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BookREVIEW: Difficult Topics in Group Psychotherapy

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Jereme S.Gans

New International Library of Group Analysis 2009

Series Editor: Earl Hopper.

London: Karnac Books

pp 250 £22.99 (paperback)

Review by Vivian de Villiers

This book is a collection of eleven papers dating from 1989 to 2008, five written by Jerome Gans as the only author and six papers Gans wrote in collaboration with other well known experts in the field of Group Psychotherapy. All the papers have previously been published in the International Journal of Group Psychotherapy. The chapters are linked with helpful and interesting autobiographical notes written by Dr Gans.

I found the first two chapters enlightening and reassuring. Chapter One deals with the detection of shame in a group as well as with shame in the therapist, how it presents and suggestions how to manage it. I find the humility shown by the authors refreshing and the suggestion to replace a ‘grandiose professional ego-ideal’ with a ‘realistic professional ego-ideal’ a hopeful and freeing permission. I have experienced the disturbing power with which a group member can deskill and shame a group therapist by using scorn and disdain and the powerful illusion created in this process. Chapter One, the detection of shame, helped me to recover from that and to find a way of managing the situation in a compassionate and more constructive way (Gans & Weber, 2009, pp. 11-12).

In Chapter Two, hostility in group psychotherapy is explored. Gans starts the chapter along the lines that; ‘the brain starts thinking at the moment of birth and stops functioning when the group leader is faced with hostility’. He describes a sudden outburst of hostility as the psychological equivalent of a cardiac arrest and feels that creative thinking is unlikely to happen on the spot. One has to have pre-planned ways and techniques of handling the hostility when it presents and he places hostility on a continuum from irritation to pre-oedipal rage (Gans 2009, p. 41).

Gans describes a vignette of a hostile interaction and then walks one through the thinking process using a number of theoretical models and the reason for deciding on a particular intervention. He refers to Horney who viewed anger and hostility as reactive products of a menacing environment characterized by rejection, savage criticism, ridicule, coldness and humiliation. The task of the group therapist, informed by neoanalytic theory, is to help the group to understand that the individual’s ‘provocations, although problematic to her, were her creative way of surviving the brutal world of her childhood’ (Gans 2009, p. 51).

Concurrent dyadic and group therapy with the same therapist is discussed in Chapter Three. There is a section on the criteria for group membership as well as transference and counter-transference in individual and group psychotherapy.

Chapter Four is dedicated to the role of money in therapy with an interesting autobiographical note on Gans’s personal journey in relation to money.

I found Chapter Five on indirect communication and Chapter Six on difficult patients particularly helpful. Given that I am a ‘Sullivanian’, it was good to see a reference by Gans to Harry Stack Sullivan’s ideas in relation to participant observation. Gans mentions counterprojection and eye contact and describes his experience in training when a supervisor commented on his lack of eye contact with a paranoid patient. He says it would have been more helpful if the question had been phrased as follows: “Dr Gans, I noticed that you limited your eye contact with your patient. Do you have any thoughts about why?’’(p. 103).

The guiding principle of indirect communication is considered to be the protection of the most vulnerable group member when a direct response by the group conductor could increase shame and impact negatively on the therapeutic alliance. It can also be used to help postpone a confrontation with a group member whose connection with the group is solid but the therapeutic alliance with the group conductor unstable. Indirect communication can take the spotlight off the group member and I found the many examples and vignettes enlightening. Indirect communication can also help to avoid the trap of one-to-one therapist-patient explanation and promote exploration and group interaction (Gans 2009, p. 106).

In Chapter Six the difficult patient is conceptualised as a co-constructed product of the patient, the group-as-a-whole and the group therapist. This is framed as a unique learning opportunity when one asks ‘What is it about me or in me that makes this difficult patient so difficult for me?’ The difficult patient provides other group members opportunities to become curious about what it is about themselves that makes the difficult group member so annoying, infuriating and irresistible to them. Other members can try to fix in the difficult patient, issues that sometime in the future they will be ready to address in themselves. The difficult patient also helps the group learn a great deal about the group conductor, how he deals with relentless challenges and with the difficult group member getting under his skin. Group members size up how safe or unsafe it will be for them when their turns come to unleash the more uncivilized and loving parts of themselves in the group and on its leader.

Silence in group therapy sessions is discussed in Chapter Seven and in Chapter Eight the missed session is looked at.

Chapter Nine is on courage, the first section being a plea for greater recognition and appreciation of our group members’ courage. While enlarging ‘the capacity to suffer meaning’ can be transforming, it is also very frightening. The process of emotional learning involves relinquishing old constructs and suffering the fear of being temporarily lost until new understanding emerges (Gans 2009, p. 193). Shapiro and Gans also look at the courage of the group therapist and for example the need to confront one’s mistakes openly as well as dealing with prejudice and hatred in self and others.

The book concludes with an epilogue where Dr Gans explains that the selected papers map his own journey from shame to courage. He ends on an encouraging note for readers, suggesting to focus not only on what is problematic in ourselves and patients, but also to appreciate and respect the gifts that we have gotten from our life experience, including those experiences we may have elected not to have (p. 224).

I missed the launch of this book at the AIGP conference in Rome in 2009 by accident given that I gave in to the temptation of sampling Italian food at the time of the launch. This led me to rediscover the book only when I volunteered to write a review. I was lucky. I found it stimulating, a treasure trove of ideas and suggestions and very generous and courageous of Dr Gans to take us on his journey from shame to courage. I recommend it to students as well as qualified therapists.

Vivian qualified and worked in South Africa as a medical doctor before moving to New Zealand where he lived for 12 years and worked in psychiatry and in general practice. After immigrating to the UK he qualified as a group analytic psychotherapist and has been working for the past decade in the NHS with clients with alcohol dependency. He has been an experiential training group conductor at the Minster Centre as well as at the London Centre for Psychotherapy for some years. He has a private  practice and is a member of the Institute of Group Analysis, London.