The Challenge for Group Psychotherapy

Analytic Group Psychotherapy with the Aged, Part 3

The group began with four members—Bill, Jack, Mabel, and Hilda.

Bill was in his early sixties, unemployed and twice divorced. Very little information could be obtained about the estrangement of his first marriage. The second marriage was arranged for him (very probably by a marriage broker) and he accepted with the idea that he would be taken care of by this woman. The second marriage terminated when the wife could no longer accept his complete dependency upon her. He had formerly owned a window-cleaning business, but was unable to continue on his own or to seek other employment after losing some of his customers. Past episodes of depression had been treated with electroconvulsive therapy. He was referred for treatment by his son, who felt that the father might become more active through psychotherapy. Psychological tests results revealed characteristics of senility with a diagnosis of organic psychosis and a prognosis of “he will soon be helpless enough to need the supervision of a home for the aged.”

Jack, an engineer employed by a municipal government, had been a childless widower who remarried in his mid-fifties. This second marriage occurred after his physician had informed him that his acute abdominal reactions would be helped by “seeking the aid of a psychiatrist or marry this woman.” The marriage was marked by continual strife and at the time he sought treatment, Jack had separated from his second wife. The clinical diagnostic impression during the initial interview was “anxiety reaction in a passive-aggressive personality.” The psychological test results, however, “suggested the presence of a paranoid, schizoid disorder … the quality and level of intellectual and emotional impairment are also suggestive of the possibility of some organic disorder, if not lesional, then perhaps on a vascular basis.”

Mabel, a housewife in her late fifties, also worked with her husband in a manufacturing business. She had two sons, one in his mid-twenties, the other in his late thirties. Her older son had been divorced twice and was, at the beginning of her group treatment, engaged to be married for the third time. Mabel had undergone one year’s psychotherapy approximately twenty years prior to her being seen for group therapy. As a young mother, she had become frightened when handling knives. The thought of hurting her children had become so intense that she sought treatment. The present reasons for seeking psychotherapy were com plaints of vaginal stirrings associated with sexual anxiety and guilt when in the presence of a male, regardless of age, color, or race. The clinical diagnosis was “anxiety state and a passive-aggressive personality.” The psychological test results were interpreted as “borderline schizophrenia on the brink of a psychotic outbreak,” with a “bad” prognosis.

Hilda was in her mid-sixties and was employed as a senior bookkeeper for a labor organization. She had been divorced for over twenty years and had one living child, a thirty-three-year old daughter. Her married life had been fraught with conflict, finally ending in separation from the husband, whom she characterized as a psychopath. Approximately twenty years ago, a son, age ten, was killed by a fall from an apartment building window. She had had intermittent psychotherapy sessions since 1944 at a psychosomatic clinic in a general hospital. She applied for treatment at this time because of asthmatic attacks and also because she felt withdrawn and was unable to effect close relationships with people. She anticipated retiring from work soon and hoped, with retirement, to be able to enjoy this period of life. She was having intense conflicts and overt battles with her daughter, who she felt was self-destructive. A clinical overview led to a diagnosis of “passive-aggressive personality, psycho-physiological reaction (asthma).” Her reactions on the psychological tests suggested “borderline schizophrenia with paranoid trends.”

Bill left the group after a few sessions. Agnes, Joan and Henry joined the group soon afterwards. Lila joined the group a few months later.

Joan was a housewife in her mid-fifties. She was reared in a home with many children. The mother became ill during Joan’s early youth, leaving the responsibility of rearing the brothers and sisters to her. She felt overwhelmed with the burden and felt an obligation to assume the mother role and was never able to satisfy any childhood feelings or desires. The constant and continual feelings of having to “give” while never experiencing “receiving” resulted in intense resentment. She had a son in his early thirties who had become engaged and who was planning to marry in the near future. She experienced the son as the only possession that was hers alone, and his marriage represented complete loss and anticipated desolation. This loss resulted in depression and suicide attempts. Psychological tests evaluated her as follows: “At present, patient appears to be at a precarious balance, where she seeks support in order to retain contact with reality, but which she finds difficulty to accept.”

