CAT (Classroom Assessment Technique) OPTIONAL (For Participation) Read this e-Library resource as provided in your syllabus: Treating the Dismissive-Avoidant Group Member Read “Treating the Dismissive-Avoidant Group Member" by Marmarosh, Markin, & Spie

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http://dx.doi.org/10.1037/14186-008 Attachment in Group Psychotherapy, by C. L. Marmarosh, R. D. Markin, and E. B. Spiegel Copyright © 2013 by the American Psychological Association. All rights reserved.

This chapter focuses on more dismissing-avoidant group members— those members with high attachment avoidance and low attachment anxiety. We focus on how these members relate to others in the group and how group therapy can facilitate changes for them by enacting past working models of self and other in the group. The chapter is divided into three parts. First, we discuss dynamics that are likely to unfold between group members with a more dismissing-avoidant attachment and the group. Second, we describe how the leader’s attachment influences the work with more dismissive group members. Finally, we outline group therapy goals for more dismissing-avoidant members and offer suggestions on how group therapy can facilitate the achieve- ment of these goals. A case example is used to illustrate attachment-related problems for more dismissing-avoidant group members as well as possible group leader interventions.

7 TREATing ThE DiSMiSSing-AvoiDAnT

gRouP MEMBER

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144 attachment in group psychotherapy

ThE MoRE DiSMiSSivE MEMBERS AnD ThE gRouP

According to Wallin (2007), more dismissing-avoidant patients often avoid emotions that stir up feelings of vulnerability, and they have a particularly difficult time coping with these emotions when they are stirred up in treatment. Rather than expressing their internal experiences verbally, they often rely on subtle cues to express their underlying emo- tions (guerrero, 1996; Wallin, 2007). These patients are more inclined to say everything is fine while clenching their fists, averting eye contact, or smiling during emotionally painful interactions. Dismissive adults prefer more physical distance from others (Kaitz, Bar-him, Lehrer, & grossman, 2004) and demonstrate less facial gazing, vocal and physical supportiveness, and listening to their partners in videos interacting with a romantic partner (guerrero, 1996).

in addition, these more dismissing-avoidant individuals often engage in defensive self-enhancement, which means they suppress negative aspects of themselves and instead focus on their strengths (Mikulincer & Shaver, 2007b). The simultaneous suppression of negative emotions and expression of grandiosity further mask any aspect of a true self. The avoidance of emo- tions and self-inflation are examples of the deactivation that characterizes these individuals. They have learned to dismiss their needs for others, including group members, leaders, and the group as a whole. Researchers have shown that more dismissing-avoidant individuals tend to dismiss the benefits of the group, focus on their personal goals versus group goals, and have negative attitudes toward the groups that they belong to (Rom & Mikulincer, 2003).

For example, Amy would minimize the importance of the leaders by interrupting them while they were talking, devalue the members by rejecting their feedback, and minimize the importance of the group by comparing the group with other groups that were more desirable. over time, other members started to confront Amy about her inability to value them. one member, Frank, revealed that he believed Amy thought she was “too good for the group.” Amy agreed and did not seem to mind the feedback. She often perceived the group’s confronting her as evidence that they were envious of her. group members eventually rejected Amy. When the leader explored her reactions to being left out, she shared that this was not new for her. She was often rejected as a child, although she did not reflect on this with any emotion. it became evident that she had learned to reject others as a way of bolstering her own self-esteem and protecting herself from inevitable rejection. Despite this revelation, group therapy continued to be a challenging process for Amy, and she eventually dropped out of the group.

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treating the dismissing-avoidant group member 145

Challenges to Cohesion

group therapy is challenging for more dismissive-avoidant individuals because the act of seeking help challenges their internal working model of themselves as strong and of others being weak. needing the group or acknowledging their vulnerability in the group has the potential to rouse early painful losses that originally led to deactivation (Beebe & Lachmann, 2002; Schore, 1994). Rom and Mikulincer (2003) actually found that individuals with more dismissing-avoidant attachments had greater group-specific anxiety because the stress of joining a group inhibited their ability to deny anxiety. unfortunately, continuing to defend against this vulnerability with self- sufficiency and superiority leaves them lonely and rejected (Fosha, 2000). Mikulincer and Shaver (2007b) stated that even though avoidant individuals experience loneliness, they continue to deactivate and remove themselves from social relationships. not surprisingly, Kirkpatrick and hazan (1994) found that greater avoidance was correlated with an increased likelihood of being single and alone.

