By Dr. Matthew Bennett; Copyright 1997
Until fairly recently, many types of psychopathology were considered beyond the pale of treatment in group settings, even by some of the most influential thinkers in the field. Among the types of psychological problems traditionally considered intractable in group settings were the personality disorders and character pathology in general. In 1985 Yalom included paranoid and antisocial character types along with organic patients among patients unlikely to benefit from group psychotherapy. Relative Drawbacks to the Group ModelWriting in 1988, Nonna Slavinska-Holy wrote “group psychotherapy seems a poor choice for most patients with narcissistic personality disorder” (p. 10). It must be noted that the personality disorders have traditionally been considered highly intractable in general, associated with early dropout rates, serious morbidity, and poor outcome (Gunderson, 1984). Within the context of the modern health-care system, with emphasis on proven short-term behavioral programs with quickly measurable results, clinicians naturally undertook to develop technical advances to facilitate the “long and tricky process” (Alonso, 1994) of treating character pathology. The resulting search for effective and efficient treatment models contributed to a rediscovery of group psychotherapy, with its obvious advantages of efficiency and financial economy, by clinicians and providers alike (Buchele, 1994).
However, the advantages offered by group psychotherapy models in the treatment of character pathology have proven to run much deeper than economy. Recent theoretical and outcome research has indicated that group models have proven particularly useful for many persons with personality disorders, and that the group models may even be more effective than individual psychotherapy in their own right (Budman & Gurman, 1988). In contrast to the relatively modest beginnings of the group model, group psychotherapists have in recent years begun to include an ever broader range presenting problems among their patients. Generally the group literature has focused on the treatment of borderline and narcissistic disorders, but there are also indications of success with dependent, avoidant, and schizoid characters as well (Buchele, 1994). The literature has consistently identified a number of relative advantages and relative drawbacks to the group psychotherapy approach with character pathology.
One of the most potent curative aspects of group psychotherapy of personality disorders is what Yalom (1985) termed “universality”. The group may acquire the power to “muster the patience required to repeatedly confront….problematic behavior while simultaneously offering understanding” (Buchele, 1994, p. 217). In this way the group may function as a “good enough mother” in the sense intended by Winnicott by serving as a container for the pathology of the personality disordered person. The presence of the group may serve to dilute the intense transferences that characterize many dyadic psychotherapeutic alliances, as the focus of attention shifts from the therapist to the peers, who are less likely that the therapist to be unconsciously associated with a critical parent (Wells et al, 1990).
Bellak (1980) acknowledged the possible benefit to be derived from the checks-and-balances to be derived from the diversity of the group setting: because the deeply ingrained behavior patterns of personality disordered individuals is so ego-syntonic. Character disordered persons are likely to fail altogether to see their own maladaptive patterns, and they may be heavily invested in avoiding the issue in therapy. Thus the group setting “may offer better learning, unlearning, and relearning than the dyadic relationship alone can provide” (p. 17). Wells (1990) echoes the advantages of the learning effects of practice in the crucible of the group setting: the character disordered patient is provided with “modeling of flexible, spontaneous behavior and the gracious acknowledgment of mistakes” (p. 369). The more risk-taking members of the group may make more mistakes, thus allowing the character-disordered patient to identify and establish universality, while also having more “brilliant moments” which will serve as precedents for allowing oneself to become vulnerable with successful results.
According to the literature, the diversity of needs represented by the various types of character pathology have been well met by the group model in many different ways. Budman et al (1996) describe how the experiential here-and-now emphasis of groups tend to reduce the splitting and interpersonal distortions common in borderline pathologies. Buchele (1994) points to the therapeutic benefits for the narcissistic personality as “the patient’s views of themselves are revealed, mirrored, challenged, and modified because the group provides a safe, containing context” (p. 217). The obsessive-compulsive personality may find the experience of watching other members make mistakes and survive as a very therapeutic experience (Wells, 1990). Buchele (1993) notes that the multiple personality individual may benefit from “observing the amnestic barrier between personalities in others can be the first step…toward discovering the many part-objects, as well as the barriers among them, inside the self” (p. 364). Yet this last observation in particular brings up a potential limitation of the group therapy model…for it assumes that the groups are composed of members suffering from the same disorder; that the group is essentially “homogenous.”
