Consultation, Please
February/March 2003 

Dear Consultant:
I am a female therapist who has been leading a psychodynamic group weekly for 18 months. The group consists of five men and four women. The membership changed at different points, but each member has upheld the group contract to have no out of group contact without bringing it back into group. I also have had no contact with individual members of the group. Some members are in individual psychotherapy with other therapists who have referred them to the group. About three weeks ago, as I was leaving group, I was stopped in the parking lot by one of the male members who asked to talk with me about something personal. I explained that he could certainly bring it up in group the following week and ask for help from the entire group or discuss it with his own individual therapist. He subsequently has been sending me e-mails the past several weeks and now states that his "personal information" has to do with him and me. He said that he is very attracted to me, wants a relationship with me, and is unwilling to bring this up to the group or talk to his individual therapist. How do I handle this situation? I have not responded to his e-mails and he has not brought the subject up in group, but appears to be increasingly angry with me and the group. To me e-mails constitute out of group contact that I am unwilling to have with a group member. I have a signed statement from each member of the group giving me permission to consult with their individual therapist if necessary. I contacted his therapist who said that he constantly receives e-mails from his patients about a variety of topics, from changes of time, to dreams, to intensely personal information. He saw no problem with my responding to his patient and alluded to the fact that my position was very old-fashioned. I, however, feel very uncomfortable in this situation and am not willing to carry on an e-mail correspondence with any patient. I realize that e-mail is becoming very common, but I am increasingly uncomfortable in using it for personal contact with patients.

I do not feel that I got much help from his individual therapist and am increasingly uncomfortable each time I lead group or open my e-mail. I need help in dealing with the transference and countertransference of this situation.

Sincerely,
An old-fashioned therapist

Dear Old-Fashioned:
My immediate reaction to your conundrum was quite telling and helped me gain a perspective on the dynamics at play. I was looking forward to receiving the consultation request. I excitedly printed out your question and eagerly began to read. Upon reading it, I thought to myself: "Oh %@*! I don't want to deal with this." I wonder if my reaction is, at some level, parallel to your own.

You question the use of e-mail to communicate and interact with patients. E-mail is an often-used medium to connect and communicate, allowing people to stay in touch during this isolating age. But e-mail can become an excuse ??not?? to form true affective bonds. It can foster a pseudo intimacy in which we can fool ourselves into thinking we've connected. To me, this is the antithesis to what we try to cultivate in therapy groups. There are legal reasons, as well, which make communication with patients via e-mail risky (e.g., an unread e-mail sent by a patient who was in crisis). Nevertheless, I think that a focus on the e-mail debate is avoidance-much like my initial reaction was to avoid writing this response.

Discouragement of out-of-group socializing is commonplace in psychodynamic groups such as the one you describe. This guideline is set forth to foster and sustain the requisite safety, trust, and cohesion as well as ensure that members work the issues in group. Guidelines against extra-group interactions can be communicated as an absolute prohibition or a recommendation. Prohibitions are rigid and provoke acting out by members. Recommendations leave room for reaction and dialogue. Inevitably, guidelines (or prohibitions) will be tested and broken. There is meaning in this and it needs to be welcomed and explored.

You rightfully want to harness the group process to explore this issue. Yet clearly, the gentleman is struggling with emotions that he is not yet able to address openly in group. Refusing to discuss or acknowledge his struggle may feel reprimanding, withholding, shameful and authoritarian.

I encourage you to reflect upon your apparent intractability over communicating with him. Your boundaries and guidelines are well thought-out. But rigidly held boundaries suggest that something else (i.e., countertransference) is operating and inhibiting you from responding in a more therapeutic manner. What feelings are evoked in you by knowing of his attraction and surreptitious communications? Are you avoiding these feelings by refusing to communicate with him?

I suggest that you consider meeting with the group member, if even on a one-time only individual session. It would be appropriate for you to specify that the individual session is to address the current obstacle in his treatment and discuss how he can bring it back to the group. Meeting with the member may help him explore the acting out and what it represents. You could normalize and universalize romantic/sexual attraction as well as validate his feelings. An accepting, curious attitude and a willingness to hear the patient's feelings are essential aspects of therapy. Inform the group that a meeting took place and be willing to explore their reactions to this. There may be curiosity, jealousy, competition, or disapproval. Your job is not to avoid these feelings, but to help the members understand them.

Howard Markus, PhD, CGP
Rochester, New York

Dear Old Fashioned:

As I see it, your key question is how does the therapist maintain a boundary regarding contact between the therapist and group members that takes place outside of group? Your patient has ignored your mutually agreed upon contract that there would be "no out of group contact without bringing it back into group." He has broken the group boundary by not telling the group about his communications with you in the parking lot or by email.

In the first instance, you immediately reestablished the boundary by suggesting he bring up in group the thoughts he had tried to convey to you in the parking lot. In the second instance, your lack of response to his attempts to communicate with you by e-mail has left the group boundary broken and consequently has diminished the integrity of the group. Given that the patient is accustomed to communicating with his individual therapist by e-mail, he may be confused by your lack of response. On your part, the combination of the patient's actions, the critical comments of the conjoint therapist, and your inexperience with managing e-mails from patients may have left you feeling off-balance and unsure as to how to proceed.

One way to approach this dilemma is to mention as soon as possible in group the fact that the patient communicated with you both after group in the parking lot and by e-mail. You then could wait to see how the patient and the group respond. If the patient avoids discussing the content of his communications to you, you might encourage him and the group to explore his avoidance. In the unlikely event that in-depth exploration does not lead the patient to tell the group about the content of his communications, you could tell the group the content of the e-mails. Most likely, the group knows at some level there is tension between you. Additionally, the patient's violation of the group agreement may represent an unacknowledged group dynamic. A speedy discussion about these communications will relieve both you and the group and allow everyone to move on to explore the meaning of this behavior. You do not have an obligation to keep direct communications from patients to you confidential. In fact, the only way you can honor the group contract is to bring all out-of-group communications into the group.

Kathleen Ulman, PhD, CGP, FAGPA
Boxford, Massachusetts

This Consultation, Please column was published in the February/March 2003 issue of The Group Circle.