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 topic of shame in group therapy has received limited attention in the group therapy literature. When the topic has been addressed, the focus has been on the shame of the group members. The shame of the group leader and its effect on leadership efficacy and group process has received inadequate attention, given what seems to be its power and prevalence. In this article we examine shame and the group therapist with regard to (1) potentially shameful topics and (2) dynamics that evoke shame. Suggestions for both the mitigation of shame and the enhancement of the leader's self-esteem in dispatching the role and functions of group therapist are offered. In discussing this subject, we propose to normalize group therapist shame by emphasizing the challenges and complexity of group leadership. While the examples illustrate an array of emotions, our purpose is to focus on their shameful elements because they are (1) frequently ignored or overlooked; (2) not made explicit; or (3) discussed in other terms, such as narcissism. In doing so, we invite the reader to consider the clinical utility of the hypothesis that shame has a powerful presence and impact on our leadership image and effectiveness.
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.
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.
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