The Challenge for Group Psychotherapy

Analytic Group Psychotherapy with the Aged, Part 5

Reflections on the Therapeutic Group Process
An analysis of the psychotherapeutic group process reveals that in the initial therapist-centered stage, the therapist was able to offer support and to present a figure with whom the patients could identify. Taking cues from the therapist, patients initially imitated him and then spontaneously began to interact with one another. As this process continued, the group’s intellectual facade began to crumble. Although they were not consciously aware of this, the effects of emotional involvements became manifest in the patients’ interactions. Thus, the therapist was offered appropriate opportunity to intervene by focusing on individual, as well as group, resistances.

The understanding of each patient’s psychodynamics was relatively slow in coming. Following Bill’s departure and the arrival of Henry, Joan, and Agnes, the therapist became more aware of the meaning of each individual’s behavior. With the passing of time, it became evident that each patient in his own way was acting out lifelong, neurotic reaction patterns. The therapist neither condoned nor rejected; he accepted each member’s right to his own feeling and desires. Consequently, rigidity began to diminish, resulting in the patients’ ability to accept themselves, as well as others in the group. Thus, the group members were able to relate to each other with more intimacy; they explored more intimate details of their lives and offered emotional, rather than intellectual, support to each other.

A wide variety of defense mechanisms were manifested, but the most predominant and persistent defenses were passivity, denial (of dependency needs), emotional detachment, and depression. After careful study, it was also noted that the most frequent precipitating factor that brought the patient into therapy was the actual or anticipated loss of the dependency figure. Once the patients began to interact with each other, the therapist began to focus on the meaning and effectiveness of the defense mechanisms. As a result of working through Joan’s suicidal attempt, the group members, for the first time, recognized and understood how behavior might result from unconscious needs and drives. They also became cognizant of the process by which these unconscious forces might be made conscious. They continued to perceive and utilize cues from the therapist and, although offering ego support, began to probe and analyze their own as well as others’ interactions and dreams. This procedure allowed for and reinforced the continuing development of ego strength, which, in turn, constituted the psychotherapeutic group process. The initial classroom atmosphere of the group sessions dissipated and the therapist became an object for transference relationships rather than a teacher. Emotional interaction became more spontaneous and multiple transferences were manifested in the patients’ interrelationships.

Analysis of the various patients’ multiple transference reactions revealed an acting out of neurotic patterns as an attempt to cope with unresolved dependency needs. Hilda’s efforts at extreme self-sufficiency, i.e., offering, but never asking for or accepting anything from anyone, was symptomatic of a reaction formation. Although her life was filled with activity and responsibilities, she had never experienced any feelings of personal closeness or emotional satisfaction. Mabel unsuccessfully sought to deny her dependency needs on the powerful mother figure by constantly placing herself as “the mistress of the house.” She expressed no desires or thoughts for herself, yet felt completely frustrated that her efforts were not properly or graciously accepted and utilized by others, especially her husband and sons. The early anxiety and fears of hurting her children with a knife were associated with incestuous guilt, distorted into feelings of power held over these young humans. When the eldest son, after two previous marriages, was contemplating a third marriage, her strong sexual drives were reactivated. On an unconscious level, she experienced the son’s behavior as a reflection of her own “controlled” sexual needs, which she anticipated might erupt in uncontrolled, promiscuous behavior. These sexual needs became manifest in her “sexual stirrings” when in the presence of any male, regardless of age or species (e.g., young children, animals). Agnes chose a career and an early life of “Bohemianism” to display to the world and to constantly reaffirm to herself her independence. However, when the rejected suitor threatened suicide, she married him in order not to lose this object of dependency. Jack, although constantly and emphatically denying any needs, continuously utilized passive-aggressive means of manipulating others into doing things for him. Henry’s oppressed feelings of complete inadequacy at the time he sought treatment were precipitated by the loss of his children’s dependency upon him. These children were the only ones over whom he had any power and provided suitable objects for reaction formation. The intense anxiety reactions of the other members of the group might also be attributed to a similar deterioration or failure of previous defense mechanisms.

The most frequent feeling expressed by the patients was depression. Why a depressive reaction? An exploration of earlier life patterns reveals that the depression had always been present. Further observation shows that although each patient may have been involved in various activities (to a lesser or greater degree), there is no evidence that any of these people had experienced any emotional satisfaction on a lasting basis. It appears that these individuals never realized satisfaction or resolved their oral dependency. None of these patients appears to have realized his strong dependency drives or to have been aware of the inappropriate, frustrating means taken to gratify these needs. A review of the history reveals that initial childhood dependency (with or without outside encouragement) fostered the illusion that the parent was a source of unlimited gratification. One may further find that the frustration of these needs during the childhood years tended to be experienced as rejection by the all-powerful figure, rather than as limitations of the parent. The child, unable to develop self-initiative to explore potential sources and in turn to gain experienced of satisfaction, reinforced and perpetuated the distortion that the parental figure was the only possible source of gratification. As the need for continued dependency intensified, and in an effort to regain or retain the gratification, the child adopted various defense mechanisms. In some instances, further frustration led to resentment and in turn, in an effort to provide self-gratification, may have resulted in the introjection of the all-powerful figure. Failures in this new role appear to have resulted in inwardly directed resentment and hostility to the introjected parental figure. Thus, the individual experiences a loss of self-confidence, a demeaned self-image and a rejection of self. Often the older person, as is seen in adolescents with similar character structure, behaves in a self-defeating fashion, manifested in what the author has termed “defeat by default.” The anticipation of failure and the threat of frustration result in an avoidance of initiative. The apperception of dependency, as experienced by these persons, was a sign of weakness—something that an “adult” should not have. This weakness, symbolized by dependency, was thus rejected, and the individual anticipated that it would be rejected by others. These dependency needs had to be repressed by means of reaction formation or other defense mechanisms. One may also note that some persons attempted to maintain the dependency relationship by establishing a role reversal, i.e., the dependent individual attempted to affect a nurturing role with a “sick” or “aging” parent, a sibling, an ineffective spouse, or others.
As the aging process continues, the reduction of physical activity resulting from biological changes, the modification of familiar and social relationships, as well as cultural attitudes towards the aged tend to force reality upon the older person. Those who have attempted to deny their dependency needs by developing a role-reversal relationship begin to lose the nurturing through death (as happened when Jack’s wife died) or anticipate the loss of object relationship with the nurturing figure (as exemplified by Joan, when her son was to be married). This object loss, actual or anticipated, tends to provoke the latent feelings of abandonment and annihilation, which, in turn, result in overwhelming anxiety or a panic reaction. In other instances, the older person can no longer conceal intense dependency needs by excess physical activity and therefore begins to re-experience the effects of the early, weak ego development. The depression and accompanying tendency toward withdrawal, manifested by impotence and decreased professional and social activities, become another defensive move to encapsulate and protect the brittle ego structure from experienced outside destructive forces. The older person no longer is able, with any effectiveness, to confront the threat, which he experiences as coming from the outside, and must seek and develop new methods for self-preservation. Stripped of the temporary effectiveness of previous defense mechanisms, his only recourse is to retreat within a shell of apathy. The intense resentment and hostile aggression resulting from the feelings of abandonment are directed toward the introjected parental figure.

