The group therapist must use a wide variety of techniques to achieve optimal intensity. He cannot rely solely on interpretation, the classical analytic technique, because (1) many changes in intensity level are not due primarily to intrapsychic conflicts, but rather to therapists' errors or anxiety aroused by the format of group therapy, and (2) patients cannot ordinarily accept interpretations constructively until they have developed sufficient ego strength and have learned to use the group effectively.
The basic strategy is, first, to strengthen and support the patient's ego; then, to elicit the underlying conflictual material; and finally, to work this through so that the patient can understand and gain control of his unconscious conflicts.
Following are some useful techniques. The earlier ones aim at strengthening the patient's ego through gratification and guidance; subsequent techniques temporarily loosen ego defenses to allow charged impulses and fantasies to emerge; finally, interpretive techniques are brought into play to achieve understanding and ultimately control of the defended impulses and fantasies.
It is of utmost importance that the therapist detect and deal with' countertransferential reactions since these constitute the most crucial stimuli impinging on a group and are the chief instigators of major transferential, acting-out and resistive phenomena, as well as concomitant changes in intensity level.
In relatively uncomplicated countertransferential situations, self-analysis may suffice. More complicated difficulties require consultations with peers or expert supervisors.
The first step in dealing with countertransference is to ascertain the target. In private practice, countertransference may be directed toward an individual patient, clusters of patients, the entire group, and in some cases of concomitant therapy, toward the therapist who is rendering individual treatment. In institutional settings, the therapist may, additionally, develop countertransferential reactions to supervisors, administrators or the setting.3
I have found the following techniques useful in ascertaining both the target and the content of countertransferences.* They may be used by the therapist either in self-analysis or as part of his formal supervision.
A. Listing the names of all patients in the group.
Generally speaking, the patients listed first are most liked by the therapist. Those listed last are most disliked. Those in the middle tend to be "lost in the shuffle," and those omitted may have induced neurotic conflict in the therapist.
B. Making periodic drawings of the group.
These drawings reveal the therapist's unconscious perception of each group member as well as of the total group constellation.
C. Making up a dream about the group.
This technique yields similar material to the drawings but reaches a deeper level and yields a richer content.
D. Associating a symbol and color for each patient.
Associating symbols and colors condense the therapist's myriad impressions of each patient and of the entire group. On a basis of thousands of verbal and non-verbal communications, the therapist forms a relatively invariant perception of each member. This perception affects all of his transactions with the patient throughout the course of therapy. Unless the therapist becomes aware of his fundamental perception of the patient, he will be insufficiently receptive to the full range of his patient's communications.
GRATIFY NEED FOR CONTACT
As described above, the group therapy format frustrates the patient's need for close contact with a parental figure. To offset this built-in frustration, it may be necessary for the therapist to gratify this need partially during the early phases of group therapy. The most direct way to do so is by seeing him more frequently in individual sessions.1'3 However, if this is not possible or deemed therapeutically undesirable, temporary gratifications in the group session itself may be indicated.
Overgratification of the patient's need for contact in the group is, of course, undesirable since it may have a deleterious effect on the group process and may mask the patient's negative transferences and limit the possibility of ultimately achieving reconstructive goals. The therapist must find a balance.
TRAIN THE PATIENT TO USE THE GROUP EFFECTIVELY
Many group patients report that they find group therapy exciting and fascinating, but do not see how it can help them with their individual problems. The reason for this is that they have not been sufficiently trained to see the relationship between their overt behavioral patterns in the group and their underlying intrapsychic conflicts.
To avoid this, patients should not, ordinarily, be referred to groups until they have achieved some intellectual awareness of their core conflicts.1'3
A useful way to predict the likely transferential projections and behavioral manifestations of a patient in the group is to ask him to render the following three drawings in prior individual sessions:
1) his image of the original family constellation
2) his image of the current family constellation
3) his image of group therapy.
These drawings, in addition to their diagnostic value, may be employed as a form of interpretation helping to convey to the patient the idea that much of his current behavior in the group is a transferential replay of patterns learned in the original family. The more he can see the connection between his actions in a group and chronic intrapsychic patterns, the more he will be able to use the group therapeutically.
Training a patient in using the group is an effective way to regulate his anxiety level and to avoid unproductive impasses due more to inexperience in the role of group patient than to dynamic causes. In most cases, only minimal guidance is required after the initial phases of therapy. Also, once having been in group therapy, patients can usually shift from one group to another with little or no additional guidance.
CONSULT WITH PATIENTS AND/OR GROUP
In consultation, the therapist temporarily steps back from the group process and judiciously presents to the patient, or to the group, his views as to the current status of the therapy. He outlines the chief therapeutic problems at the moment, especially impasses and/or transference-countertransference binds which block therapeutic movement, and he invites feedback from the patients.
