Journal of Gerontological Nursing

FEAR OF LOSS AND ATTACHMENT: A MAJOR DYNAMIC IN THE SOCIAL ISOLATION OF THE INSITUTIONALIZED AGED

Carol Carter, MSN; Deborah Galliano, MSN

Abstract

The administrators at a large private home for the aged became aware of the social isolation of the residents of the home. The authors worked with the administrators to develop a group experience that would assist the residents in decreasing their social isolation and the general unhappiness which seemed to accompany that isolation. The overall objective of the program was to help the residents to lead fuller and more satisfying lives while in the nursing home.

The group experience was part of a course requirement for first-year master's degree students in the Adult Psychiatric Community Mental Health Nursing Program at Columbia University. Each student was responsible for leading her own group one hour a week for eight months. Verbatim data from the respective groups sessions was shared during weekly supervisory meetings with the instructor. The data presented during these meetings were examined closely and discussed in detail, with the aim of determining the underlying concerns of group members. Once these concerns had been determined, helpful interventions could be formulated.

Background

Our group members were retired elderly men and women of different backgrounds who had come to the home under a variety of circumstances. A few were former professional people, but others were former housewives and tradesmen whose educational experiences ranged from the grammar school level to the doctoral level. Some had come to the home because of ill health, others because they were fearful of living alone in the city, and a few by choice because they fell that the home would be a convenient place to live. All members had in common the ability to ambulate on their own and to handle activities of daily living with minor assistance. Notably, despite their diverse life experiences and backgrounds, they all shared the experience of social isolation, loneliness, and unhappiness within the home.

The lifestyle and general environment of the home did not appear to add to the social isolation of the residents. The decor was bright and cheerful. Residents could choose to live in single rooms or in double occupancy, rooms, and each room had a telephone. Daily activities, such as concerts, movies, and arts and crafts, were planned for the residents to attend as they wished. However, despite the planned activities and the pleasant atmosphere of the home, the residents remained isolated in their rooms and emotionally isolated from each other.

Interpersonal withdrawal and social isolation are two major defenses readily apparent among older adults in homes for the aged and other institutions. These defenses serve as protection against anxiety associated with remembered and anticipatory loss, as well as protection against the fear that is created by the mirroring that occurs when two or more older persons converse. Because of these defenses it can be especially difficult to convince older persons to join a group. We attempted to overcome this difficulty by visiting potential members in their rooms to establish personal relationships that would support them in joining our groups.

It was soon apparent that residents were highly resistant to joining our groups. This obstacle was overcome by returning to each resident's room weekly to extend a personal invitation to attend the meetings. These personal visits were a crucial îactor in encouraging residents to become involved in the group. During these visits residents had opportunities to test thoughts and feelings on an individual basis before bringing them before the group. Feelings of rejection and the pain of loss were shared more easily on an individual basis. The sharing of these feelings formed a social bond that made group attendance attractive to residents because they could continue a personal relationship…

The administrators at a large private home for the aged became aware of the social isolation of the residents of the home. The authors worked with the administrators to develop a group experience that would assist the residents in decreasing their social isolation and the general unhappiness which seemed to accompany that isolation. The overall objective of the program was to help the residents to lead fuller and more satisfying lives while in the nursing home.

The group experience was part of a course requirement for first-year master's degree students in the Adult Psychiatric Community Mental Health Nursing Program at Columbia University. Each student was responsible for leading her own group one hour a week for eight months. Verbatim data from the respective groups sessions was shared during weekly supervisory meetings with the instructor. The data presented during these meetings were examined closely and discussed in detail, with the aim of determining the underlying concerns of group members. Once these concerns had been determined, helpful interventions could be formulated.

