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Group Psychotherapy Column

John Breeskin, PhD
John Breeskin, Ph.D.

The Co-Therapist Model in Groups

It is an unfortunate reality that many group therapists run a group therapy session by themselves and while this may appear to be an obvious income generator by the organization, I consider such a practice to be a significant professional error and I will list my reasons for this statement.

  • A single group therapist, no matter how skilled, cannot conceivably keep up with the richness of group experience. Important cues, particularly nonverbal ones, are in danger of being missed.
  • Running a group by yourself significantly increases the possibility of therapist burn out since there is no way that you can pace yourself.
  • Running a group by yourself falls below the minimum benchmark of approved professional practice and can damage you, your clients, and the agency for which you work.
  • Last, but not least, running a group by yourself is dumb; spelled D.U.M.B.

I feel so strongly on this subject that when young professionals ask me for my support, I am only too willing to supply them with ”the letter,” which comes in three flavors: Mild, spicy, and hot. An example of a mild letter follows:

Director of Training

Mercy Day Hospital

Anywhere, New Jersey

Dear Mrs. Campania,

         A young professional in your organization, Thomas D. has asked for my opinion as to the practice of having a single mental health worker running a group by himself. I don’t think that this is a wise idea, and I’m willing to share my thoughts on the subject, as I am national and international specialist in the area of group therapy under discussion.

           No therapist, no matter how experienced or skilled, can possibly follow the complexity of group process without running the risk of significantly missing important cues.

       In addition, because of the stress involved, it is all too possible for beginning therapists to become quickly burned-out.

     From a professional point of view, running a group with one therapist falls below the minimum professional requirements in the mental health field, and I’m sure your organization would not want to be in a position of giving that impression to mental health regulatory agencies.

         The sad fact is that the young man under discussion has many demonstrable potential skills to become a fine therapist. It is my concern that unless he works within a supportive professional environment, he will become discouraged and seek another professional career.

           With respect to finding an appropriate co –therapist, nothing could be easier. Asking for a volunteer and qualifying that person through a volunteer training program will cost the organization nothing. There are many fine group therapists, whom, it is embarrassing to say, have never set foot day one in any graduate school program: they are naturals and relate to people in a very positive and empathic manner.

         I hope these comments have been helpful. It if you have any questions, please do not hesitate to contact me.

Respectfully,

John Breeskin, Ph.D., A.B.P.P.

Many times, in my career, I have been asked to consult to co- therapy pairs. I have not all been surprised to find it that this compares very closely with couple’s therapy. The problems, although they come wrapped in different packages, are quite similar. The pair involved has not been able to acknowledge, let alone resolve, the power differential that exists between them. To say that”we are both the same,” is a copout. This can never be true. One person in the pair may have higher academic degrees, may have more initials after his or her name, may be more charismatic or may have more time in the organization. The nature of the power differential imbalance is immaterial, but it must be acknowledged by the two people involved in order for them to work smoothly together.

The pair has the opportunity to model collegial support and respect by their interaction for the group participants. It is not too strong a statement to say that their interaction must be seamless. They must practice picking up on each other’s comments in a non-competitive manner.

If Bob and Alice are running the group together, Alice says,” picking up on a comment of Bob’s. I would like to add…………. Bob says” that comment of Alice’s helped me understand what just happened……….” this kind of collegial support and respect will provide a powerful interpersonal model for the group participants and will significantly diminish the amount of anxious gossip that the group members exchange with one another in the parking lot just after the group meeting.

I always choose a woman to be my co- therapist in a group. This creates issues that must be addressed. In terms of dysfunctional dynamics, it is all too easy to consider my co- therapist and me to be parental figures and the clients themselves the children. If not carefully anticipated, this dynamic can turn into potentially disruptive sibling rivalry based upon the scarcity model. My second wife was a psychologist herself and we did groups as a co-therapy pair for 10 years. This could have provided a rich screen of fantasy and projection on the part of the clients since my wife and I were not only working together but we were sleeping together as well. This is still another reason why a co- therapy pair must model healthy relationship behavior in front of the group participants.

Additionally, according to my group developmental model, the person who is taking the lead for the first third of the group history, steps down, and the indigenous leaders, with the active support of the co-therapist, takes over the leadership of the group in stages two and three.

I am a superb bus driver; the passengers will get to their destination safely, and they will hear an interesting rap about the journey itself. I am also a loyal and helpful bus passenger provided, of course, that I trust the bus driver. This is still another positive role model that co-therapists can offer to their groups.