Agnes was a married, childless woman in her mid-fifties, who had continued her profession as a registered nurse. She was the younger of two female siblings born in Russia. The parents appear to have favored the older sister, leaving her to fend more or less for herself. As a teenager, Agnes was sent to the U.S. to live with relatives. She studied nursing, became interested and active in what might be considered avant-garde activities and lived what she described a “bohemian” life. She lived with her husband for some time before getting married. She had no desire to be married but felt forced into matrimony by her husband, who threatened to commit suicide if she did not marry him. She had been diagnosed as “passive-aggressive personality” and received intermittent psychotherapy from 1948 to 1953, either in mental health clinics or privately. She sought treatment at this time because she was unable to concentrate on her work, “feelings of depression … feelings of inferiority,” and a panic reaction that she associated with an inability to relate to, or gain sexual satisfaction, with her husband. A Rorschach examination administered in 1948 revealed “although paranoid tendencies are strong, there is still sufficient contact with reality to mitigate against a psychotic withdrawal. The present trend in the intellectual activity is on an obsessive level apparently. Anxiety, at times, may amount to panic, but generally, it is fairly well controlled by neurotic defense mechanisms.”

Henry was a married man in his mid-fifties who had two married daughters. His history revealed a lifelong pattern of functioning in a very compliant manner. He felt that through compliance, his dependency needs might be satisfied. His marriage was centered on his wife, who not only dominated the family, but also appeared to have been the driving force in his business. His only feelings of “adequacy” were experienced in the relationship to his children during their youth. When the children married and began to assume their own individuality and independence, Henry felt that he no longer had any control or power. His only feelings of ego strength appeared to be derived from the children’s dependency upon and acquiescence to him. He had been a retail merchant but had been forced to sell his business because of anxiety reactions when dealing with women customers. He felt coerced by any aggressive action, which resulted in feelings of overwhelming panic. The initial psychiatric interview revealed a diagnosis of “involutional syndrome with depressive state.” Prognosis was noted as “guarded” and his acceptance for treatment was questionable, dependent upon his acceptance for this age group. Although he had had no previous psychotherapy, he had received two series of electroconvulsive shock treatments in 1954 and 1955. Following the last series of five E.C.T., he suffered memory impairment. He had applied for treatment because of depression since 1954 and his inability to deal with women. Psychological testing results revealed “presence of a picture of severe depression where involutional features and/or repressed sexual problems play important roles. The presence of additional symptomatology is indicated. Patient appears greatly in need of supportive treatment at the present time, as well as assurance and help in rerepressing the disturbing sexual material.”

Lila was a spinster in her sixtieth year of life and was working as a college professor. The clinical diagnosis on the initial psychiatric interview was “reactive depression (involutional personality), passive- aggressive personality.” Although she had previously applied to two agencies for treatment, she had been refused because of age. She presently applied for treatment because of experienced problems with creativity and an inability to effect a marriage with a man she had been seeing for twenty years. She described having wanted to get married all her adult life. However, she always felt unable to satisfy this desire because of obligations to an aged father. Upon the father’s death two years prior to her seeking treatment, she experienced herself in a state of “complete loss.” She felt herself to be completely alone and was unable to effect a marriage.

Reevaluation of the sessions showed the group therapy process to be consistent and continuous. The course of treatment for each of the patients who joined the group, however, varied. With regard to the initial attitudes, as well as reactions to the group and progress, reactions varied from intense enthusiasm to hopelessness. The group therapy process was very similar to heterogeneous groups of adults in a younger age range. The first session was initiated by silence, each one looking around and waiting for someone else to start. The therapist remained silent, allowing the patients to take the initiative. After a few minutes, introductions began, and the members of the group questioned each other and told their reasons for coming to treatment.

Hilda was the only person who had had any prior knowledge of group psychotherapy and had applied specifically for this treatment modality. Her information had come from lectures on mental health, which she ‘attended regularly. She told the group her early feelings of rejection, which she attributed to feelings of inferiority and inadequacy. She described her inability to ask for anything, feeling that this would only demonstrate inadequacies and, in turn, result in rejection. During the time she lived with her husband, she constantly needed to “give” him and was never able to ask for anything for herself. The severity of her inability to allow herself to depend upon anyone was manifested in her inability to ask the husband to work and support her and the children. As she continued to describe her lifelong pattern of relationship, she attributed her major problem to constant and persistent feelings of anticipated rejection and an inability to relate to people on an informal, personal basis. She felt and hoped that the group situation would offer an opportunity to learn and overcome the reasons for her withdrawal from personal and emotional involvements. She entered the group with great enthusiasm and in the first session assumed the role of assistant therapist. She was most helpful to everyone. In a very forceful manner, she clarified questions about the value and techniques of psychotherapy; she offered support and advice to those with intense anxiety; she probed and questioned; and she presented problems in relationship to childhood experiences. The group members’ reactions to her became very ambivalent—those in need of answers looked to her as a fountain of knowledge yet resented her authoritarian manner.

