Grupos em Gestalt terapia: Por que ?
Gestalt Therapy Groups: Why ?
Serge e Anne Ginger
Ecole Parisienne de Gestalt, Paris, França
Resumo
Os autores relatam 28
anos de experiência intensiva em andamento degrupos de terapia (3 dias
completos por mês, freqüentemente em um ambiente residencial), em
diferentes cidades francesas. Esses grupos oferecem um corpo e implicações
emocionais e muitas vezes são combinados com sessões individuais
(um coquetel de potencialização). Eles são liderados por
um casal de terapeutas (co-terapêutica sem confluência). Alguns
aspectos importantes são destacados: a confidencialidade, "abertura
límbica", experiências, e alguns jogos e exercícios.
A questão permanece: o que a terapia individual tem a oferecer, que não
poderiam ser trabalhados em grupo?
Palavras-chave: Grupo; Gestalt Terapia; a confidencialidade;
o corpo e a implicação emocional; co-terapia.
Abstract
The authors
relate 28 years of experience of intensive on-going therapy groups (3 full days
per month, frequently in a residential setting), in different French towns.
These groups offer a body and emotional implication and are often combined with
individual sessions (a potentiating cocktail). They are led by a couple of therapists
(co-therapy without confluence). Some important aspects are underlined: confidentiality,
“limbic opening”, experiments, and some games and exercises. A question
remains: What does individual therapy have to offer, which could not be worked
out in a group setting?
Key words: Group; Gestalt Therapy; confidentiality; body and
emotional implication; co-therapy.
Introduction
Our 28 years
of clinical practice (1971-1999), within the Ecole Parisienne de Gestalt (EPG;
Paris School of Gestalt) inspired us to put the following thoughts to paper…
We have led many hundreds of intensive 3- to 4-day groups, thematic workshops
(sexuality, couples, dreams, etc) and especially on-going therapy groups
(2-3 intensive days each month, in several French cities, with constant group
composition). Many of these groups are still running, uninterrupted, since 1978.
We would like
to highlight the richness, often underestimated, of Gestalt therapy groups,
versus traditional individual therapy (one-to-one); we recommend a combination
of these two formats wherever possible.
Here, we will
discuss individual therapy with follow-up within the group, as compared
to groups, centred on process and group phenomena, where the group
is considered as the client : as developped at the Cleveland Institute for example
(Polster, 1973; Zinker, 1977; Clarkson, 1993) and in Brussels (Wollants, 1996).
Neither shall we investigate in this article what we call "socio-Gestalt",
or Gestalt of an organization considered as an organism (Ginger, 1987); nor,
generally speaking, Gestalt applications in organiza¬tions, institutions
or businesses (Masquelier 1995).
Our experience
has shown that nearly all kinds of problems can be worked on in a group
situation, whereas many cannot be efficiently treated in an individual
therapy setting. Let us name, for example, problems of timidity or inhibition
(either in a group, or with members of the opposite sex), or on the contrary,
excessively self-centered people, who constantly invade other's boundaries…
We shall return to such themes later on.
It should be specified that in the framework of our group therapy, our style of Gestalt implies strong emotional involvement with bodywork, and is not restricted to verbal exchange (Ginger, 1987; 1995), as is more often the case with individual therapy.
The setting and the working conditions
Our groups
usually have about ten participants per therapist, ie twenty in groups co-led
by a therapeutic couple (which is our preferred way of working).
Our groups
are "slowly open", ie new members may enter when a place becomes available
when another leaves (Masquelier, 1998). There is thus a waiting list
(which may last from weeks to months).
This also implies
that the person who is preparing to leave the group (after 12 - 18 months, on
average) announces his intent at least one session in advance (usually,
the month before). This way, each group member has time to get ready to say
goodbye, and finish unachieved business. The departure may include ceremonies
or rituals, which are the responsability of the departing member: sharing memories
with each participant, pre¬sents, songs, poems, etc. At the same time, the
future new member receives notification one month in advance.