Background

Our group members were retired elderly men and women of different backgrounds who had come to the home under a variety of circumstances. A few were former professional people, but others were former housewives and tradesmen whose educational experiences ranged from the grammar school level to the doctoral level. Some had come to the home because of ill health, others because they were fearful of living alone in the city, and a few by choice because they fell that the home would be a convenient place to live. All members had in common the ability to ambulate on their own and to handle activities of daily living with minor assistance. Notably, despite their diverse life experiences and backgrounds, they all shared the experience of social isolation, loneliness, and unhappiness within the home.

The lifestyle and general environment of the home did not appear to add to the social isolation of the residents. The decor was bright and cheerful. Residents could choose to live in single rooms or in double occupancy, rooms, and each room had a telephone. Daily activities, such as concerts, movies, and arts and crafts, were planned for the residents to attend as they wished. However, despite the planned activities and the pleasant atmosphere of the home, the residents remained isolated in their rooms and emotionally isolated from each other.

Interpersonal withdrawal and social isolation are two major defenses readily apparent among older adults in homes for the aged and other institutions. These defenses serve as protection against anxiety associated with remembered and anticipatory loss, as well as protection against the fear that is created by the mirroring that occurs when two or more older persons converse. Because of these defenses it can be especially difficult to convince older persons to join a group. We attempted to overcome this difficulty by visiting potential members in their rooms to establish personal relationships that would support them in joining our groups.

It was soon apparent that residents were highly resistant to joining our groups. This obstacle was overcome by returning to each resident's room weekly to extend a personal invitation to attend the meetings. These personal visits were a crucial îactor in encouraging residents to become involved in the group. During these visits residents had opportunities to test thoughts and feelings on an individual basis before bringing them before the group. Feelings of rejection and the pain of loss were shared more easily on an individual basis. The sharing of these feelings formed a social bond that made group attendance attractive to residents because they could continue a personal relationship with the group leader. Sharing their feelings with us on an individual basis also served the purpose of helping the residents to determine whether we would reject them, as others had done when they made their feelings known. Returning each week developed and strengthened their trust in us, in turn enabling them to attend meetings.

Fear of Abandonment

Although our continuous visits motivated a few residents to attend the initial meetings, it was apparent that members were not emotionally attached to the group. They continued to test us and each other. This distancing was evident when residents failed to remember the time or day of group meetings, or when they scheduled other appointments for the one hour a week that we met. Underlying this behavior were the residents' needs to vent their anger toward family and friends whom they felt had rejected them by allowing them to enter the nursing home. Because we were outsiders and transient in the lives of the residents, it was safer for the residents to redirect this anger toward us than toward their families. The anger also was channelled toward the nursing home in general through complaints about the food, the employees, and the other residents. However, residents were careful not to complain too much, as they depended on the nursing home and the employees and could not risk angering anyone. Therefore, the students became the primary targets for their anger. The form in which this anger was expressed is typified in the following examples. In one group a member arrived 25 minutes late for the meeting and said to the group leader, "Young lady, let's get started because I can't stay very long." Another resident in the second group would sometimes look through a magazine. When he finished reading he would disrupt the conversation by singing. When reminded that he was disrupting the meeting he would stop for a while, only to begin a few minutes later. Repeated behavior of this type indicated that the group members were maintaining emotional distance through their rejection of the group leaders and other members.

Initially, these occurrences were uninterpreted by us because we were unable to face our own feelings of anger and rejection that resulted from the group members' behavior. It was difficult for us to realize that these seemingly harmless old people were capable of inducing such angry feelings in us. We accepted this behavior from them without question, out of respect for their age. However, the anger fostered in us by the group's behavior was being vented elsewhere. Just as the group members had redirected their anger at their families toward us, we redirected our anger at the group toward our superivosry instructor. We felt that she had given us an impossible task by assigning us to these groups, and we were fearful that our group would abandon us and cause us to fail the course. In this way, we continued to feel angry and frustrated in our group work without confronting the group members with their behavior.

