontations are modulated and made possible by the simultaneous offer of support and empathic identification. The skillful leader can, if necessary, regulate the force and sadism of the confrontation. Confrontation more readily mon “sibship” more friendly
see their
by a that of the and less
than
own
experience
characterological both
ously. The participation
A man from man who was have difficulty
‘
same
‘Of course,’
support
One
need
not
and vicari-
for silent to par-
always
be
in the
a grouse hunting family was told by another also to the manor born that he seemed to accepting his ‘ ‘aristocratic roots. ‘ ‘ When
in anger,
the
in others
and
focus in the group allows the patient is too threatened
ticipate more directly. “hot seat” in a group.
from
problems
confrontation
shifting when
he replied
peer is received and accepted offered by a “parent.” The commembers makes the experience rejecting. Finally, members can
‘
‘
‘You
only
know
sort of family, ‘ defused the anger
‘
that
because
you are
the soft-spoken and demanded
rejoinder, an honest
interfere
patients’
self-scrutiny.
Many
of
the
patterns
that
with
relationships with others do not reflect regression in the face ofunconscious conflict but seem instead to result from early deprivation and fixation. Uncovering and interpretation of conflict do not seem useful for these kinds ofproblems. Balint (8)labeled the predicament
ofthe
her
need py, with tionships, emotional
modes Impulsive
patient
“the
for “healing, its supportive can often experience
of relating
basic
that
and
fault”
and
described
his/
not explaining.” Group theraatthosphere and multiple relaprovide some of the corrective move
allows
people
beyond
to try
fixated
out
new
patterns.
Behavior
A considerable number of young adults find it difficult to control the need to act immediately on their feelings. The unique advantage of group therapy is that some members of the group become participants in the patient’s characteristic pattern of action while others serve as the chorus to the drama, commenting on the behavior. The psychotherapist conducting individual therapy often finds it more difficult to be both participant and observer. The temporal simultaneity or conAmfPsychiatry
134:2,
February
1977
131
WHOM
TO
REFER
FOR
GROUP
PSYCHOTHERAPY
tiguity of action and commentary tend to force the patient to examine feelings underlying the action. Commentary from other group members is experienced, as noted earlier, as less threatening than that from the therapist. The actual data of the patient’s behavior are available to the therapist, and his/her comments can take
into
account
all parties
in the
interaction,
focusing
attention on initiators, recipients, and witnesses. For instance, he/she can say: “It appears that Tom gets himself attacked, something Steven is only too happy to engage in, while Mary says, ‘Let’s you and him fight’.” The therapist can see first-hand how the patient gets himself attacked. These data are much harder The
to come problem
within
the
leading
by in individual for the therapist
group,
to intimate
i.e.,
therapy. is to contain
to prevent
subgroups,
sexual or anger
the
feelings
action
from
to fragmenta-
tion. Responsibility for group boundaries and rules are shared by the leader and members. The more disturbed and fragmented the members, the more responsibility the leader must take for group rules. With healthier patients, responsibility for group rules is given to members. In discussing these rules and their infringements, group members can learn about the feelings that underlie action. It is our belief that the group leader should strive to make the group a setting in which interpersonal relationships and personal expression can be approached playfully. Like play, the expression of real feelings and reactions need not have weighty consequences in action but instead can be an opportunity for learning.
feelings about the leader. Peers view of the therapist as a human and idiosyncracies. Mr. E joined
the group
despite
can present being with
a realistic limitations
the fact that he believed
the therapist was insufficiently experienced to help him. A referral by the group therapist to an individual therapist was unsuccessful. The patient could not find the right therapist and derogated the efforts of the group leader. The group repeatedly pointed out to him that he wanted a god, not a human being, as a therapist. They also told him that he talked down to the therapist as though he thought of himself as superior. He was eventually able to accept a referral-this time to a woman, even though he believed “no woman could know enough to help me.” He was able to agree with the group therapist that seeing a woman therapist would enable him to detour his need to expect too much of certain men and his disappointment with their failures. The new therapist and patient were able to begin productve work within a short time.
