Consultation, Please
December 2002/January 2003

Dear Consultant:
I am a male therapist who has been leading groups for more than 10 years. One is an ongoing psychodynamic process group, which has met for over a year. The group had consisted of five men and five women. Three months ago, I added a sixth man to the group, who has been an individual patient of mine for several years. He originally came to me because he had difficulty dealing with other people. He is a 35-year-old unmarried man, who appears extremely shy and withdrawn. When I suggested that he try going into a group to work on his issues, he looked terrified, but was willing to give it a six-month trial. The group greeted him warmly and has made various attempts to include him. However, other than giving his name, he has refused to talk at all. Last week in his individual session with me, my patient revealed that he was dealing with his sexuality and didn’t want the group to know that he had learned that week that he is HIV positive. Three months ago, one woman stated that she is a lesbian. Members expressed surprise but appreciated her candidness and have felt more open to discussing their own sexuality issues. (The new member was not yet in group at that time and since he has entered the group, she has not been forthcoming with any additional information that about her sexual preference.) As the new member continues to remain silent, I fear that he will be scapegoated by the group. Additionally in the past few weeks, the group is expressing themselves more carefully with each other and appears to be reluctant to talk as intimately with one another as they had before this member joined. I am wondering if I made a mistake in adding this member and would welcome your assistance in helping me think through this current dilemma.

Sincerely, 
Doubting My Judgment

Dear Doubting:
I support the new member’s self-care in choosing not to talk in group. I would encourage him to continue to do what feels safe and to talk when he is ready, especially since he does not know how group members might react to his HIV status. At the same time, knowing that he is shy, that he has come into an ongoing group, and that he has spoken little in three months, I might ask him directly about his experience of being in group so that he has some way to begin to talk about what is going on with him. Although he is not talking, he continues to attend group so he must be getting something for himself.

If he continues to remain silent, it may indicate that he would better be served in a group dealing specifically with sexual identity issues or HIV status. I would discuss this during individual therapy and see how he reacts. He may need support and permission from the therapist to leave the broad-based group and attend one that focuses on his specific needs without feeling that he has failed or let the therapist down by leaving this group. 

I do not think it was a mistake to bring this man into group, but his recent change in HIV status might mean that he needs a group that could more specifically address his immediate concerns. Often individuals dealing with sexual identity and HIV positive status do better in homogenous rather than heterogeneous groups when they first begin to deal with these issues. 

Marti Kranzberg, PhD, CGP, FAGPA
Dallas, Texas

Dear Doubting:
You’ve presented three areas on which to focus: the group, the individual patient, and you. Starting with the group, any time a new member is added to a group there are risks ranging from turmoil and regression (to be expected) to “death” of the new member (“infanticide”), other members, or even the entire group. As any good parent would do, you must spend time with the group helping them to prepare for the change and to talk about the new arrival. Be prepared as the new addition will no doubt rouse members’ early childhood memories.

I was struck by your description of the individual patient when you introduced the idea that he join a group (“he looked terrified”). He might have experienced your proposal as therapeutically aggressive. In individual sessions, did you help prepare him for the group by exploring his reactions before joining (and then check in with him after he joined the group)? I think your fear of scapegoating by the group (not ignoring his complicity) is well founded. His apparent isolation is a setup, requiring immediate intervention. What subgroup exists or needs to be created for him? Taking a larger view, his recently revealed physical condition and sexuality issues increase the importance of his being in a working therapeutic environment sooner rather than later. His difficulty dealing with other people, therefore, may have to wait. Doubting your judgment may have been a very wise thing to do.

Most importantly, what about you? Ask yourself the following: What was going on for you at the time you decided group therapy would be helpful for your patient? Why was your gut reacting to his “look of terror.” What is your experience of the members’ growing carefulness. If it hasn’t has been brought up in session by a member, what has stopped you from bringing it up? How have you dealt with self-doubt in the past and in other areas of your life?

Finally, are you in supervision? If so, I strongly suggest it be with a therapist who has led groups and understands group dynamics, and, more importantly, knows you and your style of working. Even with extensive education and experience, it is crucial to have ongoing (dare I say never-ending?) training.

Jeffrey Price, MA, CAC II
Longmont, Colorado

This article was published in the December 2002/January 2003 issue of The Group Circle.