This behavior continued unchanged for the first ten weeks of our meetings, until we discussed our own anger openly during supervision. At that point we realized that our feelings of anger and rejection were similar to the feelings many of our group members experienced in a nursing home. They were unable to recognize or admit openly that they felt rejected by family members and society, and were angry as a result of this rejection. They could not express these angry feelings to those close to them or directly to nursing home staff because they needed these people and feared total abandonment if their feelings were known. However, they could act out these feelings of anger safely with students, who would be in their lives only temporarily. They were unable to acknowledge their negative feelings toward loved ones, even to themselves, so these unacknowledged feelings became evident in their relationships with us. The group members behaved in a way that induced feelings in us that they were unable to face in themselves. We, in turn, were unable to face the angry feelings our group members had induced in us, and we redirected this anger toward our supervisor. We realized that before this process could end we would have to accept our own angry feelings toward our group members and admit them openly to the group. This would then give group members sion to see these feelings in selves and how they affected behavior.

The following is an example how this process was brought to attention of the group and group's reaction to the tation:

Group Leader (GL): I've been with you for over eight weeks and it that each week the attendance has creased. It's a sad feeling for me to think might lose you.

Group Member (GM): I knew you hurt by it. I saw disappointment on face each week.

G.L: I've seen sadness and ment on some of your faces someone doesn't attend the meetings.

The purpose of the group intervention was to help members to recognize their of rejection and abandonment well as to give them permission share those feelings with the This was proven effective when group member responded by ing the anger she felt when sitting eat with people who spoke a ent language and excluded her the conversation. This was a form rejection about which she feltangry, and her ability to verbalize this the group demonstrated her ing ability to accept her anger others who had rejected her.

The leader of the second expressed her feelings to the members in order to help them accept their own fears of rejection:

G.L: I've been wondering about difficulty we all have in getting each week. I sometimes feel that if I not try especially hard that I would you all and have no group. My feeling related to the fact that group come late and leave early as if they to leave me before the group was

The group was silent at first, a few members protested that group leader should not be fearful. Following the group leader's ple, members began to their own feelings:

Mrs. M: I met a lady here who was very lonely. She had just come to [the nursing home]. I felt the lady help and I told the nurse about it. I feel important that the nurse returns to this woman and doesn't just see her once.

This reaction showed concern that because of the group's rejecting behavior, the group leader would leave them. Mrs. M was saying indirectly that the group and the group leader were important to her and that the angry and rejecting behavior exhibited by the group members toward the leader was not a true indication of their feelings toward the leader.

At this point, another underlying concern of the residents became evident. They feared that they would become emotionally involved with the group leader, only to suffer loss later. This fear was a primary cause for their rejecting behavior and lack of emotional attachment to the group leader.

The group members' early rejection of the group leader could be seen as serving two functions. The group's rejecting behavior allowed them to vent their anger toward family and loved ones safely, without risking further rejection from those to whom they were close. However, the group members' angry, rejecting behavior also protected them from further emotional pain. Because their behavior kept group leaders at a distance, group members forestalled the emotional attachment which they feared might result in the pain of loss and abandonment.

Mrs. M's statement conveyed her concerns about being abandoned. This theme of abandonment and loss was reinforced by Mr. B., who responded to Mrs. M's comments by saying:

Mr. B: My wife was on the eighth floor and she was ill. A young woman used to come and ulk to the patients each day, but one day she just did not come anymore.

Fear of attachment because of anticipatory loss is a predominant theme in the lives of older people. Repeated loss is a massive psychic trauma for any age group, and in old age losses are numerous. At this time of life, individuals frequently must deal with the loss of family and friends as well as the loss of physical strength, health, and appearance. The number of losses people in this age group must face are so numerous that eventually many individuals avoid situations in which they risk suffering another loss. New emotional attachments, as offered by the group leaders were, therefore, met with ambivalence. Although the new relationship offered relief from loneliness, it also involved potential danger. We took every opportunity to interpret for the group the many ways in which this fear of attachment and loss resulted in social isolation and decreased the quality of their interpersonal relationships. Intervening in a situation in which the group members' need to avoid attachment was manifested by decreasing group attendance, the group leader stated:

G.L: I'm wondering if you avoid getting close to each other by staying away from meetings. In this way you can avoid the pain and sadness of losing someone with whom you've been close.