Rather than
weekly or fortnightly workshops of a few hours, we prefer intensive,
longer workshops: 2 to 4 full days, often residential, in
the country. This allows progressive warming-up, followed by deeper implication,
in emotionally secure conditions.
We usually
work seated on the ground, on thick carpet, with mattresses and cushions. This
lets each person change position easily, and find the right distance between
themselves and the others: participants neither feel isolated nor "imprisoned"
in a chair.
From the first sessions, we emphasize confidentiality -- which is not a limitation, but rather a freedom: any subject can be discussed in the group, in complete safety. This includes forbidden desires (sexual or aggressive, for example), unusual experiences, shameful or violent traumatic events. All may be stated, even role-played – within the framework set by the therapist(s), but all may not be acted out! Sexual and aggressive acting out are not allowed – but tenderness, or controlled conflict are.
"Double locking"
When participants
are liable to meet outside the group, in other situations (especially in an
advanced workshop for therapists, for example), we institute reinforced confidentiality,
that we call "double locking."
The first "turn
of the key" concerns the outside: nothing must be said (in a way
that would identify the person concerned) about what was said or done in the
group. We must say that we are pleasantly surprised at how well this rule of
privacy is respected, with very few exceptions.
The second
"turn of the key" concerns the inside: the client himself.
It is agreed that whatever is said or revealed in the therapeutic session
remains confidential and is never referred to outside therapy, even with
the person concerned. For example, if Colette is working on conflict with
her lover, or discusses the drug addiction of her teenage son, other group members
will be careful not to ask questions if they meet her again, either in the group
or elsewhere. This may seem artificial, or even somewhat inhuman (after all,
it is natural to speak about concerns with friends), but it seems to us, with
hindsight, particularly liberating: each participant may broach any
topic, any problem, without fear of being "branded" for ever, of being
"followed around" by his problem.
Of course, the person concerned may refer to their own business as they wish, and may spontaneously inform the others; in this case, the other group members will not pretend to ignore the issues, but these issues must never be brought up by another. However, the question may be raised, if this is useful, in a later therapeutic session. This rule is obviously also excellent training in confidentiality for future therapists.
The "crystal ball"
In our on-going
groups, we have an entry ritual: the "crystal ball". The
aim of this game is to help new members join an already-formed group. Instead
of asking the new arrival to introduce himself or herself as usual, the group
participants "introduce" him or her! Each one concentrates attentively
on the new member and shares what he imagines:
"I imagine
that you live alone with two children" … "I imagine you are
a school teacher, and very strict with the students" … "I think
you might be a doctor with an interest in homeopathy, very sweet and patient
with your patients" … "I see you when you were ten years old,
living on a farm, with a big dog by your side" … "I think you
read many books at once and leave them lying about, opened at the page you're
up to, all over the furniture in your appartment" … etc.
The aim of
the game is to allow a certain amount of time for the new member: the whole
group is centred on him for at least 10 minutes, and each tries to
"sound his depths", to absorb his look, his clothes, his expression.
Obviously, this game is done as soon as possible, before the person concerned
has a chance to reveal himself. There are thus only non-verbal clues, mostly
unconscious.
The person
being introduced does not react, whether what is said rings true or not; neither
does he take notes, but simply listens to the effect he produces, the
first impression he gives. At the end of the game, he says what he felt, what
surprised him, what was true (often many things) and incorrect, and he rounds
out the introduction by adding what he wishes.
We thus have
a lively, full portrait, including both personal and professional characteristics,
and the new person generally feels understood and integrated. Many months later,
when he leaves the group, each still remembers the initial picture and highlights
the changes. Some even request a new "crystal ball" for their future,
rather than for their past!
Members of
an on-going Gestalt group, who are trained in listening to their intuition
and in limiting their projections, often paint a remarkably exact portrait.