Consultation is a supportive technique in that it brings about a temporary diminution of transferential intensity and releases the patient from the anxiety inherent in having his defenses challenged. It is also a form of gratification; most patients appreciate having the therapist take their opinions seriously. Moreover, it is an educational technique helping the therapist and patient reduce extraneous (non-dynamic) causes of anxiety. Finally, it is an interpretive technique to the extent that it helps focus the patient onto key problems in his personality.
The use of audiovisual techniques as an integral part of an ongoing therapeutic produce is a form of consultation.6 In looking at a videotape or listening to a sound recording together, therapist and patient step back temporarily from the process and attempt to comprehend and improve it.
The main limitation of consultation is that, carried to an extreme, it may unduly curtail the precipitation of full-blown negative transferences and anxiety reactions and limit the possibility of working these through. But clinical experience indicates that consultation need not detract from an analytic orientation, if properly used.
REFORMULATE THE TREATMENT PLAN
If the therapist, after consultation and/or supervision, determines that he has committed technical errors or has been deflected by countertransferential distortions, he must reformulate his treatment plan.1
Essentially, this involves going back to an earlier phase of therapy to solidify the therapeutic alliance, to obtain a better psychodynamic understanding of the patient, and to make more effective use of the various treatment modalities at his disposal (e.g., combined therapy, conjoint therapy, family therapy, etc.).
Most often, the short-term effect of this technique is to reduce intensity. However, once this has been accomplished, the therapist may, if indicated, proceed in the opposite direction and increase intensity by bringing into play the techniques discussed below.
INTRODUCE FACILITATIVE TECHNIQUES
Included here are any techniques introduced into the group, by the therapist to elicit material (interactive or associative) which has not spontaneously emerged.
Early psychoanalysis assumed that all of the patient's neurotic conflicts would emerge in the transference. We now know that patients' reactions to realistic aspects of the therapist's personality and techniques unquestionably limit the range and quality of the material elicited. A similar situation obtains in group therapy. Core conflicts often do not emerge spontaneously within a particular group, or even within several groups led by the same therapist, over considerable periods of time.
The range of facilitative techniques currently in use is enormous. (Most of the new "encounter" methods are essentially facilitative techniques.) Generalizing about their effects on intensity level is difficult. Some raise it by loosening defenses and getting at phobic impulses and fantasies. Others lower it by creating a non-therapeutic "game-like" atmosphere which gratifies patients too much - makes therapy too easy for them. The best techniques, from the analytic point of view, are those which enable the therapist to deal effectively with phobic material while simultaneously keeping anxiety at optimal levels.
Facilitative techniques are useful in eliciting "milestone experiences" which can subsequently be worked through intensively in much the same way as one works with a meaningful dream in psychoanalysis.8 They can provide valuable grist for the therapeutic mill, provided they are followed up by dynamicallyoriented working through.
It should be noted, in passing, that the use of facilitative techniques in groups long antedated the encounter movement. Some of the leading figures in analytically-oriented group therapy have utilized facilitative techniques for many years. Thus, for example, the "going around" technique of Wolf and Schwartz11 and the utilization of dreams as "group property" by Kadis8 may be seen essentially as facilitative techniques.
RESOLVE GROUP RESISTANCES
As mentioned earlier, common group resistances raise the intensity level of each group member but obscure or present a skewed picture of his psychodynamics. Therefore, the therapist cannot effectively elicit and work through the specific unconscious conflicts of each group member until he has resolved existing group resistances.* Techniques for detecting and dealing with group resistances have been outlined by the author in a previous article.2
Briefly, these involve:
1) Studying the network of interaction (both transferential and non-transferential) within the group.
2) Determining the stimuli which precipitate the group resistance. (Most often these consist of the therapist's actions or other common stimuli impinging on the entire group.)
3) Ascertaining which patient or patients initiate the group resistance.
4) Dealing interpretively with the transferences and resistances of the resistance leaders.
5) Interpreting how the more passive members utilize the resistances of the leaders to reinforce their own resistances.
EXTEND THE LENGTH OF SESSIONS
Time-extended group sessions (or "marathons" as they are popularly called) can, if used in conjunction with ongoing individual or group analytic therapy, enable the therapist to achieve more exquisite control of intensity than is usually possible in standard group therapy sessions.
Extending the length of a group session automatically "compresses" the experience10 and raises intensity by temporarily weakening defenses and allowing charged material to surface. (The fact that most patients who elect to participate in marathons are already primed to deal with conflictual material greatly accelerates this process.) Also, it allows the therapist to bring :nto play a wider variety of techniques to elicit core conflicts, as well as affording him more time to work these through. * *
The danger of precipitating untoward intensity levels (an inherent danger of all "marathons") is minimized in the context of an ongoing therapeutic program since the therapist has the opportunity to control these in subsequent individual or group sessions.
