The detection of shame in group psychotherapy: uncovering the hidden emotion.

Shame, recently so extensively investigated in the individual and family therapy literature, has remained curiously underexplored in the group literature since Alonso and Rutan's noteworthy article on the subject in 1988. Shame is frequently bypassed because, as a result of its hidden nature, its presence is often not detected. This article strives to insure that shame does not go unaddressed. We catalogue and discuss six defenses that may suggest the subterranean workings of shame: (1) focusing on themes that stress similarities among members, (2) generating feelings of scorn and disdain, (3) avoiding here-and-now material, (4) inducing guilt, (5) transference reactions, and (6) preserving the illusion of the leader's infallibility. The best antidote for shame's neglect is a heightened readiness to detect it. Such detection is important because shame plays some role in many of our patients' complaints.

Silence in group psychotherapy: a powerful communication.

Silence in a psychotherapy group, including leader, member, subgroup, and whole-group silence, is a common phenomenon with many possible forms, uses, and meanings. Five common sources of silence in group psychotherapy are described: situational factors, individual dynamics, member-to-member interactions, group dynamics, and leader-related dynamics. Silence can reflect defenses or indicate conditions favorable to intensified group work. Silence, sometimes mistaken for psychological inactivity, should be viewed as significant communication.

The missed session in psychodynamic group psychotherapy.

Missed sessions in group psychotherapy are often overlooked or not talked about, thus forfeiting an important therapeutic opportunity. Group members miss meetings for many different reasons, be they the result of real-life events or clinically driven occurrences. Missed sessions can have important emotional and metaphorical meanings for the missing member, the other group members, and the leader. Countertransference difficulties may interfere with optimal exploration of the many meanings of missed sessions. Five clinical examples illustrate meanings that may reside in the missed session. A cancellation policy that provides a framework for such exploration is recommended.

Narrative lessons for the psychotherapist. Kafka's The Metamorphosis.

Literature has much to offer the psychotherapist. This paper has discussed some lessons for the psychotherapist contained in Franz Kafka's short story, The Metamorphosis. The therapist, like the therapist-reader of this story, can empathize with Gregor's monstrous change but still must hold him personally accountable. At the same time, the therapist-reader becomes increasingly impressed with the malignant nature of the Samsa household, and its role in generating Gregor's capacity for self-deception. The story also instructs about the paradox of catastrophe: Gregor is treated no less respectfully after his metamorphosis than he was before it. The therapist is thereby reminded of the centrality of feelings in human affairs. The constriction of Gregor's space does not cut him off from human feeling; rather, Gregor's inability to access, know, and take responsibility for his own feelings, especially his destructive ones, results in his constrictedness and detachment. In thinking about the story as dream, or in imagining a patient's account of a reality situation as if it were a dream, unseen mental process and content become more apparent. The disgusting, loathsome arrangements that people make with each other can evoke, be it in the therapist-reader or the therapist, reactions of aversion or hate. Such arrangements become more understandable when the importance, sometimes the necessity, of human attachment is appreciated. And finally, Kafka's The Metamorphosis alerts us to a sometimes but powerful preference and countertransference pitfall: we don't want to be bugged.

Difficult patients: their construction in group therapy.

Written from the perspective of intersubjective theory, this article addresses how the leader and group members co-construct the difficult patient. Too often, therapists and patients have tended to attribute difficulties in therapy groups to "the difficult patient" without appreciating how they themselves contribute to the construction, the needs this construction serves, and the potential value of such patients to the group. Mistakes in group leadership, vicissitudes of intersubjectivity, disturbing intrapsychic defenses, and whole-group dynamics interact to produce the difficult patient. Also discussed is the group member who is difficult but who no longer meets the criteria for patienthood. By exploring the factors involved in the co-construction of the difficult patient, the authors hope to guide clinicians in the deconstruction of such impediments, thus allowing the difficult patient to become "just another group patient."

The leader's use of indirect communication in group therapy.