I will always remember a nun, Mother Superior in a convent, who came incognito,
in very ordinary civilian clothing (having requested confidentiality, as she
wished to deal with her sexual difficulties). The group immediately said "You
remind me of an old-fashioned school teacher" … "Yes, a teacher
in a religious school" … "I think you must be a nun!" …
"Yes! You are the Mother Superior in a convent!" … etc. The
group members thought they were joking… yet their intuition was remarkably
accurate!
Other examples
are even more astounding: I cannot resist the pleasure to share two other specific
occasions:
"I see
a tapestry on the wall in your home; you are embroidering a landscape, with
a pond and some sheep, and a thread of white wool is hanging on the wall, with
the ball of wool resting on the floor!" (The person concerned suspected
a secret visit to investigate her home!)
"You have
a secret lover; no-one knows... It's the village potter; he lives in a small
house away from the town and you visit him secretly at night…" Nobody
did know, but the young woman thought she had entered a group of clairvoyants
(thus the name of this game: "the crystal ball").
The only explanation that I can offer to explain such (frequent) specific remarks, would be related to direct communication between the unconscious minds, some sort of thought transmission… But these phenomena remain unexplained by science – just as, witnessed in labora¬tory conditions, young babies dream not only at the same time as their mothers, but even the same sort of dreams (as seen with cerebral imaging techniques).
"Floating hot seat"
Therapeutic
sequences follow, at each person's request, in no particular order,
depending on what emerges in the group. One person may work on something for
20 minutes, and after a general feedback, another follows and works on their
own issues for 40 minutes; some express themselves with a phrase or two, about
how they felt, others return to a major problem, already treated the previous
month… Each is accompanied by the therapist(s); the other group members
intervene mostly when asked, by either the client or the therapist. They express
themselves freely after the therapeutic sequence, during the feedback.
The client
in the therapeutic sequence is not asked to sit in a particular place, for instance
on a predetermined "hot seat": he begins where he is. This is called
the "floating hot seat" (Polster, 1973). He may change places during
the session, if necessary: finding the right distance, enacting
a described situation, seeking a symbolic object, building a representative
mini-sculpture (spectogram), meeting with one or several of the group partici¬pants,
etc.
Of course,
the therapist may also change places is this is appropriate: he may approach
or move away from the client, or accompany him when he moves, etc.
In practice,
during most sessions, there are several changes of position and enactments.
In our style of working at the EPG, it is rare that the whole session remains
purely verbal and static, with each staying in his original seated
position.
Obviously, this style is better adapted to the group situation, and more difficult to apply in individual therapy.
"Limbic Opening"
Thanks to neuropsychology
research (Changeux, 1983; Vincent, 1986; Ginger, 1987; Damasio, 1994; Goleman,
1995; Ginger, 1995), we know now that physical movement solicits mainly the
brain's right hemisphere. This right side is responsible for spatial
orientation (while the left hemisphere manages temporal orientation). We also
know that the right brain is more sensitive to emotions, and is in direct relation
with the deep limbic zones – where emotional memories are stored
(amygdala), and where memories and learning are treated (hippocampus). We also
know that one of the basic emotions — joy, sadness, fear, disgust,
anger, desire or surprise — is required for long-term memory
storage.
Thus, movement
and emotion (from the Latin, "ex-movere" = to make a movement
towards the exterior) participate in what I call "limbic opening"
(Ginger, 1987), which allows the experience of the therapeutic session to be
durably stored in the cerebral structures. Let us stress that verbalisation
is, in a way, the "subtitles" which favour subsequent access to the
areas concerned, and continuation of the work already started.
These recent
neuroscientific discoveries explain and validate the usual sequence of events
in Gestalt therapy: physical expression, emotions, verbalisation of identification
and sharing… as opposed to the traditional psychoanalytical order (verbal
association, leading to a possible emotional feeling, with little physical involvement).
Once again, we would like to underline how much easier and more natural it is to mobilise both body and emotion in a group situation, than in a dual interview setting.
The interpersonal approach
Gestalt therapy
groups add the interpersonal (interpsychic) aspect, funda¬mental
in human relations, to the intrapersonal (intrapsychic) and transpersonal (spiritual)
approaches : the importance of the former was emphasized by the British
School of Object Relations (Klein, Fairbairn, Winnicott, etc.).