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Group Psychotherapy: Sparky Tilts at Windmills

John Breeskin, PhD
John Breeskin, Ph.D.

I am really quite a mellow person, however, when something raises my ire, I react very strongly. This column will illustrate this phenomenon all too well.

I wish to discuss two recent articles, one in the Wall Street Journal and the other similar one in a publication by the American Group Psychotherapy Association. (Of which I am a card-carrying member.) The unhappy title from the Wall Street Journal is, “No Joke: Group Therapy Offers Savings in Numbers.”

The first article is not difficult to read or to understand, as it takes a simplistic view of group therapy as a treatment modality. I have no trouble with this idea; however, the rationale offered is that group therapy is cost-effective, and that should be its selling point. To use cost-effectiveness in this manner is not only misinformed, it is ultimately ridiculous.

Group therapy has inherent benefits, and doesn’t need to be judged on a dollars and cents basis. To make my point, I want to discuss the Great Bed of Ware. There was a tavern, during medieval times, on a main road out of London, where weary travelers could put up for the night. The bed itself was approximately 10′ x 10′ and was covered with a green fabric. It looked like a gigantic putting green. As mud spattered travelers came off the road they were chucked on the outer periphery of the bed with their feet in the middle, while still wearing their boots. There was always room for one more. The warmth of the bodies in the bed was substantial and kept out the chill night air. In addition, people woke up next to one another and shared a common experience. This is my concept of group therapy. We gain warmth, support and belonging as basic human needs.

The article goes on to suggest that the reluctance to consider group therapy as a treatment model is due, in part, to the idea that mental illness is infectious and the feeling that if a therapist’s attention is directed toward another group member, there will be less available to the others. This is a deadly example of the scarcity model. In fact, behavior of one individual and group is a learning laboratory for all of the others. It is an enhancement model. The metaphor here is” Stone Soup.”

The article goes on to say that an inherent problem in groups is to find sufficient clients. This is nonsense: I have run as many as six groups a week with unbelievable attendance. In fact, one men’s group of mine did not have an absent group member for 17 straight weeks. This should go in the Guinness Book of Records.

I consider individual therapy to represent a model of the world which is unhelpful. The idea that one person is there for other person’s benefit suggests that individual therapy is like a hothouse orchid, which can only flourish in an artificial environment. The fact that group therapy powerfully reflects the family of origin is an obvious point. Needs are met, through negotiation, in the marketplace: this is a realistic view of life.

The idea that certain diagnostic categories do not belong in group is erroneous as long as the “Noah’s Ark Rule” is kept firmly in place. (No more than two schizophrenics, no more than two borderlines or no more than two depressives or the group can become symptom driven.) In fact, the idea of more than two depressives in a group is quite depressing.

The idea that a therapist has less power in groups than he or she has an individual therapy just isn’t true since the group leader’s task is to develop indigenous leaders, which, in time, will replace him or her in the center of the group. All is not lost in this article, however, since the final quote is:” By the group we are wounded, and by the group we are healed.”

The second article from the AGPA itself, unfortunately, mimics the first article with the same tired economic rationale but has errors all its own. The statement that children, adolescents and adults can all successfully participate in groups is just plain false. There are specific exclusionary criteria, which flat-out contradict this conclusion.

I hope the reader of these articles will become aware of the inherent value of group therapy as a treatment modality and not get caught up in an economic value argument.

References

Helliker, K. (2009). No joke: group therapy offers savings in numbers. The Wall Street Journal, D1. Retrieved from http://online.wsj.com/article/SB123785686766020551.html

American Group Psychotherapy Association. (2009). Group psychotherapy emerges as a cost-effective and highly beneficial mental health treatment in challenging economic times [Press Release]. Retrieved from http://www.agpa.org/newsroom/releases/2009%20Press%20Releases/AGPA-4-09-groups-work-in-economic-downturns.pdf

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Group Psychotherapy Column: Creative Group Exercises

John Breeskin, PhD
John Breeskin, Ph.D.

I have been collecting group exercises since the bygone days of the human encounter movement, which dates me as a 50 year group therapist.  During this time, I have gradually evolved and become far more radical in the kinds of exercises that I develop and two examples will follow:

My group and I will be attending a Friday, Saturday and Sunday silent religious retreat at the Holy Cross Abbey, which is located on the banks of the Shenandoah River looking into the Blue Ridge Mountains. The retreat is a silent one and the fellow participants are usually noviates and priests. Since there are no cities nearby, I typically sit outside, watch the sun set and the stars appear overhead. It is, to me, a deeply spiritual experience. The group will number eight and will not be able to talk to each other until after the retreat is over.