The difficulties these members struggle with not only leads them to be more inclined to struggle in the group process but can often lead to premature termination from group treatment. Tasca and colleagues (2004) found that women with more attachment avoidance were more likely to drop out of group therapy. Because these group members are challenging in group and at risk of premature termination, it is helpful for group leaders to keep their avoidance of painful pasts in mind. Although they can often appear arrogant or independent on the surface, they have turned off proximity-seeking behaviors and are often seeking relationships but without the ability to accept intimacy (Mikulincer & Shaver, 2007b).

Interactions With Other Group Members

Because dismissing-avoidant group members avoid the direct expression of their true feelings or internal states or are completely unaware of them (Fraley & Shaver, 2000), it is sometimes difficult to identify their under lying emotions or presenting problems (Cassidy, 1994; Main & Weston, 1982; Wallin, 2007). one way to understand how these individuals truly experience themselves in the group is through the feelings and experiences they induce in others they interact with via projective identification (Wallin, 2007).

Bion (1961) was the first to apply the concept of projective identification to groups and defined projective identification as the process of a member disowning unacceptable aspects of himself or herself and projecting them onto the group as a whole, its leaders, or specific members. Yalom and Leszcz

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(2005) defined projective identification in group as the “process of projecting some of one’s own (but disavowed) internal attributes into another, toward whom one subsequently feels an uncanny attraction–repulsion” (pp. 365–366). Rutan and Stone (1993) clarified that projective identification is a two-party system because it requires one who projects the unwanted parts and another or multiple others who accept the projections in the group. By exploring pro- jective identification, we can learn what is going on inside of the dismissive group member who may not have awareness of his or her underlying feelings or needs, and we can see what is being activated in the group. A wonderful example of projective identification in a group with a more dismissing-avoidant member is depicted in Yalom’s (Yalom & gadban, 1990) video demonstrations of group therapy, described next.

Case Example: Interactions With a More Dismissive Group Member

Dan, a more dismissing-avoidant group member, comes late to group consistently and avoids participating fully in the sessions. Yalom is the first to confront Dan about not participating in the group. At first, the members express their desire to have Dan participate in the group, but his vacant reactions lead them to question why he is even coming to group in the first place. During the session, he blames his work for his lateness and his wife for his problems, and he minimizes the members’ request to have him participate. gradually, during the session, the members become more and more frustrated, and eventually, they become aggressive in their attempts to get a reaction from him. Yalom recruits all the female group members to “tell Dan what it would be like to be with him 24/7 . . . to be married to him.” Dan continues to look calm, cool, and collected while each female member tells him how challenging it would be to be his wife. not surprisingly, he becomes more defensive and appears to withdraw even more.

At some point in the session, a female member reveals that Dan had told her in private that he was frustrated with the group and often felt that it was a waste of his time. We also learn that as a child, Dan struggled with his parent’s alcoholism and his own feelings of inadequacy and rejection. We can imagine that Dan’s bids for emotional connection were often unmet, and he learned to disavow his own needs, feelings of anger, or his experience of disappointment in relationships. These disregarded parts of him appear to be induced in the others through his passive-aggressive behaviors, which also happens in his marriage. he denies having any needs or feeling angry while those around him feel completely needy and enraged.

This example highlights how the more dismissing-avoidant member, Dan, is not forthcoming about his true feelings of resentment and anger, and he does not appear to be aware of how his own needs are easily dismissed.