In fact, many
clients request psychotherapy not only to deal with internal uneasiness,
but also (or mainly) because of relationship difficulties: marital
or professional conflict, excessive shyness or difficulty with maintaining a
clear position, poorly-contained irritability or aggressivity , etc.
Group work
facilitates experimentation (Clarkson, 1993) of such relational difficulties
in situ, in the here-and-now of their natural or stimulated appearance;
whereas individual therapy only allows for verbal references —
reported after the fact, and altered, both consciously and unconsciously.
We could, for
example, observe or experiment with a young man's difficulty in approaching
a woman; or the uneasiness, paralysis, suspicious aggression or excessive submission
in a woman, when she is confronted with the slightest hint of male seduction.
Such attitudes
are often exacerbated by sexual traumatic events, sometimes explicit
(rape, identified sexual abuse), sometimes less obvious, pre-conscious, repressed
or even imagined. The therapist's work is not to establish accuracy of the events
(which in any case is often in vain, and traumatic), but does necessitate in-depth
exploration of the victim's subjective experience. This could include psychodramatic
re-enactment (Ginger-Peyron, 1992), with simulated (and enacted) physical
aggression, which awakens the invasive feelings of fear, panic, anger and often
guilt. We usually suggest, with this sort of experience, a short sequence where
the victim himself or herself enacts the attacker, so as to dissolve
the deep neurological "imprints" of passive submission.
The support
of a familiar, close-knit, even "accomplice" group facilitates
not only the enactment, but also a deep "plunge", within a secure
environment — when there is well-integrated confidentiality. In addition,
the percentage of sexually abused group members is generally higher than the
victims imagine (25 – 40% in current French therapy groups) — which
helps to dedramatise the event, and often diminishes shame and guilt.
When one person evokes such abuse, it is not infrequent that many other participants
touch on similar problems, which they may never have mentioned to anyone, for
their whole life. The courage of a few, wins over the timidity or modesty of
the others; our experience shows, contrary to what one might think, that sexual
trauma is dealt with more easily in group therapy than in individual therapy
— where the closeness and intimacy with the therapist may be paradoxically
inhibiting.
In general,
the group situation facilitates controlled enactment, of not only aggressivity
but also tenderness; both are at least difficult to handle, even forbidden
in individual therapy, for obvious deontological reasons. Even if the
therapist is very clear in his gestures and actions, it is impossible to exclude
ambiguous or biased interpretation by the client.
Many other
relationship and social behaviour patterns require effective group presence,
in order to be identified or experienced. For instance, the
frequent tendancy, which is quite unconscious — and so, neither worked
on (nor lived through) in individual therapy — to "invade the territory"
with constant remarks, in an overwhelming histrionic or narcissistic need. Similarly,
some paranoid, masochistic or schizoid traits are more easily identified in
a group setting than in individual work.
A variety of
collective techniques may be used: dance, sculpture, psychodrama, going
round the group (where each says a phrase, or receives a personal message from
the client) and, of course, a wide variety of personal development games and
exercises. In practice we rarely use such techniques, except as short warm-up
sequences. There are also exercises in duos or in small groups, such as the
trust walk, making contact with the eyes closed, sensory awareness, games to
stimulate awareness, exercises of choice, physical confrontation, territorial
defence, carrying, rocking, jumping into emptiness, etc. These games are not
programmed in advance, but are suggested to amplify or explore a new, emerging
individual or group situation, and are adapted to each setting (Zinker, 1977).
Finally, the
group members can sometimes come out with what the therapist himself refrains
from saying: "You are beginning to annoy me, with all your whinging"
… "Surely you're not going to carry on again, like you did last time"
… "Oh shut up, give someone else a chance to speak!" …
etc. The therapist can, if necessary, soften the overly-brutal truth…
If the therapist is not alone, but co-leads with a colleague, each may take on a different role: one can provoke the client, whilst the other stays at his side; one can encourage him to act and the other, advocate waiting…
Cotherapy: confidence but not confluence
It is clear
that if two people co-lead a group — which is the norm, in on-going groups
at the Ecole Parisienne de Gestalt — that it is not worthwhile
if they always agree, and propose the same thing!