The major therapeutic forces and advantages of the psychotherapy group process are the multiple transferential relationships and interactions and the patients’ confrontations with reality factors. The additional advantages of the limitation of the group constellation with respect to age range for the older person is that each individual is able to experience himself as being among peers. The acceptance by others enables the individual to accept his conflicts as a manifestation of unresolved early needs, rather than as a manifestation of weakness. Also, he is able to develop an ability to accept others and to relate to them interdependently. He learns more appropriate means of expressing his needs to “take,” as well as to “give” help to others. This giving, taking, and sharing bring about development of increased ego strength and the experiencing of himself as an individual. The ego boundaries become more flexible and his mobility becomes less restricted, resulting in a modification of the self-image. The awareness of himself as an entity in the reconstructive psychotherapy group appears to be a completely new experience for the older person. With the gaining of ego strength and the modification of his self-image, the patient is thus able to express his needs appropriately, and he seeks satisfaction outside the therapeutic constellation. This latter situation may be exemplified by Henry’s change from complete compliance and submission to a position where he was able to attend a fraternal organization meeting and, for the first time, demand his rights as a member.

Group therapy is not and should not be considered as a panacea for treating all psychological problems of older people. Although group psychotherapy has proven to be most effective with this age group, limitations exist and have been demonstrated in the group described. One definite therapeutic failure was Bill. The question arises as to whether Bill failed to benefit from group psychotherapy because of faulty selection, because of the other patients’ emotional reaction to him, or because, prognostically, he was a very poor psychotherapeutic candidate. It is the author’s opinion that the first two and possibly the third factor may have been involved. The therapist permitted, and in so doing perhaps inadvertently condoned, the group’s demand that Bill relinquish his dependency upon his son. The therapist also did nothing to prevent the son from withdrawing Bill from treatment. (No follow-up was done to encourage Bill to return to the group or to be seen individually.) It is also possible that Bill’s lack of participation in any outside activity may have created a feeling of being different from the others and thus an isolate in the group. If so, it may be advisable that such patients (isolated in society) be placed in Golden Age clubs, “social rehabilitation groups,” day centers for the aged, or other activity groups.· Participating with others in daily activities may aid the socially isolated individual to experience feelings of acceptance, encouragement, and recognition for his efforts. With this continued activity, he may begin to experience satisfaction in achieving, eliminating, or at least diminishing the feeling of complete uselessness and frustration.

The psychoanalytic treatment of the older person by group psychotherapy has provided ample evidence that this method, with rare exception, can effect reconstructive psychological changes. The degree of change tends to vary, and one must note that experiences with this age group, as compared with younger adults, reveal that the degree of psychotherapeutic progress is not exclusively dependent upon age. Individuals initiating group psychotherapy in the middle and late sixties and continuing in psychotherapy until their seventies have shown personality changes manifesting successful reconstruction. On the other hand, there is the rare exception who terminates therapy with no observable change (e.g., Bill). Also, there are some individuals who show varying degrees of change, vacillating from a state of effective functioning to one of almost being inept, and who appear to need psychotherapy on a more or less lifetime basis. It is suspected that individuals typifying this latter group have undergone traumatic experiences of affect starvation and deprivation during their early development (very likely the first year). The faulty initial ego formation has become fixed and is receptive to little modification or permanent change. These persons, young or old, very likely will always function on an orally dependent level, requiring continued nurturing object relationships and ego support to enable them to function on any effective level. Their oral dependent needs cannot be satiated, and the loss of nurturing object relationships is experienced as an overwhelming threat to a very brittle ego structure. Agnes, in the aforementioned group, may typify the affect-starved and deprived individual. For as long as she could remember, the mother favored the older sister, continually depriving and rejecting Agnes. One may suspect that the affect deprivation existed from birth, resulting in a distortion during the initial development of the ego. Although she experienced occasional aid and support during her course of psychotherapy, there appeared to be no persisting positive effect. When her dependency needs and demands were gratified, she felt “pacified” and was able to function in a relatively effective manner. However, she had a low tolerance level for frustration, and when her demands were not immediately met, she would react with intense hostility and threats. Also, she left treatment on several occasions when she felt “good.” The loss of needed ego support obtained from the psychotherapeutic experience would result in a deterioration of functioning, forcing her return to psychotherapy.