Hilda continually supplied and fed others, but could ask no direct help for herself. To ask for help directly would be to admit dependency needs, which to her meant weakness and, in turn, would expose her to rejection. The resulting frustration of not being able to ask for or accept help from others provoked and brought about an exacerbation of an existing asthmatic condition. Since she was unable to accept help from family or friends during the anticipated course of treatment, her physician was forced to hospitalize her for special medication. When she returned to the group, the therapist focused on her problem of denying “dependency needs.” When asked to associate to this reaction pattern, Hilda spoke of a lifetime, repetitive pattern which reinforced childhood experiences that “proved” she could depend on no one but herself. Persisting in her efforts to work through this conflict, she experienced no further acute attacks, and the diminution of her rigid “self-sufficiency” was slow, but continuous. After several months of apprehensive caution that other group members would not accept her as a person, she finally expressed the desire for some social contact among the members following the group sessions. Expression of this need and desire precipitated the recognition and working through of her self-sufficiency as a reaction formation to dependency needs. The other group members began to accept and relate to her as a peer rather than as the “voice of authority.”

Hilda’s relationships with persons outside the group, as reported, manifested growth toward emotional maturity. The relationship with her adult child became that of mother and daughter, with each being able to accept her respective role. During the summer, Hilda, for the first time, was able to take and enjoy a holiday. She took a cruise to the Pacific and upon her return, reported having been able to socialize and develop friendships among the other passengers. At work her relationship with co-workers became increasingly satisfying and the fear of approaching retirement disappeared.

Mabel’s initial reaction to entering group therapy was extremely ambivalent. She expressed reluctance as well as doubts about her ability to discuss her sexual anxiety with “strangers.” She also feared that instead of getting help, her “vaginal stirrings” would be provoked by the men in the group. At the same time, she expressed a great desire to please the therapist by accepting “what you feel is best for me.” During the pre-group individual sessions, her overt reactions and nonverbal communication suggested feelings that she could evade discussions of her conflicts and by some magical means passively resolve her problems. This hypothesis tended to be proven valid when Mabel entered the group. Her problems and conflicts became unknown to her. She described herself as a successful business woman who although “not more intelligent” was much stronger and more effective than her husband. Childhood experiences were described in a manner which implied emotional deprivation and unwarranted demands, e.g., mother’s entrusting the entire household activities to her. When anyone probed as to her problems, she would respond, “If I knew them, they wouldn’t bother me and I wouldn’t have to be here.” During her early experiences in the group, Mabel continued to deny any personal needs and assumed the role of the “good mother” who continually supported and encouraged others to reveal their problems. After a relatively short time, members of the group began to dispute her facade of being a devoted and “perfect wife and mother.” This confrontation by the group provoked intense anxiety, resulting in a modification of her “good mother” role in the group. Her rigid hold on “having no problems” disappeared, she began to ask help from other members, as well as to interact on an emotional level with them. She developed a strong, transferential sibling relationship with Agnes and reported that while talking with Agnes, she felt they were like “two little girls who were exchanging confidences.” She experienced intense antagonism toward Jack’s passive-aggressive behavior and identified him with her “weak husband.” Jack’s impotence reinforced the transferential relationship with him. She spoke of occasional sexual relationships with her own husband and insisted that the infrequency was because she did not want to “tire him out.” As the course of therapy continued, Mabel’s concept of the therapist as the sole agent for help began to wane and she was able to rely upon and relate to other members of the group. Although somewhat sporadic, she was persistent and questioning of the other patients’ exclusive dependency upon the therapist, insisting that other members could also offer help and insight. Her relationships and reactions within the group precipitated associations of early childhood experiences of her mother’s complete domination over all the children, which appeared to have continued to the present time. Although having taken care of the younger male siblings during childhood, she could not recall having seen a naked male until she got married. All men in her life, starting with the father and including siblings and her husband, took on the image of weakness and ineffectiveness. She described the promiscuity of her thrice-divorced son, whose behavior became clear to her as an acting out of her own unconscious sexual drives and fantasies. Focusing on the fixation of her psychosexual development, Mabel began to work through her intense dependency needs on the mother. Her dreams began to manifest her conflicts and her associations pointed up the dependency needs in conflict with intense rivalry and hostility to mother’s authoritarian role in the patient’s home. As she continued to work through her infantile role with the mother, Mabel’s relationship with her husband and children took on a more mature and realistic role. The resulting progress of Mabel’s persistent therapeutic efforts was manifested in two significant incidents that occurred approximately twenty-four and thirty months respectively, after she entered the group. One evening Mabel came to the session with a feeling of exhilaration and excitement. Although speaking infrequently, her occasional reactions were vibrant and effective. She then told of a dream and during the associations to the dream, reported that during the past week, she had experienced sexual orgasm on two occasions. This was the first time in her life, after forty years of marriage to the same man, that she had experienced a sexual orgasm. Several months later, during a group session, Mabel manifested anxiety and was unable to attend to the group interaction. When questioned, she reported that her mother was in the hospital and she was quite concerned about her health and was to visit her after the group session. At the next meeting, Mabel told of visiting the hospital after the previous session and of being informed that her mother had just died. She reported and manifested grief at her mother’s death, but said she had no undue depression or overreaction of anxiety. She then described having taken mother’s death as a natural course of life, which she would not have been able to do only a few months before.
Jack’s initial position in the group was one of contradiction. He described his life situation as a picture of perfect adjustment. However, when other members of the group received any emotional support, he reacted with intense resentment. Inquiries about why he was in the group provoked an antagonistic response to the effect that his story had already been reported to several people on an individual basis. He said that repeating it in the group was unnecessary. He was “not a believer in confession” and would not reveal the traumatic experiences in his life unless the therapist convinced him this would be of value to him. During the first two months, his efforts, other than those used to deny all personal problems, were directed towards proposing jobs for Bill and giving advice to the other members in a rather condescending manner. Attempts to provoke Bill resulted in negative reactions from the other group members. Upon confrontation, he denied any hostility, insisting that he was merely trying to be helpful. He would then use the negative reactions for withdrawing, saying that he did not have to talk and remaining silent for long periods of time. When the therapist and other members of the group focused upon this passivity, Jack denied its use as a means of drawing attention to himself. At the same time, he denied any desire for help for himself. His continued hostility and aggressive “help” were used by Bill to justify withdrawal from the group. When he experienced the feeling that he “drove” Bill out of the family, Jack reacted with guilt feelings and remorse. However, with the addition of new members, he again became hostile toward both Joan and Henry for their means of controlling others through their passive behavior.