Indirect Communication (IC) is a leadership technique designed for those situations in which the leader must respond immediately but doing so directly might be a clinical mistake. As defined in this report, IC refers to times when the leader addresses someone by speaking about that person to someone else or by thinking aloud while speaking to no one in particular. The author distinguishes IC from other modes of indirect communication. Pitfalls of direct communication and ways in which IC avoids them and provides therapeutic alternatives are discussed. The leader's use of IC helps achieve two major goals: (1) the creation of an enlarged work space, safe enough for patients to express their more irrational and distressing feelings, and (2) the therapeutic handling of these uncivilized parts of each member as they emerge. Several clinical examples are presented. Misuses of IC are discussed.

T-groups (training groups) in psychiatric residency programs: facts and possible implications.

The authors studied T-groups offered in psychiatric residency programs in the United States in 1992. A 32-item questionnaire was sent to the residency training directors of 297 psychiatric programs and 34% responded. Results of the questionnaire are presented and their possible implications are discussed. These include: (1) programs that offer T-group value it as indicated by the time allotted to it, the quality of the T-group leaders, and the objectives within the residency program it seeks to accomplish; (2) 45% of respondents not offering T-groups cite negative attitudes toward T-groups (theirs or their residents) as a reason for this decision; (3) T-group, often equated with psychodynamic process, may have suffered the same recent deemphasis as has the teaching of psychodynamic psychotherapy; (4) and T-group, by its very nature, has educational as well as therapeutic features, a combination that creates tensions with regard to the T-group contract, especially the items having to do with confidentiality and attendance. The authors suggest group therapy will be a primary treatment modality in the coming years of economic constraint. They also recommend making a case to residency training directors for T-group and its inclusion in psychiatric curricula.

Taking a history of childhood trauma in psychotherapy : achieving an optimal approach.

The authors examine the process of taking an initial history of childhood abuse and trauma in psychodynamic psychotherapy. In exploring the advantages, complexities, and potential complications of this practice, they hope to heighten the sensitivities of clinicians taking trauma histories. Emphasis on the need to be active in eliciting important historical material is balanced with discussion of concepts that can help therapists avoid interpersonal dynamics that reenact and perpetuate the traumas the therapy seeks to treat. Ensuring optimal psychotherapeutic treatment for patients who have experienced childhood trauma requires attention to the following concepts: a safe holding environment, destabilization, compliance, the repetition compulsion, and projective identification.

Indirect communication as a therapeutic technique: a novel use of countertransference.

This paper presents a technique to deal with therapeutic impasse in the treatment of resistant or very troubled patients. The novel feature of this technique is the indirectness with which therapists communicate with their patients. Therapists think aloud while not looking at their patients; patients "overhear" rather than hear. In their soliloquies, therapists make use of their countertransference for therapeutic purposes. Direct communication in such situations is often impossible or counterproductive and continued silence may not be in the patient's best interest. This paper provides the background for these ideas, describes the productive use of this technique in three clinical situations, and provides a theoretical rationale for them. The conceptual frameworks draws from Winnicott's ideas of the True and False Self, play as it relates to therapy, and the regulating functions of a positive holding environment for disequilibrating countertransference. Several factors contribute to therapists' concerns about employing this technique: the need to appear sane, fears of relinquishing eye contact, and apprehension over exploring the projective field. Instances when the use of indirect communication is not indicated, ill-advised, or contraindicated are discussed.

Money and psychodynamic group psychotherapy.

Money may be the most upsetting and therefore the most avoided topic in group psychotherapy. To overcome this resistance, the leader must secure prospective members' willingness to speak openly about financial matters. Financial issues particular to group therapy emerge when money is normalized as a topic for discussion. These include lowering or not raising fees, rescheduling, leaves of absence, combined and conjoint therapy, and nonverbal behaviors. Several case examples are provided. Members' strong feelings toward the leader around financial transactions often find expression in angry accusations. Suggestions for dealing therapeutically with countertransference reactions to these accusations are offered.

The leader's use of metaphor in group psychotherapy.