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treating the dismissing-avoidant group member 147

he withdraws into his work and continues to struggle with relationship issues. The group becomes a microcosm of his outside world (Yalom & Leszcz, 2005), with Dan re-creating a similar dynamic in the group to his relationships with his coworkers and wife. Those who interact with Dan find themselves angry and alone. Projective identification is one significant way more dismissing-avoidant individuals can express their underlying emotions in the group without having to be weak or needy (Cassidy, 1994). if the group leader can process this enactment in the session, the leader has a powerful tool to explore what is happening in the group and within individual members.

group members, like Dan, who have dismissing-avoidant attachments (high avoidance and low anxiety), often engender complex feelings in other members. Alice, a more preoccupied group member, starts to blame herself during the session and worries that something she said in group angered Dan and made him come late. She swallows her own feelings of anger and instead appears concerned that Dan is angry with her. it is not uncommon for more preoccupied members to be activated by more dismissing-avoidant members because the dismissing-avoidant member’s rejection and neglect activate the more preoccupied person’s worst fears. More preoccupied individuals often doubt themselves and personalize reactions in the group. When they are activated, they tend also to increase pursuit of the more dismissing-avoidant individual and can be intrusive in their attempt to increase intimacy (Lavy, 2006). This pursuit often leads more dismissing-avoidant individuals to withdraw even more (Bartholomew & Allison, 2006).

Secure members are critical to the group process because, like secure individuals in a couple, they tend to buffer the effects of members with a more dismissing-avoidant attachment (Ben-Ari & Lavee, 2005; Feeney, 2005). Secure partners are more forgiving (Mikulincer, Shaver, & Slav, 2006), can express vulnerable feelings (Feeney, 1995), can self-soothe (Mikulincer & Shaver, 2007c), are more compassionate (Mikulincer & Shaver, 2007c), and can model how to address conflict (Paley, Cox, Burchinal, & Payne, 1999). Likewise, the leader’s attachment style is also critical to facilitating a secure base in the group.

ThE gRouP LEADER’S ATTAChMEnT STYLE AnD ThE DiSMiSSivE gRouP MEMBER

Wallin (2007) argued that how a therapist responds to the patient’s projection and the enactments is influenced by his or her own attachment orientation. A more dismissing-avoidant therapist may engage in deactivation, avoiding the patient, whereas a more preoccupied therapist may engage in hyperactivation, becoming overly obsequious or intrusive and pursuing.

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The secure group leader is able to regulate his or her emotions, facilitate curiosity about his or her experience in the group, and help group mem- bers observe their reactions in the here and now. Yalom and Leszcz (2005) described this as the leader “retaining or regaining our objectivity” (p. 45). in the video, Yalom does this by stepping back from the enactment to reflect on the process that is evolving in the group. he wonders aloud what is happening when Dan withdraws and the group becomes “louder and more shrill” as they attempt to get Dan to speak more authentically. in attachment terms, Yalom is exploring the deactivating behavior in one group member and how it is pulling for hyperactivating behaviors in the others. At the same time, Yalom is facilitating group members’ mentalization by having them step back and reflect on the emotionally charged group process so that they can make sense of what is happening within themselves and in the group.

gRouP ThERAPY goALS FoR MoRE DiSMiSSivE gRouP MEMBERS

The major task of group therapy is to help a more dismissive member move from an avoidant orientation to one that is more relational and secure. This requires that the individual rework internal models of others as weak and inferior and of the self as superior and self-sufficient. This is no easy task and involves challenging these implicit patterns of relating as they occur in the here and now of the group. Because dismissive members have learned to disavow painful emotions such as shame and aloneness, they are excellent at intellectualizing, but they often lack the capacity to access emotions and experience them relationally (Fosha, 2000; holmes, 1996; Main & Weston, 1982; Wallin, 2007). here we discuss how empathy, insight, mentalization, and emotional regulation are key treatment ingredients to helping a dismissive group member move toward more attachment security.

Using Empathy to Experience Core Affect: Walking the Tightrope

one of the reasons dismissive individuals do not have access to certain painful emotions is because of their defensive exclusion of attachment-based memories and thoughts (Fraley & Shaver, 1997, 2000; Schore, 1994). When it comes to more dismissing-avoidant group members, it is helpful to keep in mind their struggle with vulnerability and experience of shame. Early in their development, they were most likely met with indifference, disdain, or even dis- gust when revealing vulnerable affective experiences (Main & Weston, 1982; Schore, 1994). The group leader must balance the need to confront the member’s avoidance while also remaining sensitive to his or her underlying humiliation.

