Discussion of ?common dilemmas in combined individual and group treatment? by Anne Alsonso and J. Scott Rutan

Abstract

This article provides an excellent discussion of the dilemmas therapists face when practicing combined treatment. I would like to add to the authors' work by elaborating on one of the dilemmas they mention. I shall also discuss another kind of dilemma these authors do not mention, but one that I believe many of us struggle with when practicing combined therapy. Under the rubric of privacy versus secrecy, Alonso and Rutan note a problem whereby patients reveal material in the individual session that they are reluctant to expose to the group. The problem for therapists is one of maintaining silence to avoide shaming the patient, but, at the same time, risking a collusion with the patient's resistance to the group. This dilemma raises for consideration the more general issue of how to work effectively with shame and humiliation affects. The role of these affects in the therapeutic process has been historically underestimated. Helen Block Lewis (1971) has done much to change this by sucessfully demonstrating the omnipresence of shame and shame-related affects in the therapeutic situation. Especially, she has shown how they are frequently mishandled by therapists and that this contributes powerfully to resistance and/or early termination. Lewis points out that both patients and therapists strive to avoid shame experiences because they are more profound and debilitating than the more easily managed feelings of guilt. Typically, in the guilt experience people feel bad for something they have done, while with shame people feel bad because of who they are. When shame is the dominant experience, the person is full of self-loathing, and this leads to withdrawal from confident interaction with the environment. There is the wish to disappear, sometimes for good. This point has particular relevance for those of us doing combined individual and group therapy because exposing oneself to both therapist and fellow group members is thought to be the central activity leading to change in such therapies (Bloch & Reibstein, 1980). This very same exposing, however, is what triggers powerful shame reactions. I would like to demonstrate this phenomenon, as well as some of the attendant transference and countertransference feelings and behaviors, with a