By Graeme Daniels

(This article first appeared in the July/August 2008 issue of East Bay Therapist)

A problem of misunderstanding? In some settings I've heard the term "process" used with at least three different meanings, two of which are clinical. The first meaning is administrative, and systemic, as in process of a business-model. Process as in procedure, I've observed, is what one colleague (with tongue firmly in cheek) called "a molasses-like movement of ideas or action within a hierarchical system like, say, a hospital, or an agency." That's what people mean when they refer to a "process unfolding."

The second meaning refers to the internal work of an individual's therapy, with therapeutic assistance being that of a catalyst: the client is "processing" material, drawn out by a probing facilitator. The last meaning, that which is most relevant to any discussion of a system's communication, or certainly to any discussion of group therapy, is one which carries the least shared understanding, and incurs the most resistance.

Perhaps it's an issue of application. The process of group therapy that I'm referring to is the relational information that passes between group members, versus the content–that is, the explicit words spoken, the substantive issues, and the arguments advanced (Yalom, 1995). In this context, process refers to a meta-communication between members, sometimes conveyed non-verbally.

In my role as group therapist, I am constantly on alert for these moments of multi-layered communication, and as a supervisor, I am frequently urging other therapists-in-training to observe patterns of process, and to orient their groups–in plainspoken terms -- to the value of learning from such exchanges. Reflecting upon these roles, group therapist and supervisor (of, predominantly, group therapy), I begin to notice an interesting array of resistances to the process orientation. It calls to mind an article by a Murray Bowen acolyte, Michael Kerr, entitled: "An Obstacle to 'hearing' Bowen Theory". In it, he wrote of the negative reactions of students when observing the Bowen theory in practical application. Likewise, I repeatedly observe the squirming in chairs, and the quiet sniff of distaste, when faced with the prospect of making process comments in groups.

Thinking more broadly, maybe the issue is one of assimilation into systems. When speaking of the contrast between outpatient groups with members of equal circumstances, and those wherein one member of a family is admitted to an inpatient unit and another participates on an outpatient basis, I draw attention to the relative intensity of the latter groups. They don't go home together, I succinctly conclude; there's no shared drive home in which individuals might recriminate one another for things said in the just finished group meeting. The difference is important, I assert. And so, there is a system beyond the present system to be concerned with. Group therapy, especially of a process-oriented approach, contends with this vast exterior system on a constant basis. I'm referring to social norms, family norms, the norms that state, for example, that commenting upon the manner of communication (especially of strangers), is rude, or at least disorienting.

Consider the following question, posed by a therapist to a new group with a homogeneous set of problems, composed of psychologically-minded members: "Does anyone in the group have any feedback for what's happening between John and Sarah?" (I shall deliberately exclude the content). Such a statement may be calling for group members to comment upon how the exchange illuminates the relationship, though the question's open-ended nature easily allows group members to choose a content-oriented response instead.

More than likely, members would select from the following options: a review of the information provided by the two members, giving advice or otherwise attempting to problem-solve for one or the other; offering acceptance, mirroring, or a declaration of shared experience. Even in groups of motivated members, who have been screened for group therapy, and oriented to the norms of the group process, comments upon meta-communication are often withheld, or else left to the group therapist to reveal.

"That's your job," I once heard a group member say. That terse reply suggests clues to the resistance to process, a matter expanded upon in Mathew Miles' essay, "On Naming the Here & Now". In it, he writes that "here & now" comments, those references to immediate events in a group that form the nuts and bolts of the process orientation, recall the childhood experience of being controlled and criticized. We remember being told to look at people when we're speaking to them, to stop interrupting, and to take our hands out of our pockets. If group therapy is to recreate this old experience, or even to just provide echoes of it, then it would be infantilizing. Furthermore, Miles writes, such a focus would intensify self-consciousness, and render a discussion of communication more complex, if not overwhelming.

A content focus is, therefore, safer and easier. Of course, group therapy is intended to do more than merely draw attention to, or even correct, all manner of verbal and non-verbal behaviors. What distinguishes the here & now focus from this disconcerting social template, is what Yalom refers to as the second tier of the here & now focus, that of process illumination. This is the dimension that provides examination, and understanding. Ultimately, it calls on members to follow the track of their exchanges, reflect upon them, and draw a non-judgmental learning experience as to how they relate to others.

All of which becomes more fascinating when thinking of groups with adolescents, or groups with so-called "low functioning" populations. Consider some of the terms or ideas already used or referenced in this article: hierarchy, self-consciousness, infantilizing, problem-solving, group safety. The reader can begin to gain an idea as to why certain populations would resist process-orientation, or else why mental health professionals would resist it on their behalf.

Recall Wilfed Bion's three basic assumptions of group life. The first basic assumption is one he called dependence. In a basic dependent group, one notices the group searching for an oracle or a deity, from which all security, nourishment, and direction come (Bion, 1961). Especially in hospitals, where little, if any, orientation is provided as to group therapy, we can imagine why adolescents would readily adhere to hierarchies and depend upon a leader, but why they might also bristle at a therapist that constantly drew attention to their mannerisms, or syntax, assuming a critical intent on the part of the therapist?

We can also understand why highly anxious individuals, accessing treatment in order, primarily, to relieve symptoms, might be disoriented by a therapeutic approach that, for example, re-directs questions away from the facilitator, but rather towards the group, and which constantly seeks to decentralize the group tasks. This approach places implicit responsibility upon the group to self-activate. This question of client/patient, or group responsibility for change versus therapist responsibility for the process (here, as in procedure) of change, is one which all therapists must address, repeatedly. The meaning of the "that's your job" rebuke is to resist shared responsibility.