We usually
work with mixed therapeutic couples, a man and a woman.
It is important
that they understand eachother well enough, and that there is sufficient trust,
to cope with therapeutic discord — sometimes amplified —
and let the client assume responsibility for his choices. One may be deliberately
stimulating and provocative ("paternal"), and the other can show compassion
and support ("maternal"). It is often interesting to swap roles, to
avoid habituation and maintain the clients' freedom of choice. The two therapists
can even "argue" publically in front of the client… This reminds
him of his own daily life, both during his childhood and at present, and facilitates
transferential projections (Petit, 1980). Lateral, fraternal-type transference
also occurs, which is not unimportant.
However our
two co-therapists do not always work together: most of the time, the group is
divided in two, each smaller group in a different room: some with the female
therapist, the others with the male therapist, for the half-day (3-4
hours) session. After the morning, each participant chooses with whom he would
like to work: he may either continue with the same therapist, or he
may go with the other. He could even work through the same issue with
a different therapist, for instance… We appreciate such richness and diversity
of therapeutic vision and support, and we like the client to have freedom of
choice (Ginger-Peyron, 1990).
It goes without saying that in order to maintain therapeutic coherence, it is clearly stated that the two colleagues practise shared confidentiality, ie. each informs the other of what he considers important. This obviously implies frequent discussion and coordination between the therapists, prior to each session and after each half-day. Such exchanges allow a coherent therapeutic strategy, as well as mutual, on-the-spot supervision.
So, what does individual therapy have to offer?
Faced with
the numerous advantages of individual Gestalt Therapy within the group
setting, we may wonder what the individual therapy setting — which is
more frequently practised — has to offer.
First of all,
it is simpler to set up — for both therapist and client: appointment
times and frequency are flexible, according to mutual availa¬bility, payment
can be negotiated, the room does not need to be too large, etc.
Above all,
it is less intimidating for beginning clients: it is rare that they choose to
expose their problems straight away to "strangers"; the initial demand
is generally specifically individual, and confidential.
Apart from
such practical issues, are there specific indications for indivi¬dual therapy?
This choice
may be made to protect the client, or protect the group: very shy people
who would not dare speak in public, or those who have trouble expressing
themselves: those with limited education, foreigners, stammer¬ers,
etc.
Some professions
are not well accepted in groups, due to negative a prioris, or on ideological
grounds: psychiatrists, priests, nuns, politicians, police¬men, prison guards,
…
The same applies
to certain practices, especially pedophilia. In fact, it is difficult
to treat sexual delinquents in an unprepared group.
The group may
also be contra-indicated for certain pathologies: aggressive paranoids
can be hard to control in a group, as they try to control everything themselves,
by criticising every therapeutic proposition.
Histrionics
may attempt to use the group as witness to their difficulties, or deliberately
dramatise to attract attention or sympathy.
Major deppressives
may be paralysed, overwhelmed by the effort required to take their place, and
take time for their therapeutic sequence. Similarly, those suffering from social
phobias, and those inhibited when they feel the eyes of another upon them.
In general, care must be taken before offering group therapy to certain clients who are seriously disturbed… or who disturb the others! Nevertheless, with experienced therapists and adapted rhythm and methods, these are the clients who will gain the most benefit from the group setting — where they are confronted with social reality, and real relation¬ships. Moreover, Gestalt in small groups is used in many psychiatric hospitals.
A potentiating cocktail
Finally, our
experience shows us that the richest format is a combination of individual
and group therapy, with the advantages of both. We advise this, wherever
possible, with the same therapist.
For example:
an intensive group workshop every month (16 hours or so), and a weekly 50-minute
individual session. If the client lacks time or money, the individual sessions
may be decreased to one session per month, between the groups, or even to occasional
sessions (Perls, 1967). It is also possible to begin and end with a period of
individual therapy, to prepare the client, and finish off.