Finally,
the
acceptance
by the
patient
of the
limita-
of the transference object is greatly enhanced by the real gratification provided by the multiple relationships offered in the group. All demands for gratification are not focused on one limited being (the therapist). When life or death is dependent upon the vicissitudes of an untestable transference, as is often the case with some suicidal patients, the addition of group therapy multiplies the possibilities of gratification and reduces the all-or-none impact of the individual transference. tions
Transference SUMMARY
Group therapy is extremely useful when predicted or existing transference cannot be placed in perspective by the patient who insists on the “reality” of feelings. Szasz (9) has emphasized that transference interpretations always involve reality testing and that the patient must be able to experience certain feelings as being inappropriate to the therapeutic relationship. If the patient is unable to do this, therapist and patient have a difference of opinion rather than an opportunity for understanding. Dealing with such problems is easier in the group, which offers the patient several unique opportunities. The reality-testing clarifications are offered by peers rather than by the object of the transference distortions; thus they can be more readily accepted by the patient. Ms. D was a waif-like young woman who had almost no relations with her family and required constant support from her therapist. Moreover, she sought a second therapist on whom she also made demands. In the group she felt that
the
rejecting not only worried
her. The other group members did she get her share of attention that she was the leader’s favorite.
Members sharing the 132
Am
therapist,
by
not
gratifying
her
of the group can support the perspective they have gained
J Psychiatry
134:2,
February
1977
wishes,
was
pointed out that but they were
AND
There
are
uniquely
three
types
of
problems,
then,
the
the power
necessary
support
of transference and if the patient
is over three major
from
in group of interpersonal
that
individual
problem
areas
to group of group
the patient is extremely trustful of others. This populations and among
that
therapy: relationships
are
1) unsatisfying patterns 2) tendencies to put feelings immediately into action, and 3) the potential to develop a transference that will be difficult to interpret and study. Although these problems are often associated with one another, the presence of any one of them is sufficient to suggest referral to a group. This referral may require modification if, for example, the patient is also in crisis. Patients in crisis require immediate help and intervention that is best supplied by individual therapy. Unless the group is organized around a shared common crisis (e.g., natural groups like mourners or arranged groups like heart attack victims), group cohesion does not take place rapidly enough to provide the new member with
approachable
Modification
patient by on similar
CONCLUSIONS
individual
can provide. wants help we have
therapy referral
therapy
,
and
After the crisis with one of the
described,
referral
is indicated. is also
required
when
paranoid and severely misis often the case in inpatient drug addicts, and techniques
HENRY
and goals of group therapy must be modified accordingly. Examples of such modifications are mandatory treatment, introduction of co-leaders, and increased frequency of group meetings. The leader may need to focus his/her expectations on helping group members to tolerate being in each other’s presence, with confrontations
kept
The third tion of group ic problems ence best
to a minimum.
set of circumstances referral is the existence
requiring modificaof specific neurot-
for
which the development of a transferneurosis and its analysis are indicated. This can be achieved in individual therapy or analysis,
growth, patients.
2.
Int J Group
O’Brien
CP,
478,
person that groups have much her ongoing support during therapy and often for some
Groups
must
this
type
of patient.
be seen
as useful
to offer patients and his/ the transition to group time after its beginning.
places
for change
and
with
WILLIAM
KATES
for second
-class
DH:
Charles
RM,
9.
et al: Group
Arch
of Brief
Gen
vs individual
on psy-
Psychiatry
Basic
Brown
and
Books,
J: The
therapy.
27:474-
Springfield,
Ill,
Focal Psychotherapy: Philadelphia, JB
concept
a Psychotherapist:
& Co.
Practice
A Clinical
1974
of Group
Psychotherapy.
of character, character Psychiatry 14:513-522,
Fault-Therapeutic Publications,
Szasz T: The communication ent. BrJ Psychol 32:161-170,
J Psychiatry
An ExLippincott
1970
Compr
M: The Basic Tavistock
E:
A: Becoming
Little,
Am
Psychotherapy.
PH, Balint Psychoanalysis.
ID: The Theory York,
Guttmacher Balint London,
BA,
research
1975
1963
Balsam
Boston,
and group 8.
A Study
Balint M, Ornstein ample of Applied Co, 1972
New
Ray
schizophrenics.
C Thomas,
Primer.
7.
KB,
of hard-nosed
25:185-197,
1972
3. Malan 4.
review
Psychother
Hamm
chotherapy
6. Yalom
for
by the patient of a referral to group on both the conviction of the referring
treatment
H: A soft-hearted
groups.
supplement
to treatment
not as second-class
1. Grunebaum
5. Balsam
acceptance depends
AND
REFERENCES
where the search for an answer to the question, “How did I get to be this way” is also best pursued. Concurrent or subsequent group therapy may be a useful The therapy
GRUNEBAUM
problems, 1973
Aspects
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between
child
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