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treating the dismissing-avoidant group member 149

in the early phases of group therapy, when the group is forming, more dismissing-avoidant individuals tend to be more sensitive to the pressures of belonging and struggling to determine how group can help them while also maintaining their distance. This struggle is often typified by coming late, missing sessions, giving advice, remaining silent, telling jokes, or talking about outside events that are safe to talk about. it is important to keep in mind that these individuals may not be able to identify how they are really feeling, let alone be able to share what they are feeling with others.

An empathic leader holds back from challenging, too soon, the natural defenses that these individuals have relied on over the course of their lifetimes. it is helpful for the leaders to acknowledge these members’ self-sufficiency and their independence in the group, which is at odds with opening up and joining the group. These members struggle with a challenging dilemma: If I want to stay strong and rely on myself, I will be alone; if I open up and depend on the group, I will be weak and needy. in the face of this dilemma, the group leader can admire the group member’s independence, which has gotten him this far, but the leader can also comment on how this self-sufficiency has left the member alone and feeling disconnected to people, the issue that most likely brought him to group treatment in the first place. To change means they will have to start feeling.

in addition, researchers (Mikulincer, Birnbaum, Woddis, & nachmias, 2000) have shown that more avoidant individuals easily suppress attachment- based concerns if they are not under stress, but they lose this ability in certain situations. group therapy, with its many ongoing processes, can function as a stressful environment for these members and allow for more underlying attachment-based processes to surface. The following case example demon- strates how the group process activated Raj and facilitated his exploration of his attachments in the group.

Case Example: Using Empathy to Elicit Core Affect

Raj was a 45-year-old, single, engineering professor with an obsessive type personality. he was a workaholic who valued his career and academic success. Although he was doing well in his professional life, his relationships failed miserably. he was single and wanted to be married, but he was detached and judgmental. he was also triggered by people’s demands on him and often distanced himself from needing anything or anyone. one way he avoided depending on others was focusing on his work and obsessing about the details of his research. he often would fall silent in the group when others were vulnerable, and he would give logical advice that always felt a bit patronizing. it was as if he did not know how to connect or have social skills. Although group members repeatedly gave him feedback, he never seemed to be able

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to change the way he engaged with the group. Raj intellectually understood that he avoided his needs and feelings, but he could not help it or access more vulnerable parts of himself. he would often say with a sense of annoyance, “i just don’t understand what you want from me.”

During one session, Raj reacted to nancy, a group member who was describing her dependence on her boyfriend.

Raj: Why do you care so much what your boyfriend thinks? You should be more independent. i was independent since the age of 5. [The group is again frustrated by Raj’s arrogance, superiority, or lack of empathy, but this time, Raj leaves a clue that the leader immediately follows. The leader knows the group could go down the same “frustrated feedback track.”]

Leader: You have been independent for so long, since you were 5 years old. What was going on at that time, Raj? [The leader imagines that Raj is not trying to be difficult but is just unable to tolerate any expression of neediness. She speaks in an open tone and thinks he would feel safer if the leader acknowledges his strength and inde- pendence. She hopes that this empathy will lessen his defensiveness and allow him to explore what part of his childhood is related to his self-sufficiency.]

Raj: [struggling at first] nothing. i was just an independent child. That’s all.

Leader: Raj, this is important. Let’s think about it. What might have been going on that made you feel you were strong and independent since, as you said, the age of 5.

Raj: [without emotion] Well. one thing was being the one in my family chosen to be sent to boarding school. i think when i was 5. Why is this important, anyway? Why are you asking me about this?

Leader: That’s a good question. it is my experience that we all bring our past experiences into our current relationships and that what happened when you were 5 might help us understand how you feel in the group, why independence is so important to you, and why you respond the way you do to members, like nancy, when they reveal their needs. Does that make sense? [This intervention is aimed not only at clarifying things for Raj but also at helping the other group members empathize and mentalize as to the deeper roots to Raj’s behaviors in the group.]

Raj: [seeming to appreciate how the information could be useful] i guess it sounds logical. Although i don’t think that anything that happened to me at 5 is impacting me in here.

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Leader: i know. Maybe this may not be relevant, but let’s see where it goes. i know others in here may benefit from getting to know you better.