This intervention was answered by Mrs. B, who said with a chuckle: "If we stay here for ten years or more we'll all be gone."

Although Mrs. B's statement was made lightly, the group leader silently interpreted the statement to mean that members felt it was dangerous to get too attached to each other. Closeness would only result in pain and sadness, because each of them would be dying soon. Mrs. B's statement confirmed that the group leader's interpretation was meaningful.

The theme of loss and abandonment intensified around missed meetings, which tended to evoke past memories of loss. Attendance at a group before or after vacation times was extremely difficult for members. This became apparent after the group leaders missed a meeting during a school holiday. Only half the members attended the first meeting after the missed session. In one group one of the members began by saying:

Mr. G: People will not be coming to the meeting.

Mrs. B: People make promises and dont keep them.

On the surface the group members were speaking of the members who were absent that day. The underlying feeling was that the group leader, who was untrustworthy, would encourage them to become emotionally involved in the group and then abandon them without regard for their feelings. This fear resulted from thegroup'ssensitivity to loss, which led them to view the group leader's vacation as abandonment.

In the weeks preceding a missed session the members expressed their feelings about the meeting to be cancelled. This was evident during one such meeting when many of the members came late or failed to attend. Mrs. M. expressed the latent feelings of the group:

Mrs. M: I read in the newspaper about a young woman who left her children to go dancing in the discotheque. She left the candles on the Christmas tree burning and the tree fell on the crib and burned the children to death. The mother was laughing in the picture.

Mrs. W: That's just terrible. The young today can really be mean.

These statements expressed the group's underlying feelings toward the group leader's impending vacation. The group leader was seen as an abandoning mother and the group as the helpless children, who had become emotionally attached to her and were now being left in a vulnerable position. The group leader could have responded:

We've been meeting weekly and have begun to grow close to each other. But now Christmas vacation is coming and we'll be missing a meeting. Are some of you feeling badly about my taking a vacation at this time?

This interpretation would have helped group members to discuss their feelings about the growing attachment they were experiencing toward the group and their underlying anger toward the group leader for abandoning them.

We used our knowledge of the significance of missed meetings to help members deal with their reactions to loss and abandonment. When it was necessary for a group leader to miss a meeting, it was helpful to give members time prior to the missed meeting to express their reacitons. At these times we listened to and interpreted their comments, keeping in mind that the content of the meeting was related to the upcoming cancelled session. We used this time to make group members aware of their reactions.

Fear of Attachment and Loss

The theme of attachment and loss was apparent when residents spoke of how different it was for those within the home to get to know one another. Members attributed these difficulties to differences in nationality and language among residents. The group leader responded to this by saying:

What I'm hearing are remarks of how different you are from each other. Perhaps saying this somehow makes it easier for you to stay apart and and not take the risk of getting close to each other.

This interpretation was directed toward group members to determine how their attitudes were really distancing maneuvers that perpetuated the senses of isolation.

During one meeting group members were talking about their life experiences and fear of attachment was, as usual, underlying theme of the discussion.

Mr. S: People do learn from their experiences, but some people are afraid to be sensitive and keep things to themselves. Some poeple go through life mechanically without really living it.

G.L: Yes, people do learn from past experiences and if a person learns that giving of himself and being involved can result in loss and pain, it is natural that he would try to avoid pain. But in doing this he loses a lot of the benefits of being close to people.

The theme of fear of attachment and loss remained a topic discussion throughout subsequent meetings. Members gradually were able to speak more openly on themes. After 20 sessions emotional attachments began to develop between group members, as well as between group members and the group leader. This was a desirable development, because a wider scope of emotional attachment would bea buffer, preventing the loss of any one person from being too painful. Attendance at this time was stable, and members began to interact between group meetings, if only to ask whether the other member would be attending. Group members began to show concern for one another, and the presence of each member at the meetings became important to the group as a whole.

