Tuesday, August 11, 2015

When Group Therapy Worked

Like many others in late 1980s Manhattan, David Payne underwent psychodynamic psychotherapy. A novelist by trade, Payne describes the experience well:

I first entered individual therapy in the late 1980s, in Manhattan. Once a week for six years I strolled happily northward up Columbus Avenue from my apartment to my therapist’s office in the West 90s. Our sessions were a high point of my week. And why not? I got 50 minutes of undivided attention from a smart, empathetic professional, there to help me find out who I was and to address the old malaise that brought me to her door. “Narcissistic injury,” I learned to call it.

My therapist helped me understand how and where the early breakdown in parental “mirroring” had occurred that led to my condition. I felt I was on an important adventure with her. Like a skilled research librarian, she led me into the stacks of my past and pointed out key scrolls and papyri, helped me translate them from the primitive language of feeling into words and conscious understanding. By the time I left, I felt I’d begun to gain a modest erudition.

If therapy is about gaining understanding and insight, Payne acquired his share of both. If therapy is about learning how to speak the language of therapy, Payne succeeded. Unfortunately, when it came to real results, changes in his behavior, therapy was unsuccessful.

In Payne’s words:

 I entered individual therapy as a problem drinker in denial of my problematic drinking; six years later, when I left, that hadn’t changed. I also entered therapy in a fraught long-term romantic relationship, unhappy with my partner; six years later, I had gained few intimacy skills and never seriously asked myself whether my partner and I were capable of healthy intimacy, or even if we wanted it. When I left therapy, we were engaged.

If education is the litmus test of effective therapy, I’d count those years a rich success. It isn’t, though. I now believe the proper litmus test is change, and I can’t point to a single meaningful and measurable change that eventuated from the work I did.

It was not, as I explained in my book The Last Psychoanalyst, an accident that psychoanalysis and its attendant therapies never really promoted themselves as able to treat or to cure mental illness. At best, they offered access to knowledge. They said that insight and understanding would allow the patient to improve his life, but, if it did not, it was not therapy’s problem.

Years later, Payne was living in North Carolina with his wife and two young children. He was still an alcoholic and he was miserably unhappy. Having had his fill of individual therapy, he decided to try group.

Here he recounts how members of the group called him out on his behaviors in ways that his congenial Upper West Side therapist never did:

 I’d be telling a story and someone would chime in: What you did with your wife in that instance sounds like what your mother or your father used to do to you. I’d listen, blink, resume my story. Five minutes later, wrapping up, I’d say: “And you know what suddenly strikes me? I think what I did with my wife in this instance is what my mother or my father used to do with me.” And the offended party would say: “I just said that! You erased me!”

It wasn’t that I was pretending not to have heard. I genuinely had no recollection. Only when the group prevailed on me to tape record and listen to the sessions did I realize they were right. There they were, making their points; there I was, slightly later, repeating what they’d said verbatim, with no awareness. Zero. It was mind-boggling: Why did I erase them and their comments, especially the helpful ones?

For my part I do not think that the insight was crucial. The notion that he did to his wife what a parent did to him is frankly a banality. More interesting was the fact that he repeated someone else’s insight as though it was his own. He had, frankly, plagiarized it… without knowing that he was doing so.

Someone will be thinking that the habit might have signaled a neurological deficit—Payne was an alcoholic at the time—but still it signals a shift from introspection to taking what AA calls a searching and fearless moral inventory of himself. (If, perchance, the habit reflected a neurological problem, it might not have existed during the time he was working with his therapist in New York. But then, even if it had, his therapist might have addressed it by seeking out a childhood cause.)

The therapists in the North Carolina group also tried to undermine the narrative that Payne had been taking for his truth:

The group members, in their frank interactions with me, brought me face to face with my worst habits. The therapists would say things to me like: “Of course, it’s easier to tell yourself the story that you want closeness because you’re a good intimacy-wanting person and your wife doesn’t want closeness because she’s a bad intimacy-avoidant person. And as long as you tell yourself that, you can avoid looking at the deeper issues. Is a marriage with no real desire for closeness a marriage you want to stay in? You can always choose that. It’s just better to know the truth and choose instead of lying to yourself and staying passive.”

For whatever reason, the group therapy worked for him. It got him to sober up, which is no small achievement:

After 18 months in group therapy, I once again poured out my vodka in the yard. Since this was the 10th or 15th time I’d done it, I had no confidence I’d succeed. Yet this time it worked. I have been sober ever since. And there it was: a meaningful and measurable change as a result of therapy, the first.

By my calculation, this means that Payne has been sober for around ten years now.

Moreover, group therapy caused him to get out of his mind and back into his life. He did not like what he found, so he took steps to get on a better path:

When I left individual therapy, I was someone who chose to stay in an unhappy relationship rather than leave and risk aloneness. By 2010, six years into group therapy, I was someone else. By then, staying in an unhappy relationship had come to seem a form of self-erasure, and so I left my marriage, passing from a world that seemed full of people like me, in bad marriages and relationships, and entering a different one, a world filled with people who had found happy and sustaining love, which in time I found, too.