INSTITUTE MAJOR CONSTELLATION CHANGES
Major constellation changes (adding or replacing three or more new members) always produce potent changes in a group's intensity level. They can increase it or decrease it depending on the personalities of the original group members, the new group members, and their interaction with each other.
Since it is very tempting for a therapist to resort to constellation changes to reduce his own anxiety, their use should be avoided until he has fully explored his own countertransferences as well as the transferential network within the group. He should have no hesitation, however, in changing constellation should he determine that his group is structurally unworkable.
FRUSTRATE THE PATIENT'S TRANSFERENTIAL NEEDS
Frustrating the patient's needs renders the patient's defenses temporarily inoperative and brings underlying impulses and fantasies closer to consciousness, inevitably raising the level of intensity.
Some of the most intense group experiences reported in the literature are those in which the therapist systematically withheld all verbal communications for long periods of time as part of his treatment plan.9
Frustration techniques are indicated when patients are highly motivated, have reasonably good egos, are in a good working relationship with the therapist, and are in the middle or later phases of therapy.
Frustration may, in some cases, lead to valuable insights and even working through without interpretive interventions. However, in most cases, the therapist must employ interpretive techniques to help the patient integrate the charged material that has been elicited.
Interpretive techniques increase intensity by loosening defenses and bringing the patient closer to charged repressed material. They lower it by helping him desymbolize unconscious fantasies and projections. Their ultimate goal, however, is more ambitious than mere regulation of intensity level. It is to help patients achieve better control of their behavior by exploring the relationship between their overt actions and underlying nuclear conflicts.
Essentially, interpretation in groups involves the following steps:
1) Detecting repetitive, disturbed patterns of overt behavior manifested either in the patient's verbalizations about himself or in his defensive maneuvers.
2) Pointing these patterns out to him and to the other group members (who then aid the therapist in detecting further manifestations of the behavior).
3) Getting him to agree that a specific pattern is indeed operative.
4) Determining which stimuli in the group trigger these repetitive patterns.
5) Using the overt behavior as a jumping-off point for investigating and working through the underlying defenses, fantasies and impulses.
6) Demonstrating the ramifications of his group behavior to outside relationships.
Ideally, these steps lead to a) lessened need for defensive maneuvers; b) more direct and appropriate gratification of needs, fantasies and impulses, and, eventually c) substitution of more appropriate defense mechanisms and interpersonal maneuvers. Some patients spontaneously hit upon more effective interpersonal transactions; others need the help of the therapist and group members to suggest more viable alternatives.
The errors to be avoided here are: a) focusing too much on interpersonal aspects of the patient's behavior, b) too heavy concentration on intrapsychic aspects of his behavior, and c) insufficient integration of the interpersonal and intrapsychic aspects of his behavior.
MARVIN L. ARONSON, PH.D.
1 . Aronson, Marvin L. Patient Selection in Group Therapy. Voices IV (1968), 93-95.
2. Aronson, Marvin L. Resistance in Individual and Group Psychotherapy. American Journal of Psychotherapy XXI C 1967), 95-96.
3. Aronson, Marvin L. Organization of Programs of Conjoint Psychotherapy in Mental Hygiene Clinics. Psychiatric Quarterly [supplement] XXIX (1 965). 299-31 0.
4. Aronson, Marvin L. Acting Out in Individual and Group Psychotherapy. Journal of the Hillside Hospital XIII (1 964), 43-48.
5. Aronson, Marvin L. Technical Problems in Combined Therapy, /nfernat/ona/ Journal of Group Psychotherapy XIV (1964), 425-430.
6. Berger, Milton. Integrating Video into Private Psychiatric Practice. Voices V ( 1970), 78-85.
7. Kadis. Asya L. A New Group Supervisory Technique for Group Therapists. Voices VII (1971). 32-33.
8. Kadis, Asya L. and Aronson, Marvin L. Dreams in Analytic Group Psychotherapy. Unpublished manuscript, Postgraduate Center for Mental Health, 1 970.
9. Markowitz, Max, Schwartz, Emanuel K., and Lift. Zanvel. Non Didactic Methods of Group Psychotherapy Training Based on Frustration Experiences. International Journal of Group Psychotherapy XV (1 965), 220-227.
10. Riess, Bernard F. Experience Compression in a Managerial-Psychological Team Approach to Executive Efficiency. In Progress in Clinical Psychology. New York: G rune & Stratton, 1971, 125-141.
11. Wolf, Alexander and Schwartz. Emanuel K. Psychoanalysis in Groups, New York: G rune & Stratton, 1962.