This is typical of field excursions that my groups and I have made together. We have gone to Frank Lloyd Wright’s Falling Waters, in Western PA, the National Arboretum, in Washington DC and the open air Hirschorn Sunken Sculpture Garden on the National Mall.  We will do at least one visit of this type per calendar year.

The second exercise that I will be suggesting to the group stems directly from a mind-blowing book that I have just read titled The Gift: Imagination and the Erotic Life of Property, by Lewis Hyde. Borrowing liberally from these ideas, I will be giving a gift to one group member and asking him to receive the gift and to pass along a gift of his to another group member. Once the circle is completed, I will be given a gift which is the cumulative product of the exchange in return. It is important to point out that the profit motive in this transaction is completely subjective and even spiritual. We will discuss what it like to first receive a gift and also to give it.

Stay tuned for a further news bulletin as my group struggles with my radical ideas. I hope this makes sense to you.  Please let me know if we have a deal.

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Group Psychotherapy Column: Current Thoughts about Group Therapy Theory

John Breeskin, PhD
John Breeskin, Ph.D.

After 50 years of running a wide variety of groups I am tentatively ready to make some general statements about the field. These thoughts are the result of a lengthy process of my learning and they represent, as clear as I can make them, a part of my current conceptual framework.

I use, as fundamental building blocks, the sequence of:

  1. 1. A focus upon internal- personal learning
  2. 2. A focus upon intra-personal learning
  3. 3. A focus upon transpersonal learning

Another way of saying the same thing is looking inward, looking outward, and looking upward, always remembering that Jungian archetypes are the DNA of the unconscious.

These concepts are fundamentally based upon the four beats on the kettle drum as follows:

  1. Forming
  2. Storming
  3. Performing
  4. Adjourning (A necessary addition which cannot be ignored)

As an additional complicating factor, as if the topic were not complicated enough, the group, from a psychodynamic point of view, operates on two levels simultaneously. Level one consists of the content of the group’s membership with one another and can be thought of as content in the here and now.

The second level, operating simultaneously with the first, consists of the powerful family of origin dynamics which are inextricably merged with level one. The group functions on both levels simultaneously and every action on the part of group members can be looked at through the twisting tube of that kaleidoscope. A group member, for example, can act toward other group members with contempt but he/she is accurately mirroring how he/she was treated when growing up.

A fair pictorial analogy would depict a group therapist juggling tomatoes while blindfolded. Another ingredient in the Stone Soup is, for me, comfortably within this theoretical framework, is whether or not the individual group member presents himself/herself as either a victim or a victimizer. The “Rhyme of the Ancient Mariner” by Coleridge is particularly appropriate here as is the most famous short story in English literature by Herman Melville called “Bartelby , The Scrivener “ which is, to me, the Victim’s National Anthem.

Still another compelling image from my symbolic toolbox: My clients who define themselves as victims try to pay for my services by using counterfeit gold coins. I carefully bite the coins, learn that they are counterfeit and let my client know that I know. Then I take out a purse of true gold coins and I offer one of them to the client has a temporary loan until he/she can mint one of her own and repay the loan. As to reader will have determined a long time ago, my clients are very high functioning human beings and they have no trouble following me at the symbolic level.

It is my earnest hope that I have succeeded in thoroughly confusing the gentle reader of this paper. That has been my hope from the start. I hope that I have succeeded.

Your Friendly Shape Shifter Who Promises to Continue,

Sparky

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Group Psychotherapy Column: Experiential and Didactic Group Therapy Program: The Sad Lady’s Group

John Breeskin, Ph.D.
John Breeskin, Ph.D.

Negativity as a Group Dynamic

John Breeskin, Ph.D.

It would be totally naïve for a beginning group therapist to think, for a moment, that a group of people who are motivated to interact positively with other group members would be free from the effects of negativity toward other group members. The sources of this negativity, in my theoretical framework, are at least two:

1. The component contributed by the client’s overt behavior such as withdrawal, pressured speech, sporadic attendance, diva demands for attention, obvious negativity and resistance. These should be addressed as legitimate group dynamics in terms of the desire to grow counterbalanced by the desire to remain the same and there are various group therapy techniques to turn the spotlight on such behavior. (Switching roles and being the other person would be an example of one of these techniques.)