At this phase in the group's development, the members became more receptive to interpretations. Although members did not always respond to interpretations when they were offered by the group leader, frequently they discussed the interpretation later. This occurred on both conscious and unconscious levels over the course of subsequent sessions, and illustrated to us the importance of reviewing the previous session before each meeting to remind ourselves of the ongoing themes of discussion. This continuity of theme helped us each week to understand the latent content of the group discussion. It also impressed upon us the growing cohesiveness of our group; the members had begun to work on concerns common to each of them. This was illustrated during one session when the members were discussing the death of a person known to most of the group members. In response to the sad tone of the conversation the group leader said:

Although I didn't know E., I'm getting a very sad feeling listening to you speak of her death. I'm thinking about how all of you experienced many losses in your lives and yet the pain of loss isn't any easier. I wonder if sometimes that might make it difficult for you to get close to people?

The group was silent, then the subject was changed abruptly by one of the group members. The issue of death and loss did not surface again during that session, and the group as a whole appeared not to respond to the interpretation. However, during the next session this latent theme of death surfaced again. The members began to speak of dangerous situations they had experienced. This discussion related directly to the emotional danger that the group leader had recalled when she had spoken of the pain of loss and fear of closeness. It is interesting that although the group leader'1 did not see this connection immediately, one of the group members who had heard the interpretation the previous week did:

G.L: It seems that what all of you are saying has something in common. You're speaking about situations where physical strength is the issue.

Mrs. S: One time I was in an elevator with a man and a woman. The man stopped the elevator between floors and stole my money.

Mrs. AS (responding): I don't think we're talking about physical danger. I think we're talking about emotional danger.

In this example, although the group leader's interpretation did not focus directly on the main concern of the group members, this did not affect the ongoing theme of the discussion. Mrs. S continued the discussion on the theme of danger, which was raised in response to the previuos week's discussion of close emotional relationships and the pain of loss. Furthermore, group members were developing close relationships within the group, and this resulted in a latent feeling of danger because of anticipatory loss. Mrs. AS was able to verbalize the underlying theme of the group pertaining to emotional danger. By using the group leader as a model, she was able to interpret the content of the group's discussion.

Clearly, the group discussion related directly to the discussion of the previous week. This continuity theme was apparent throughout the group's development, as group members became able to discuss their fears of emotional attachment more openly.

Termination

We were aware that members of each group would have a long termination phase because it took them so long to become attached during the beginning phase. We did not expect termination to become a task for them so early in the group's development, and group members began to terminate long before the group leaders gave thought about it.

Termination had special significance for members in each group because it represented a repetition of past losses that made the initial attachments so difficult. Their emotional reactions to ending the group sessions provided us with the opportunity to help work through their feelings of loss and abandonment.

During this phase one meeting focused on group members who had joined the meeting late. Mrs. M stated how important she thought it was for each person to attend each week. Mrs. S rationalized her concern by adding that their presence each week was necessary for satisfying the educational requirements of the group leader. The leader in this group realized that group members were concerned about her motivation for participating in the group. They had become emotionally attached to her and feared that she had not become attached to them but was only fulfilling educational requirements. One member expressed her feelings by saying:

So many people use you and then go on about their business without giving you another thought.

G.L.: Perhaps you are thinking that I, too, am using you and will leave you.

Mrs. L: I was in a group last year with a young girl from Columbia; she left and we never heard from her afterwards.

The members were beginning to think about the group's coming to an end. At this time they were unable to acknowledge their emotional attachment to the group leader. By not acknowledging their feeling of closeness toward the leader, they could avoid the emotional pain associated with loss and abandonment. To deny themselves the recognition of the group leader's emotional attachment to them was another way of ignoring their emotional attachment to her. In so doing, they would avoid the pain of termination. But to allow group members to avoid the emotionally painful feeling of terminating with the group leader would hinder them in developing future relationships. In addition, they would remain unaware that their fear of loss would hamper their abilities to develop new emotional ties.