Payne is quite correct to compare and contrast therapy that worked and therapy that did not. Obviously, not all individual therapy resembles the psychodynamic treatment that he received in New York. And there are so many variations in the practice of group therapy that it would be foolhardy to say that it works consistently.

He concludes:

Part of it was that having nine different mirrors reflect back my problematic behavior brought into brilliant and incontrovertible light what I had been able to avoid confronting in a one-on-one exchange. Individual therapy also encouraged me to focus on the past, the injuries I’d received in childhood; group therapy forced me to see who I was now, the sometimes injurious adult I had become. For me, that was the bitter pill that led to change.

Apparently, an obsessive interest in the past was counterproductive, but  seeing how you look to others produced meaningful change. It should not be too much of a surprise. Psychodynamic therapy focuses on guilt; Payne’s group therapy was controlled shaming.


Anonymous said...


Anonymous said...

The distinction between guilt and controlled shaming is dubious. Both are simply personal thoughts about personal pain although social interaction generates and triggers these persistent or transient thoughts. Since a person who is caused much pain in childhood can't possibly get the "right" idea about it (reasoning in causal terms is emergent in adults) he or she necessarily gets a confused which generates persistent feelings of guilt (blaming self/others) and shame (judging self/others as defective). Psychotherapy begins with a label on the "disorder" so it repeats the judgment that one is defective (shaming). It pretends the external other is the authority on healthy versus sick relationships so the patient is automatically in the presence of an external authority figure. This is all a reenactment of parent child relationships.

The group probably had enough enlightened members to support acceptance for Payne and yet to call him out on his resistance to change. The erasing of experience happens because the brain is what engineers call an adaptive filter. The child does not want to be like his or her shaming, guilting, self-other erasing parents, and yet he or she has no choice but to become like some adults and to erase parts of his or her experience. We understand this when a soldier erases painful memories in war, or war victims cannot recall horrid acts of violence. The distinction in childhood is that the child is much less empowered than an adult to do anything other than adapt automatically to the conditions present in life: one forms adaptive emotional and cognitive filters. The process of changing the properties of steel is called "annealing" and this term has been used in neural networks for the process of training and retraining a machine capable of adaptive filtering of inputs to outputs. However, if we recognize that adaptive learning is both a source of will and uses will power as an input (feedback loop) we must let go of many of our moral judgments and therapy must change from its historical model.

I fired a therapist who had a nasty habit of treating me the way his abusive parents treated him, and erasing memories of these incidents. The group had no power to stand up to this wounded authority figure because they lacked insight into the process of how one is attracted to the wounding authority figure the way an abused woman stays with an abusive man: she wants him to change because she is fighting the old battle from childhood instead of recognizing that being treated properly has a real payoff - her cognitive emotional filters don't give her the same payoff as a girl who was admired and allowed to express love toward women and men rather than erased and caused pain. I see the same adaptive process at work in all human interactions and no one has complete control over the natural adaptive properties of the human body and brain. Sometimes for me it is like watching a tragedy in slow motion.

Changing behavior does not change one's cognitive filters. A criminal typically refrains from crime in situations where the odds are high of getting punished. This ability to behave according to the accepted or lawful norm does not reduce the impulse to harm others when one can get away with it. Many parents mistreat their children in privacy or have aggressive control issues over small children, but act normal in public. Thus there are patterns of cognitive filters and behavior at work.

Stuart Schneiderman said...

I wrote two books about the differences between shame and guilt. You might want to consult them.

Anonymous said...

Centuries ago the philosopher Baruch Spinoza provided a reductionist model of emotion which conforms to my experience. Spinoza wrote: emotion is a feeling of desire, pleasure, or pain accompanied by an idea about its cause. The causal ideas evoke muscle-memories including speech and gestures because we are social animals (apes) who learn via interaction with others from an early age.

Guilt means, "I am in pain and its my fault."

Shame means, "I am in pain and I'm not good enough to make it stop."

A therapeutic (healing) process requires not only a change in behavior but a corresponding change in the content of one's ideas triggered autonomously in the body/brain. When it permits a person to transform his or her experience from one dominated by pain to one dominated by authentic pleasure in commonly recurrent social context then I would refer to the healing process as unshaming.

Stuart Schneiderman said...

As I said, you should read what I have written about shame and guilt. Your definitions are clearly inadequate.

Anonymous said...

In your emotional judgment the definitions I articulated are clearly inadequate. But to decide whether my definitions are adequate or inadequate I infer from my experience that you must be experience some mixture of pleasure and pain while reading my words above (even if you are not conscious of the process while I am aware of such process). Therefore in my emotional judgment my definitions are adequate.

Ignatius Acton Chesterton OCD said...

And now we see the limits of subjectivism.