Special Treatment Considerations
Group 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.
Scapegoating 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 scapegoating.
The 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.
Patients 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.
Patients 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.
A number 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.
The 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.
A more 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 described previously.
Nevertheless, 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.
Not 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.