The basic idea
is that group sessions can thus be brought up in detail, and explored more
profoundly in individual therapy; at the same time, the therapist and the
client can prepare together the following group session.
To illustrate:
"Next
weekend, pay particular attention to your pre-contact with each person";
"Try to avoid waiting to the last minute before starting a therapeutic
sequence";
"You could try to give more room to the others, and not always be the first
to jump in";
"Be careful to stick to your own point of view, your own experience or
feelings, rather than slipping into your usual confluence… and do not
hesitate, if appropriate, to try this out with another participant".
It is obvious
that although therapeutic sequences in the group are often discussed in individual
sessions, the contrary is not the case, and these remain completely confidential
and are never discussed by the therapist in the group, unless the client has
previously agreed.
Sometimes we
welcome clients to the group who are in therapy elsewhere
— even in another type of therapy — provided their therapist agrees.
Some clients continue individual psychoanalysis, while they come to
monthly Gestalt group workshops. However, we systematically refuse
two simultaneous individual therapies (which would lead to transference
dilution, and encourage deflection); we also refuse two parallel group
thera¬pies — which create loyalty issues which are more destructive
than enri¬ching.
The combination
of group therapy (including regular emotional and physical implication)
and individual therapy (more verbal) with the same therapist allows,
in practice, to significantly reduce the length of the therapy.
We carried
out a longitudinal study on 200 clients with common existential problems:
difficulties in social, love or sexual relationships, post-traumatic disorders
(following rape, attack, rejection, sudden abandon, etc.), marital conflict,
chronic professional conflicts, unresolved bereavement, reactional depression
following identifiable situations or events, etc. (Ginger, 1987).
Significant, even spectacular improvement was seen, by the client's entourage, by the therapists and by the clients themselves, in two thirds of cases, within one year. This represents on average 100 hours of group therapy (6 weekends) and 40 hours of individual therapy (throughout the year, less holidays, illnesses and unpredictable events). These results are comparable to those we have seen after 2 or 3 years of individual therapy.
Conclusion
The time has
come to reinstate Gestalt therapy groups in their rightful place: having
become fashionable in the 60s and 70s, they subsequently lost credibility because
this therapeutic approach was sometimes poorly used, or over-used
: problems included insufficiently-trained or unsuper¬vised leaders, a lack
of clear rules, poorly-managed groups, haphazardly constituted, with people
of diverse motivation, sometimes a mini-society of fringe elements…
We think that
a coherent therapeutic strategy, with man-woman co-therapy
and complementary individual sessions — frequent or otherwise —
makes it possible to reduce the duration of, as well as enrich,
therapy for a large majority of clients.
Individual
therapy within a group setting brings together traditional intrapsychic therapy,
interpsychic therapy and relationship experimentation in the
group's here-and-now. This combination can be used and modulated at will, with
an integrative perspective including both Gestalt and the contemporary version
of object-relation psychoanalysis (Delisle, 1998).
Wider implication
of the body and emotions — facilitated by the group setting —
encourages group experiences to be durably imprinted in the deep
neuronal circuits of the limbic brain (stimulation of production of
neuromediators, and new synaptic liaison formation). This neurological hypothesis
(Ginger, 1995) could explain these empiricaly observed results, which can be
spectacular.
Group therapy
is thus doubly justified:
It allows
profound individual physiological imprinting
It takes into consideration that man is above all a social being, inseparable from his cultural context (Perls, Hefferline, Goodman, 1951). The here-and-now of the present experience is influenced by the past, not only by personal and family history, but also and above all by History: the culturally-transmitted history of peoples and of humanity, which permeates myth and rite, and which makes sense of present experience, and imprints it within a permanent collective context (Cyrulnik, 1997).
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Serge Ginger
E-mail : s.ginger@noos.fr
Recebido em:
20/10/2010.
Aprovado em: 01/11/2010.