Raj: Well. You know i was born in india and moved here later in life to go to college. it is very common in india to send children to boarding school to learn English to get an education. i was honored to be the one selected in my family. i did very well and graduated at the top of my class. [Raj focuses on educating the members and defensively showing off his success.]

Leader: You adapted so well and were extremely successful at such a young age. You said that is when you became independent. Can you say more about that—about the experience going to boarding school. [The leader empathizes with Raj. She does not immediately challenge his defenses at this time and instead explores his success to help him open up more about his experience.]

Raj: [spoken without emotion] Well, i was told i would be going to school and that this was a good thing for the family. Then we packed that night, and we left in the morning. i saw them a year later.

Julie: WhAT?! You did not see them for a year?

Raj: Well, i didn’t know that it would be a year [said with slight annoyance].

Mary: Still. That’s horrible. You were only 5 years old. You were so young. i am a schoolteacher, and i think that is a young age to be away from your family for a year.

Raj: [looking disgusted] You don’t seem to understand. it wasn’t horrible. it made me who i am, and i owe my family so much for that opportunity. [Raj feels misunderstood and leans back in his chair. The leader, sensing the increasing defensiveness and wanting to respect Raj’s cultural background, empathizes with his experience of not being understood.]

Leader: Raj, i wonder if the group is not as familiar with indian culture, and it is very important for us to appreciate the value of educa- tion and being selected to attend school. You have something important to share with us. Could you tell us what it was like for you? [The leader attempts to empathize with Raj and repair the rupture to continue to make space for him to express himself.]

Mary: i’m sorry, i jumped in. i would like to know more. i have strong reactions when it comes to children. [Mary is more secure than some of the other members and is able to acknowledge her own anxiety. She expresses interest in bringing Raj into the group despite his hurtful responses in the past.]

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nancy was silent during the interaction, and the leader was keeping her in mind because Raj had judged nancy earlier in the session. The group leader was also trying to facilitate Raj’s openness in the group. She felt her way into his experience and empathized with his strength while facilitating some curiosity about his experience of being independent at such a young age. The leader was aware that exploring Raj’s memories of being 5 years old would likely expose his more vulnerable emotions and possibly move toward his affect. This would also be more challenging for Raj, whose attachment needs were consistently denied.

Facilitating Emotional Insight Into Underlying Feelings and Defenses

Fosha (2000) described how more dismissing-avoidant individuals have learned to deal without feeling, and the price they pay for not feeling is “isolation, alienation, emotional impoverishment, and at the best, a brittle consolidation of self” (p. 43). The group leaders must facilitate a secure base within the therapy group for dismissive individuals to feel there is any value at all to exploring their emotions within a relational context. group member– leader interactions are likely to trigger these unwanted emotions immediately and offer multiple opportunities to understand their instinctive avoidance. For example, Raj was triggered in the group by a fellow group member’s open- ness about her dependency on her boyfriend, and that is when he proudly announced that he was independent since he was 5.

Researchers (Mikulincer, Shaver, gillath, & nitzberg, 2005) have found that more dismissing-avoidant individuals are motivated by egoistic outcomes, and the group leader may need to start with helping the dismissing-avoidant member identify a selfish motive to open up in the group. The leader focuses on Raj’s strength and independence, and she maintains Raj’s specialness in the group by addressing his ethnic background and the lack of the group members’ knowledge of his diversity. he is the expert who can explain something to the group. The leader also addressed the cultural diversity in the group to facilitate safety for other members in the group who come from a different background to promote an openness and respect to differences (DeLucia-Waack, 2011).

Clinicians (Fosha, 2000) and researchers (Main & Weston, 1982) have described how dismissive group members, like Raj, are more likely to rely on repression and avoidance when core affects surface because these core affects were not welcomed in their earlier attachment relationships. in the following example, we see how the group leader took note of Raj’s nonverbal reactions and continued to explore his childhood in the group to increase his disclosure of personal information that could lead to emotional expression.

The leader sensed Raj’s need to defend his cultural background and was also aware that he might feel unique in being the only indian American in the

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group. Raj seemed to appreciate the acknowledgment that he was different and that he could educate the group about his ethnic group identity.

Raj: Well, i came from a large family in india. i am the oldest. i have two younger brothers and two younger sisters.

Steve: Were you all close?

