psychotherapy has been called a hall of mirrors (Foulkes, 1961) where aspects
of oneself are seen reflected in others. Scape-goating is the process in which
individuals, by “observing” char-acteristics in another that are unacceptable
in themselves, try to deny their feelings and place them in the “offending”
person. This process, involving projective identification, is universal and
frequently activated during treatment. It is by no means en-tirely conscious
but patients often have an initial awareness that they are attempting to rid
themselves of unacceptable feelings or behaviors.
may lead to the “scapegoat’s” extrusion from the group. It depletes the group,
in the sense that specific emotional responses are not available for
examination. Many af-fects may serve as the stimulus to evoke scapegoating,
such as anger, envy, or romantic feelings. Scapegoating becomes virulent
because of affect contagion (Freud, 1955), in which feelings be-come greatly
magnified in the communication process and adds a destructiveness to
therapist’s task of protecting the scapegoat is prima-rily accomplished through
assisting members in “taking back” feelings that they are attributing to the
scapegoat. A simple illustration is members’ anger with an individual who
habitually arrives late. That person might be accused of wanting to avoid the
group. Analysis of the members’ vitriol may reveal that they are also avoiding
other intense group feelings. Such an analysis enables the scapegoat to become
linked with the others rather than have an isolating experience.
communicate powerful feelings nonverbally. Discrep-ancy between verbal and
nonverbal messages is confusing, but frequently the latter element is received
as the “truth”. Patients may tell sad stories and laugh, or they may relate a
success in a dreary manner. Members may pull their chairs outside the group
circle, sit close to or opposite the therapist, shift position in their chair,
or not look at one another during emotionally laden inter-changes. White knuckles,
crimson blushing, or a black dress are additional colorful communications.
learn to address these meaningful communica-tions as they become comfortable
examining in-group behaviors. However, many times the person may be unaware of
sending nonverbal messages, and confrontations can be experienced as intrusive
and threatening. Stereotyping certain behaviors as car-rying predetermined
meanings is a common error, and patients learn, sometimes through painful
experience, that the sender may have highly personal meanings attached to the
behavior Exploration of nonverbal behaviors is often a powerful entry into the
recipient’s and the sender’s current and past feelings.
of individuals appear to be good group candidates, but they prove to benefit
little from participation or they seem to obstruct the treatment process. These
individuals, generically labeled “difficult patients”, can be conceptualized as
having sig-nificant relational problems that interact with a particular group
culture (Roth et al., 1990; Stone and
Gustafson, 1982). Although such individuals are often diagnosed as having
borderline or nar-cissistic personality disorder, not all such patients can
readily be given those specific diagnoses. Nitsun’s (1996) felicitous
expres-sion, “the anti-group”, characterizes these individuals as having the
potential to disrupt the entire therapeutic endeavor.
difficult patient should be seen in context. Some groups can accept individuals
who seldom speak, whereas others see such a person as seriously harming
cohesion and, therefore, as “difficult”. Difficult patients fill roles and are
frequently labeled “monopolizer”, “help-rejecting complainer”, or “the silent
one”. The role embodies both the individual personality and a group function.
Evidence for this assertion is found when the difficult individual is removed
and another rises to fill his or her place, which suggests that, in part, the
role was necessary to deal with members’ anxieties.
careful examination of the processes involved in the emergence of a difficult
patient may expose that such individ-uals are covertly coconstructed by others
in the group (Gans and Alonso, 1998). Interactions among members and the
therapist tend to evoke and/or exaggerate particular character tendencies of
members who often have underlying issues of forming inti-mate relationships.
The therapeutic challenge is to deconstruct the processes so all can see their
contributions to the difficult individual. This is similar to scapegoating
some patients persist in behaviors that do not change and that become
destructive to the treatment proc-ess. They evoke responses in others,
including the therapist, that interfere with a sense of safety and limit
members’ willingness to expose their inner thoughts and feelings. Many
difficult pa-tients seem unable to process their interactions cognitively but
remain enmeshed in emotional exchange. Others may interrupt emotional exchange
with intellectual dissertations.
infrequently, these individuals prematurely terminate treatment, leaving those
remaining with feelings of relief, frus-tration and anger. Other difficult
patients remain in the group and at times the therapist is faced with making a decision
that favors the group over an individual. The patient is informed that she or
he is not benefiting from the treatment modality and is asked to leave. Such a
decision should be reached only after the therapist has completed a thorough
self-scrutiny and has sought consulta-tion to explore countertransference
contributions to the impasse.