And yet moments of spontaneity and individuation do occur, even if they are cast as indicators of a resistant pathology. This is particularly true in adolescent groups, and there is some irony here, as it is adult facilitators who, as often as not, resist the process orientation. Consider the following brief exchange:

Client: (upon receiving a series of facilitator questions) "I feel like you're cross-examining me!"

Therapist: "But do you see the point I was trying to make?"

Client: "I don't care. These questions are stupid."

Therapist: "Remember, this process is not about me."

The adolescent client in this instance has made, in effect, a process comment, one which the therapist has ignored. In speaking to many group therapists about this kind of exchange, I've come across a few interesting pretexts for why the therapist would choose this tact. First of all, that the group's primary task may have been that of addressing problem behaviors, with special attention to attendant defensive thinking. The process comment in the above scenario was deemed a deflection, a defensive maneuver by the group member, and so a process exploration, one that was interpretative, but not directive, would have been misguided.

Secondly, many group therapists rightfully concern themselves with group safety, and so err on the side of containment of affect. Indulging process may lead to an escalation, a stirring of high anxiety, or scapegoating, with problematic implications for the later stability of the hospital unit, or else that previously indicated ride home.

"I was concerned that the group may become overwhelmed", said one facilitator, explaining why she consistently deferred on making process interventions. She'd actually begun the group with the glib pronouncement that the group's main purpose was to explore patterns of communication, but as the group progressed, the term "communication skills" replaced 'explore", and so a more didactic intent became apparent. This was perhaps recognized by the assembled adolescents, whose largely passive participation betrayed an unconvinced air.

Perhaps it's a question of priorities, or of assessment. It's undoubtedly true that some clients are sufficiently dysfunctional (either in terms of ego boundaries, or else cognitive ability), that the process-oriented approach is too disorienting. Imagine a highly anxious group member, whose internalization of even the most carefully neutral of interpretations evokes a panicked inference of criticism, if not accusation. Although, one might argue that even this individual might benefit, ultimately, from hearing different perspectives upon communication.

Furthermore, group dynamics take place within a broader context, no matter how hard they try to create self-containment (no outside relationships as a group rule, for example). Groups in hospital settings cannot realistically contain contact outside of group meetings, they cannot eliminate the lack of cohesion borne of high turnover, or ignore that destabilizing consequences of group disorientation; and they cannot easily take neutral stances towards the varying types of self-destructive behaviors that are often the presenting reasons for therapy.

I think it's really a matter of integrating the process-oriented approach, rather than dismissing it as contrary to the priorities of, say, behavior modification, or symptom reduction. In my work with adolescents, in particular, I observe a strain of conservatism that leads to a quasi-parental dynamic between client and clinician. It's been interesting to notice that in certain modalities (art therapy, and drama therapy) some of the inhibiting qualities of regular talk therapy are diminished. Self-consciousness is often reduced, for example, if disguised in a character.

Furthermore, I've noticed the symbolic disguise of art and drama allows for a practice of process illumination that might otherwise feel too intense, too real. The explicit disclosure of true thoughts and feelings is often perceived as too threatening by adolescents. When loss of esteem, or rejection, is at stake, truth is a risk, and its disclosure requires a sensitive development of trust. Adolescents often defend against this risk by projecting the dilemma onto adults, particularly parents: "I want to gain their trust".

A more thorough depiction of group dynamics with adolescents is provided by Pressman, Kymissis, and Hauben's 2001 article: "Group Psychotherapy for Adolescents Comorbid for Substance Abuse and Psychiatric Problems: A Relational Constructionist Approach" In this description of a combined day treatment and high school program, the authors posit several observations about adolescents in treatment:

• that adolescents construct acceptance and personal meaning through role-defined, non-hierarchical relations;
• that conflict resolution involves the emergence of overwhelming feelings that comorbid adolescents cannot control;
• that they may require extended orientation to group therapy, and may initially engage groups in a rebellious fashion;
• that the primary challenge for the patients is to learn self-control and trust of others;
• finally, and most crucially, that negative countertransference can be avoided when staff members do not feel intense responsibility and need for control.

The program structure and pattern of interventions reflect many of these baseline assumptions. The hierarchy of the program is decentralized, for example, de-emphasizing a "charismatic" leader, and instead implementing a multidisciplinary team. This tended to mitigate rebellious action. Empathy as a leading intervention, is emphasized, allowing space to de-pathologize patient behavior. Staff would empathize with the adolescents' resistance to treatment, rather than coaching a premature cohesiveness. Empathy with parents' distress replaced collusion with the need for punitive, rigid responses designed to influence negative behaviors.

In the article, examples are given of aggressive gestures, horseplay, sexual innuendos between patients and staff, that are met with largely interpretive response (only the example of the aggressive gesture led to a patient being removed from group); ultimately, that example, also was treated with an interpretive response, rather than a strictly directive intervention.

Above all, while not strictly identical to a process-orientation, the above-described model presents two provocative challenges that speak directly to what is, perhaps, a systemic resistance to process:

1. That the ability for adolescents to express angry feelings is more important than maintaining strict unit order, and
2. That a lack of strict adherence to subject matter of the group allows staff to keep abreast of the adolescents' thoughts and feelings.

The first time someone walked out of a group I was facilitating, I felt in my heart that I'd done something wrong. That action, combined with the group's subsequent blaming of the departed individual (I was briefly relieved, but ultimately confused), seemed to violate some ill-defined notion of leadership.

In this article, I've reviewed what I've observed as the resistance to a process-orientation, within a variety of different attention to group therapy with adolescents. I've implicitly advocated for a style of group facilitation that challenges order, hierarchy, even what some may term safety, and in doing so entered that ambiguous space wherein client/patient and therapist responsibility is negotiated. Once again.