2. The 2nd contributing components to this negativity comes directly from family of origin dynamics where people are replicating, in living Technicolor, old sibling rivalries, residues of unresolved conflict with parents, dysfunctional family symptomology or even unresolved issues dealing with pain and loss. This is axiomatic and no interpersonal interaction can ever be thought of as free from these dynamics and I state this point over and over again in the ongoing life of the group.

It should be quite obvious that 2 different sets of strategies are appropriate for each of these situations outlined above.

Regardless of what condition we are addressing, however, there are important communalities for the therapist to have readily available.

When I am faced with these problematic behaviors, I mark the event in my memory, reject a response from my reptilian brain and carefully think about how I’m going to reply to the negativity in the session next week. If I am judicious in my response time I am allowing for a perhaps a wondrous event to occur. The client, himself or herself, can come back the next week and actually apologize for his/her behavior and my challenge is to allow space for this possibility.

If this providential event does not occur, then I will access Plan B. which deals with my individualized response to the client’s behavior without blaming or shaming the client, but, instead, discussing and owning my feelings as to the event that just happened. This style of intervention is offered as a role model for the group members to emulate and some of them pick it up very quickly.

The theoretical model outlined above stems directly from Attachment Theory, called in oldspeak , conflict resolution, psychoanalytic hydraulic pressure from sexuality, faulty conditioning by the behavioral- cognitive therapists, genetic predisposition from the biology folks, or the Existential belief in the absurd.

I hope it is clear that I favor the last cited theoretical approach.

My approach in writing this note is to be clearly engaged in creative mischief. Please favor me with your thoughtful replies in that spirit.

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Experiential and Didactic Group Therapy Program: The Sad Lady’s Group

John Breeskin, Ph.D.
John Breeskin, Ph.D.

Somatization Disorder is a condition that is both hard to diagnose and hard to treat. For many years, I was Chief Psychologist of a thousand-bed hospital outpatient mental health clinic. While I mean absolutely no disrespect by this comment, I would classify many of the clients referred to as “sad ladies.” These were women with multiple medical folders with each thicker than the next. Their bodies were cross-hatched with medical and surgical interventions, all of which were ultimately futile. In a fit of irritation and despair, the most recent in a long line of defeated physicians would disclaim, “Get thee hence to the Outpatient Mental Health Clinic!” As a result, these dear ladies would show up in my office, rejected yet another time. Often, they were “empty nesters,” low in self-esteem and self-image, and cemented into maintenance type marriages. It became apparent to me that their numerous outpatient visits symbolically represented a deep need to be touched intimately by a caring human being.

In response to this obvious human need, I quickly designed an intensive six-week group therapy program composed of both experiential and didactic components. We covered such topics as communication skills, assertiveness training, and trust-building.

I remember clearly our very first meeting. The ladies introduced themselves one at a time, and each would outdo the next in terms of the doleful, painful details of her journey. I was astonished! I pointed out that they were competing for “Victim of the Day” awards, and, for now at least, I was less interested in what was wrong than what was right with them. I told them that they did not need to compete for my attention. I was aware that they were problematic individuals in pain and all were well worthy of my concern. After we got that initial dynamic out of the way, we launched into team-building, trust, self-disclosure, and interpersonal bonding. The ladies grasped these principles quickly and firmly, and it changed their lives. One group, because the chemistry was so great, made me an honorary woman at the end of the six weeks, an honor that I will always carry with me.

Another group that I remember with great fondness, at the end of our six weeks together, decided to carry on the group by themselves. They proceeded to hire an attorney, a financial planner, a personal trainer, and, of all things, a psychologist to provide them with ongoing therapy. The psychologist called me in great bewilderment indicating that the ladies had called him and were interviewing him to see if he met their criteria. He called me to ask if this was on the level. I told him it was and that he would be normously enriched if he passed the evaluation. When I left the base two years later, the group had started an investment club and had accomplished several humanitarian tasks. Their manifold visits to the hospital clinics had dramatically diminished.

This model can be replicated easily in many different settings. Once these powerful healing forces are energized and released, much positive change can occur. It is important to take this model very seriously. On the surface it looks very simple, but it is not at all. The twin concepts of intentional kinship and reciprocity are central components of my theoretical model, together with the ever-present mystery of agape.