This article discusses the leader's use of metaphor in outpatient, psychodynamic group psychotherapy. Four clinical examples are provided that illustrate how the phase of group development informs the leader's use of metaphor. Therapeutic features and uses of metaphor include (1) the development of ego skills that transform passivity into activity and foster the examination of unhealthy norms; (2) the modulation and rechanneling of potentially destructive affect and the intensification of affect that is denied, minimized, or avoided; (3) the creation of a verbal play space in which shared group language evolves; (4) and the provision of various levels of concreteness and abstraction as well as differing perspectives. Abuses of metaphorical interventions are discussed.

Broaching and exploring the question of combined group and individual therapy.

Combined therapy is defined as concurrent dyadic and group therapy with the same therapist. This paper focuses on a neglected aspect of combined therapy: broaching and exploring this question with one's individual patient. The author shows how raising this question: (1) alters the therapeutic field whether or not the patient joins; (2) can sharpen the therapist's understanding of the indications and contraindications for group membership; (3) offers untapped therapeutic approaches and opportunities to classify issues in the individual treatment; and (4) stirs up countertransference issues related to issues of profitability, the transference of the patient in individual treatment, and the transference of the group-as-a-whole. Several case examples are provided.

Hostility in group psychotherapy.

To run a psychodynamic group therapeutically, the leader must understand the meanings and functions of hostility. Fundamental to this task is the leader's awareness of his or her bias toward hostility as a constructive or destructive feeling and willingness to serve as a lightening rod for it. This paper discusses the sources of hostility during different stages of group development. The therapeutic handling of hostility is discussed under the following topics: theoretical considerations, defensive functions, and communicative functions. Case examples illustrate the proper handling of contractual violations, scapegoating, and narcissistic injury. Countertransference reactions to anger and rage in the group are discussed.

Dexamethasone suppression test and depression in a rehabilitation setting.

A diagnosis of depression is frequently considered in the evaluation of patients after cerebrovascular accident (CVA); however, the usual clinical signs of depression may be either masked in depressed patients or mimicked in nondepressed patients. The dexamethasone suppression test (DST), first used to screen patients with a suspected diagnosis of Cushing's disease, has been shown in the psychiatric population to be abnormal in about 50% of patients with primary or endogenous depression. This study employed the DST to assess its diagnostic value in a population of 20 CVA patients admitted to a rehabilitation hospital. The test was found to have an 83% specificity. Results suggest that the low incidence of primary depression in this setting greatly limits the utility of the DST in such usage.

Hate in the rehabilitation setting.

Hate has been overlooked as a clinical issue in the rehabilitation setting. Factors are discussed which make hate an intrinsic part of the rehabilitation process. Four common situations that involve hate are described. Dealing with hate is difficult because the natural responses, retaliation or aversion, are harmful. New ways of understanding hate that enable therapeutic responses are provided. These include viewing hate as: 1) an expression of powerlessness, not strength, which frequently results from the clinical state of regression; 2) a maladaptive way to maintain, not end a relationship; and 3) a result of staff-patient interaction, not a purely objective phenomenon. An understanding of these concepts leads to the proper use of the two major therapeutic responses to hate: empathy and nonpunitive limit setting.

Depression diagnosis in a rehabilitation hospital.

Physical rehabilitation patients frequently have extreme emotional reactions which are appropriate to their physical disability but are misdiagnosed as clinical depression. Organic illness can produce signs and symptoms which mimic clinical depression (false positives). Less frequently, clinical depressions which present atypically are not diagnosed (false negatives). To illustrate these points, 100 consecutive psychiatric consultations were reviewed to study the diagnosis of clinical depression in this setting. Diagnostic criteria for depression, specific for a physical rehabilitation population, are proposed. Consequences of the misdiagnosis of clinical depression in this setting are discussed.

The consultee-attended interview: an approach to liaison psychiatry.

The consultee-attended (C-A) interview, a format in which the liaison psychiatrist interviews the patient in the consultees' presence, is described. The background, strategy, concepts and methods, obstacles and resistances, and countertransference difficulties of C-A interview are discussed. The C-A interview is an experiential teaching instrument with which to facilitate consultees' "participant-observation," a clinical posture that complements other approaches to the care of sick people.