The presence of others in a therapeutic setting may prove to be a mixed blessing to the patient with character pathology. The sharing of feelings necessary to attain universality can be threatened or even prevented by group members who are quick to judge (O’Leary, 1996). Some characterological patients may possess shame-based identities that render them exquisitely sensitive to exposure to the group, and any judgmental attitudes expressed by other members is likely to be magnified. (Wells et al, 1990).
In order for the group to take on the characteristics of a safe holding environment for the personality disordered, the literature indicates that homogeneous groups may be most helpful. Yalom (1985) originally indicated that ego strength of group members may serve well as a basis for inclusion in either homogeneous or heterogeneous groups: higher-functioning members are less likely to suffer unduly from judgmental opinions of other members and more likely to benefit from the microcosmic model of the world afforded in a heterogeneous group (Buchele, 1994). Conversely, lower functioning and/or thought disordered patients may benefit from the higher relative safety of a homogenous group who can relate to their own experiences: Buchele (1993) identifies multiple personality and dissociative patients as among the populations likely to benefit form homogenous groups, especially as these patients often share histories of abuse which are most easily shared with those who have experienced similar trauma. Referring to narcissistic character pathology, Alonso (1992) writes “the humiliations of rubbing up against others can be tolerated as a common agony” (p. 217). However, the conduct of a homogenous group presents its own limitations which amount to challenges to the therapist: a homogenous group may become invested in symptom maintenance such that defensive functions of individuals become group resistance (Buchele, 1993).
Another apparent pitfall to the group therapy treatment of personality disorders was expressed by Stone (1995) as “persuasion by dint of numbers.” A character disordered individual may react to group feedback (and criticism) with compliance in order to get along, but such compliance often does not reflect “internalized” or “structural” change. Similarly, Wells (1990) points to the tendency of certain character types to react to feedback with “pseudo-insight” to avoid dealing with real feelings. However, O’Leary (1996) describes the more therapeutic aspects of this problem: group feedback may effect a “general taming of extreme reactions, including acting-out, which is largely brought about by the pressure to conform to group norms” (p. 94).
Group psychotherapists have begun to treat an increasingly broad range of patients with widespread success. The group paradigm offers a unique context in which character pathology can be revealed, examined, and modified, constituting in some ways an advantage over traditional dyadic therapy in which pathology may not manifest in such sharp relief, and in which there is commonly less intense motivation to change.
As a kind of microcosm of the social context in which human beings live, the group experience intersects with the various patterns of character pathology in different ways. The diversity of the types of influence that the group can have upon the individual represents a challenge to group therapists and their patients: one individual might react to the group with a submissive blending into the background to avoid conflict, detracting from their own therapeutic experience, while another might stand aggressively against the perceived recrimination and judgment of others. But the very nature of the group paradigm seems to contribute to its efficacy with a broad range of disorders, in the hands of a capable therapist. An important distinction in screening for groups appears to be ego-strength, which can be used as a basis of decision for inclusion in homogenous vs. heterogeneous groups. Yalom (1985) asserted that diagnoses per se are poor predictors of suitability to group therapy. Length of illness and level of functioning serves more effectively as a basis for group cohesion and universality than formal diagnosis (Budman et al, 1996). Such a conclusion bodes well for the mission of the group therapy paradigm to treat more kinds of patients more effectively.
Bellak, L. (1980). On some limitations of dyadic psychotherapy and the role of group modalities. International Journal of Psychotherapy, 1, 7-22.
Budman, S.H., & Gurman, A.A. (1988). Theory and practice of group psychotherapy. New York: Guilford Press.
Gunderson, J.G. (1984). Borderline personality disorder. Washington, DC: American Psychiatric Press.
Yalom, I.D. (1985). The theory and practice of group psychotherapy (3rd ed.). New York: Basic Books.