In the other group, the subject of termination was introduced in the following manner:

Mrs. M: The pigeons are losing their feathers.

Mr. M: That's a sign that spring is coming.

Mrs. S: There is something I want to talk about. I read read an article in the paper about the young people today, and their ideas about sexual relationships. The article said that young people are free in their sexua! relationships and getting divorces. They don't feel they have to stay together.

G.L: What Mrs. S. has said about marriage and commitments ties in with what we were talking about last week -getting involved and having to separate. Here in the group we are involved, yet we all know that a time will come when it will end.

Mrs. M: We'll miss you.

Several of the group members immediately began to discuss past losses and the pain involved. In this example, members introduced the subject of termination by discussing the approach of spring. As group meetings were to end in the spring, the group leader was able to recognize that the discussion related to termination.

Instead of speaking of their concerns directly, group members channelled into the subject of young people and their casualness in sexual relationships. This was an indirect way for group members to express their thoughts that the group leader was not emotionally involved with them. The leader's interpretation linked with their discussion to their primary concern, termination. Later group meetings continued to focus on loss and abandonment as termination neared.

During one session in another group, the members focused on the routine of living in the nursing home. Several group members agreed that they liked living in the home. Mr. W responded in an angry tone:

I'm here because of in-laws whom I'm not close to. If we were close maybe I wouldn't be here. . .1 wouldn't be here if it were not for you.

Mr. W* s anger was directed overtly toward his family; covertly his anger was directed toward the group leader, who was going to abandon him after having broken through his defenses of isolation and withdrawal to the extent that he had allowed himself to become emotionally attached to her.

Another session went like this: G.L: Last week we discussed the difficulty involved in developing friendly relationships here in the home. We've been meeting for eight months, and have developed close ties with each other. Perhaps you will continue in the group after I've left.

Mrs. M: When you're old you think twice about making friends. It's different when you're younger. You have all of your life ahead of you. If you lose someone you have the opportunity to make new friends, but when you are older and share your life with your friends only to have them desert you or die and leave you, it's too much heartache. You'll see if you live to get as old as I am.

G.L: What you are describing, Mrs. M., is not so different from what is happening with us here in the group. We've developed close relationships over the past several months, you've shared your personal thoughts and feelings with me, and now I will leave you very soon.

Mr. W: I've gotten to like coming here each week. I have no place else to go. When you live to get old you're more alone than ever. All of your friends are dead and have left you behind. When you're young you don't miss them that much, but when you're old. . .I'm speaking for myself. . .1 look in my address book and think of calling my friends and remember that they are no longer here, and that hurts.

It was apparent that Mrs. M was very angry with the group leader because of the leader's role in decreasing resistance to emotional attachment and increasing the vulnerability of the group members to the pain of loss and abandonment. Mr. W, on the other hand, expressed feelings of sadness. The leader's impending separation from the group was beginning to evoke in the members feelings of pain and sadness similar to the ones they experienced after separation from family and friends in the past.

The group members' reactions to termination again came through indirectly in group discussion:

Mrs. M: You know the English have caused a lot of problems for Ireland.

Mrs. S: Yes, their motto has always been divide and conquer. They go into places, stay awhile and help out and leave.

The group members began to talk about different areas of the world in which the English have interests.

Mrs. M: The English upset countries and then leave them.

G.L: I wonder if I could be thought of in that way, as starting the group, sharing some difficult times, and then leaving.

Mrs. M: I remembered the story Mr. M had told about his friend trying to rob him.

In this example, group members were indirectly expressing feelings that they were somehow seduced by the group leader into developing an emotional attachment, only to be cruelly abandoned once this attachment developed. They expressed these feelings by discussing current events that were far removed from their personal concerns about the group. The group leader's intervention linked the feelings expressed in their discussion of world events to the current situation in the group, which was of more personal interest to them.

