Consultation, Please
August/September 2001

Dear Consultant:
A group member is about to leave my group. She has more group work she could do but is choosing to do some intensive individual therapy right now with another therapist. She says that is all she can afford, both financially and emotionally, at this time. However, she wants to know if she can return to the group in the future if she feels the need. My original training was that termination was final. With my individual clients, I have become much more flexible, and they all leave knowing they can return for single consultations or another piece of work. In my groups, however, I am not so sure that returning is a good idea because of the disruption to the group. I also worry that if members feel they can always come back, it takes away from the feelings elicited by saying good-bye. What should my stance be with this member?

Sincerely,
On the Fence

Dear On the Fence
Why does she want to see another therapist, and why individually? What can’t she say to you or to the group, and why can’t she say it? Does she most want the option of returning to the group or to you? An unrecognized countertransference is suggested by the fact that, even though you do see patients individually, the option of this client seeing you individually has apparently not been explored.

How do you feel about this client wanting to leave you? Are you angry with her for some reason, or perhaps hurt, or anxious? Your feelings can be an excellent guide toward teasing out an unrecognized countertransference that, if resolved, may lead you to answering your own questions. These questions are best explored with a trusted colleague, in a peer supervision group, or even with a former supervisor. You may find good reason to modify what you were taught. 

Whatever your theoretical model or goals, any group can frustrate the patient’s yearnings for an exclusive relationship with the leader. In shame or fear, the patient may unconsciously be hiding hurt and anger and acting it out instead. Sometimes this takes the form of trying to dominate the group, or conversely of leaving prematurely. 

Even if you deal with the transferential and countertransferential issues, she may still leave. Unless clearly contraindicated, you might tell the departing patient that she can call you and you will not turn her away. However, there is no promise to provide an ongoing individual session, or a place in a group, including her old group, since vacancies will be filled in the interim. Thus, feelings of loss are maximized. Ask yourself: “Do I hope too much” that this patient will call in the future? Or “Do I hope that I’ll never have to see her again?” With the help of a colleague or peer supervision group, you may discover something you have been missing all along.

Paul Shultz, MSW, CGP
Southfield, Michigan

Dear On the Fence:
Your question brings to my mind many others having to do with the patient, the group, and you—the therapist. This is not a textbook termination as both you and the patient both recognize that there is more that could be accomplished. Rather, the patient is planning to do this in another therapeutic setting. What will she talk about in her individual therapy that she has not allowed herself to share in group? And why not in group? What dynamic concern is reflected in her request to be allowed to return later if she wants to? A rapprochement age child needs to know that she can run back to a welcoming embrace for protection, comfort, or help if she needs it, that the door will not close on her, unforgiving of her move towards autonomy. What dynamic concerns of yours may be active in response to her request or in response to her decision to leave? What else is going on in this group currently? Is the group silently containing a conflict that this member is finding intolerable? Is she a group sacrifice? What might she be feeling and thinking about you as group therapist that would be helpful for her to say aloud? In short, what is not being said? If these questions can be explored or at least raised in the group, the goodbye (when and if it takes place) will be even more powerful because the group will have become more intimate and their connection more meaningful. This will be true for all group members not just the identified individual. 

If the patient leaves and later wishes to return, and if there is an opening in your group, you and she can decide what would make most sense at that time. Indeed she may achieve significant therapeutic progress in the course of her individual therapy. Later participation in a psychotherapy group could provide her with validation of the changes she has made when she experiences herself and other group members in a new way. It wouldn't be the same group, of course, because even if all the same participants were present, they will have changed, just like the river into which you can't step twice.

The issue is not one of flexibility but of maximizing therapeutic opportunity and how to do that. The only termination that is truly final comes at the end of life. 

Alice Powsner, MSN, RNCS, CGP
Albuquerque, New Mexico

This Consultation, Please column was published in the August/September 2001 issue of The Group Circle.