Persistent focusing on his resistance precipitated Jack’s discussion of his difficulties with his second wife. He elaborated on the gastrointestinal reactions when his sexual adequacy was questioned or doubted, e.g., his dancing being unfavorably compared to his stepson’s, followed by his wife’s leaving him to dance with her son. He said that his wife told him he had no “fatherly feelings” towards her twenty-eight-year old son. As Jack began to reveal himself, the other group members’ reactions to him became positive. As he attained awareness, discussion of anticipated threats from the “female” relieved some of his anxiety. Jack began to date a widow whom he had silently admired for a number of years. After a few more months, he initiated and carried through annulment proceedings against his second wife. Following the annulment, the relationship with the widow became quite “romantic” and after several months of dating, resulted in an engagement. During the early dating with his “new love,” Jack had a dream in which he had flown a kite. He associated the sudden lifting of the kite to experiencing sexual excitement and temporary erections. This dream and his associations of related experiences brought Jack’s first hope that group psychotherapy could offer him help with his sexual problems.

Jack’s rigidity began to diminish and he became aware of and to express competitive feelings towards the therapist. He associated these feelings with early childhood reactions to his father. As the group continued to focus on his passivity and its meaning, he remembered and described more frequent dreams and he associated them to his past. During his association to one dream, he suddenly remarked, “I have never thought of this before, but it suddenly occurs to me, that in about our tenth year of marriage, I was told my (first) wife could never have a child, and right after this, right in the middle of intercourse, I suddenly had the feeling of ‘what’s the use!” The anticipated failure to achieve had resulted in feelings of “what’s the use” and the adoption of a passive role. As a result of subsequent dreams and associations, it became more clear that Jack had found and used passivity as a nonincriminating means of expressing his hostile aggression.

His entire demeanor continued to change. He no longer restricted his reactions to objective or intellectual retorts. He began to allow his imagination to function more freely and interacted with others on an effective emotional level. His behavior and its significance became more meaningful through interaction, dreams and associations. The pattern of passivity and its utilization as a means of aggressive control became evident and were focused on by the group. Jack was then able to scrutinize and attain more meaningful understanding of his behavior. With a lessening of apprehension and self-guardedness, he became more free in describing the relationship with his new fiancee. His newfound “open” attitude brought about awareness and allowed him to recognize that he had once again developed a relationship of acquiescing subservience, which was provoking intense resentment toward the female. He associated his behavior in this involvement with earlier frustrating efforts to please and win his mother by attempting to gratify her every wish and expectation. He broke his engagement and began to seek and date other women.