This group leader's intervention was confirmed when the group member responded by remembering a story of someone's being robbed. This member's association expressed her feeling of being robbed of her defenses by the group leader, therefore being left open to forming warm relationships and vulnerable to the loss of these relationships.

Though in fact the group leader in this example weakened the members' defenses purposely so that they would allow themselves to develop closeness with each other, in this instance this is not viewed as harmful intervention. The behavior of each member of both groups was maladaptive in that group members felt lonely and isolated as they simultaneously attempted to avoid emotional discomfort. After the group experience, members were more vulnerable to the pain of loss, but they had developed the capacities to initiate and sustain relationships. They no longer felt isolated and lonely. Although members risked the pain of loss by becoming attached to others in the group, they were able to protect themselves from any one loss becoming too painful. We encouraged them to form multiple attachments within the group so that the significance of any one loss would be diluted.

It was not easy for group members to express openly feelings of closenesss to each other during the group meetings. These feelings often were expressed indirectly:

Mrs. B (annoyed with another group member after he announced that he would leave the meeting after 30 minutes because he had an appointment with the pharmacist): You can get your medicine anytime. There's no such thing as having a special time to get your medicine. There's no excuse to come to the meeting and then leave as soon as you get there.

Mrs. B. was not prepared at this particular time to admit emotional attachment to Mr. J by saying to him that she would miss him if he left the group meeting.

In another group, although members were unable to express directly emotional attachment to the other members in the group, they expressed their feelings related to their group experience indirectly:

G.L: I've wondered if anyone feels surprised that the group has become important to them.

Mrs. M: I remember when the social worker left last year, we missed her so much we cried.

Mrs. S: We should think about interesting experiences that happened to us.

Mrs. M: I once went and rested my hand on a shiny snake, but the snake didn't bite me.

Mrs. M began to speak of her emotional attachment to the group in terms of past emotional attachment; however, she was unable to express her feelings directly as they related to the present group experience. Mrs S felt so uncomfortable about being invited to express her emotional attachment openly to the group leader and members of the group that she attempted to change the subject. Mrs. M followed the suggestion to discuss an interesting experience, but the latent contentof her story related to her emotional reaction to the group experience. This unusual experience of touching a snake that did not bite is an indirect reference to her forming close attachments in the group and not being hurt in the experience.

Their need to express emotional attachment indirectly related to the group members' strong fears of rejection. Open expression of their feelings would leave them vulnerable to rejection, which had been especially painful to them in the past. It was difficult for them to admit warm feelings toward the group leaders who were leaving them and about whose feelings of emotional attachment they were unsure. It was not until the group leaders admitted their own feelings of emotional attachment with group members that they could feel secure enough to express openly their feelings of warmth and closeness with the group leaders without fear of rejection. In this respect, permission was given to members to express these feelings openly. This created a feeling of safety that enabled the group members to transfer capacity for emotional attachment to other relationships.

The following examples will illustrate how open expression of feelings were retarded and facilitated by this group leader:

Mrs. B: You'll stop coming here in May. . .1 remember your telling us so.

Mrs. L: I know that you'll be glad. It's so far to travel only to have to worry about people not attending the meetings.

G.L: I will be leaving in May, but I won't be glad. I enjoy and look forward to being here with you.

This statement was noncommittal, and was matched by an equally noncommittal response by two members of the group:

Mrs. B: I enjoy doing whatever I can to help you out.

G.L: Perhaps the real reason that we each attend the group meeting on Monday afternoons is because we want to be near each other.

Mrs. B: I enjoy being here.

Mrs. L: So do I.

