by Marc G. Schramm, Psy.D., C.G.P.
A recent correspondent has been having difficulty with a new group member, whose attendance had been rather sporadic after a good initial couple of months. The therapist says he is having difficulty confronting the member in question, who mostly seems to have tales of significant woe behind his absences.
In the meantime the group had become increasingly less sympathetic towards this member, who is becoming at risk for scapegoating. This patient is unusual in the therapist's group experience, in that his attendance problems don't seem to be associated with poor attachment to the group. Most patients I've seen who have missed so many sessions would have dropped out altogether by now, or the absences would have stopped.
It sounds like the member in question has an "approach/avoidance" conflict with the group. A certain amount of neediness is paired with discomfort with intimacy. It could be helpful to explore this possibility when the patient is in group, including the gradual alienation this pattern can engender in others (as appears to be happening in the context of the group).
Such exploration should be done gently, as the intimacy involved in such exposure may contribute to this member's avoidance. Thus the therapist might start with how the continuity of group process can be affected by absences.
In these explorations, it may also be possible to use structural elements inherent in group rules about attendance. Group contracts are very helpful in this regard (see Reference: Group--"No Fine Print" parts 1 & 2). But sometimes group rules evolve in other ways.
I once had a patient whose attendance problems seriously irritated the group (myself included). Based on the group contract, I raised the issue of her frequent absences. She pleaded (as most members do in such situations) that the circumstances keeping her from group were beyond her control; asking her to leave group if she couldn't attend regularly would, she said, be punishing her unfairly.
My response to this type of claim has always been to acknowledge the feeling of punishment, but to clarify the reality issues: whether they are for good reason or ill, frequent absences prevent a patient from benefiting from group, and causes difficulty for the other members. In young groups, it is typical for other members to resonate with the sense of "punishment" as they put themselves in the position of the problematic member. In the group under discussion, however, attendance norms were fairly well established, and the group did not empathize with her rationalizations. They did, however, stress their strong desire for her to remain in the group.
It is my practice to have groups participate in managing their own boundaries. In some circumstances, this means keeping my role as more of a consultant (albeit one with veto power). Once it was established that the group wanted this member to commit rather than drop out, I asked them to suggest criteria for that commitment. They proposed that she could stay in group if she attended the next eight sessions without a miss-- otherwise, she would be asked to drop out of the group.
These criteria seemed rather stiff to me, especially given my experience with CMHC populations in this and other groups. In my role as consultant, I advised the group of my concern. I was surprised that the members remained adamant, it being rare for group to reject my reasoned suggestions.
I could have pushed more strongly, or simply overridden their proposal, but, with some ambivalence, I chose not to. In part this was due to my sense that the member would not respond to milder standards anyway, and in part I may unconsciously have experienced vicarious gratification at their strictness (I have strong countertransference reactions to absent members). But I'd like to believe that my major reason was to honor my principle of trusting the group. After all, the prerequisite of group discussion and attention to process issues (including in this case the scapegoating process) had been met, and the standard they proposed was not outlandish under the circumstances.
I'm pleased to report that to my surprise, not only did the scapegoated member make the next eight consecutive sessions, but that she never missed a group thereafter, and quickly left the scapegoat role. She noted that she experienced group's limit setting as caring and sincere, and contrasted it with the erratic boundaries in her family of origin. Had group not cared about her, they would have reacted less energetically. But if they had only been angry, they would have reacted punitively.
My next column will be on mandated referrals. I trust you won't be absent!
Marc G. Schramm, Psy.D., is a Founding Certificant of the National Registry of Certified Group Psychotherapists, a clinical member of the American Group Psychotherapy Association, and President of the Tri-State Group Psychotherapy Society. He is currently Cincinnati-Dayton Regional Director for Counseling Consultants, Inc. Call Dr. Schramm at 513-984-9222
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