Two more members joined the group after this interaction. In explaining the topic of discussion, the group leader expressed her feelings about separating from them in a more personal and meaningful way:

G.L: Before you entered we were discussing my leaving the group in May. It was mentioned that perhaps I will be happy when it's all over and I no longer have to come here. I won't be glad when it's all over. You've shared so much of yourselves with me each week and I'm going to miss you so very much, each and every one of you. I feel a special closeness to you individually and as a group.

Mrs. M: I'm going to miss you too. Will you write to us every once in a while after you leave just to let us know what you are doing?

There was an immediate, warm response by the group members to the leader's open expression of her sad feelings about leaving them, and her emotional attachment as a result of being with them and sharing so many of their feelings with them over the past months. In openly expressing personal warmth to them, the group leader gave members permission toexpress their feelings openly. They were now less vulnerable to rejection by the group leader; therefore they could express their feelings of emotional attachment with a greater amount of comfort and security.

In the second group, the group leader did not tell group members of her emotional attachment to them until late in the termination phase. Up until the time she told them of her warm feelings toward them, the group members had avoided any open statement of their feelings for her. Even when she did express her emotional attachment for the members, they did not immediately respond by telling her of their own feelings in a direct manner:

G.L: When we all began I never thought that ending the group would be as painful as it is. As I've gotten to know each of you I've grown to care for you very much. I'll really miss all of you.

Mr. W applauded and everyone murmured how nice it was of the leader to tell them how she felt:

Mrs. M: We don't have to tell her what's in our hearts. It shows on our faces.

Mr. M: That's right; just coming here each week is proof of how we feel.

Group members did not immediately respond to the group leader's open admission of being emotionally attached to them by openly admitting to their attachment to her. However, in the next session they were able to tell her directly of their own feelings. One of the members wrote a poem describing warm feelings in detail, and the poem was read several times within the group. In discussing the differences between loving and liking, Mr. M. stated:

I know there is a difference between liking and loving. This young lady here. . .1 love her.

Although the group leader's intervention as a role model in expressing her feelings for group members was not immediately effective, it was highly effective at a later time in giving members the confidence they needed to express their feelings for her. Their ability to express attachment was seen as an indication that the group experience had been successful. By openly admitting emotional attachment, even as termination neared, the members had to feel secure enough to handle the pain of loss. Had the impending loss been too difficult to handle, they would not have allowed themselves to experience the emotional attachment. Furthermore, by expressing their feelings even as the group leaders were leaving, group members showed less sensitivity to rejection. Before the group experience, fear of rejection and uncertainty about their ability to handle the pain of loss kept the group members from forming emotional attachments in the group. Because their open admission of attachment was based on their security about their ability to handle loss, it could be inferred that this ability can now be transferred to other areas of their lives.

Conclusion

As group leaders, we were gratified with the changes we witnessed as the group experiences progressed. The resistances that were present in the beginning among group members were so great that we did not expect the degree of emotional attachment that was expressed at termination. The great change apparent in our group members at the termination of the group experience emphasized the fact that this age group, which is usually neglected in the area of group psychotherapy, can benefit from this treatment modality. Because of the positive effects possible with this particular age group, working with the elderly can be extremely satisfying. This has certainly been true in our experience.

When working with the elderly, the health caregiver must stress that the mental health worker will be aware of the issues that concern this age group most - fear of loss and attachment. Because loss is so real and omnipresent among members of this age group, there is a tendency to become isolated in an effort to defend and protect themselves against the pain of loss. Anyone interacting with people in this age group must be aware of this dynamic, as it can provide a foundation that professionals and paraprofessionals use in dealing with the occasional frustration inherent in the work with the elderly. Such a foundation can prevent the feelings of futility to this age group.

Anticipating that new students would lead new groups, we maintained contact with group members over the summer by writing notes to each of them. Since group members were prepared to expect new graduate students the following September, this action helped to maintain group identity. We expect that the new students will meet with fewer group and individual resistances as they attempt to resume sessions.

Acknowledgment

The authors would like to thank Fern Kumler, who acted as their advisor during the group experience.

10.3928/0098-9134-19810601-06

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