Raj: i guess that depends on how you define closeness. i was closest to my grandparents, i suppose. Due to the limited space in the house, i slept with my grandparents at night and spent the days with my brothers and sisters. it was a busy house. [At this point, Raj folds his arms around himself as if to contain himself.]

Leader: That must have been so different to suddenly go from sleeping with your grandparents every night and having all of your family around you to being on your own at school. [The leader considers that for Raj, this may be an important memory of his grandparents and has triggering feelings within him; however, at this point, she focuses only on how different this experience was for him.]

Raj: [His expression has changed, and he avoids eye contact.] i never really thought about it that way. it was very different from living at home. i have a big family [pauses]. But i knew i was the lucky one to have this opportunity. [Raj’s struggle to suppress his attach- ment needs is profound. The group members have had a glimpse into his experience of loss, and the leader continues to track his reactions within the group, knowing that his experiences will lead to more vulnerability.]

Increasing Mentalization

in addition to empathizing with underlying emotions, it is critical for the group leader to help more dismissing-avoidant group members, like Raj, find ways of reflecting on these emotions in the group. We suggest that the group leader can help facilitate mentalization in dismissive members by ver- balizing feelings slowly, facilitating group member insight into the feelings that underlie behaviors, and encouraging interpersonal feedback within the here and now of the group. These three processes help to interrupt dismis- sive members’ avoidance of affect, which typically interferes with reflective functioning (Tasca, Foot, et al., 2011).

Emotional Regulation: Verbalizing and Tolerating Feelings

one way the group leader can help more dismissing-avoidant individuals put emotional experience into words is to reflect back the emotions that are

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nonverbally being expressed in a slow manner that is not experienced as intrusive. The group members and leaders can also explore a memory that comes to mind in the group that triggers more emotions. in the case of Raj, the group leader felt that it would be important to help him identify some feelings in the group given his resistance to the group’s interpersonal feedback and was isolating himself more and more from the group process.

Raj: Come to think of it, i never knew i would not see them for a year. i thought i would see them.

Mary: Was that customary in india? not to see your parents or family for that long a time in boarding school? [This question reflects more curiosity and openness to Raj’s cultural background and exposes what is cultural vs. what is specific to Raj’s family.]

Raj: [paused] no. other parents did come to visit, but my family lived too far away. They could not come each week. it makes sense, and it would not be practical. They had to work and did not have the money to visit. [Although Raj is still minimizing the experience, it is clear this question has touched on his emotions.]

Steve: So they lived too far away to visit you. Wow. it must have been hard to hear that they would not come to see you for a year. [Again, a group member is curious about Raj’s experience and genuinely interested. This is different from past group interactions.]

Raj: Well, they did not really tell me that. i figured it out over time.

Steve: how did you figure that out?

Raj: i guess i realized it when they didn’t come. i would go to the front hall where all of us would go to see our families on the weekend. i would go each weekend to wait, and they never came. Eventually, i realized they were not coming, and i stopped going. [Although Raj still speaks with the same matter-of-fact tone, his feelings are palpable in the room. The group is silent.]

Nancy: [in a compassionate tone, reaching out] Wow. You waited and they never came. You really must have been a strong kid to deal with that and to do so well in school on your own.

Raj: [said in a slower tone] i know it sounds worse than it was. i mean it was hard on me, but it was not so bad. [Raj again tries to protect himself from the feelings that are starting to come to the surface.]

Leader: Raj, it may not have been so bad, but you said it was hard. i imagine that 5-year-old must have been very disappointed and had many feelings before he decided to give up. Am i correct? Do your recall what that 5-year-old may have felt each week while waiting? You know, before he decided it would best to move on.

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treating the dismissing-avoidant group member 155

Raj: [speaking even more slowly] i never thought about this. i have never thought about what he was feeling each week. i don’t know. he . . . well i mean i . . . i just waited. it was hard to wait there. i am not sure this is that important. [Raj continues to hold back, but he is more open than he has ever been in the group.]

Leader: it feels to me like this is an important time in your life, Raj. This is when you learned to become so independent. Can you recall one specific time when you were waiting to help us really understand what it was like for you? What made it so hard? [The leader honors Raj’s independence and then tries to help him explore a memory that helps him identify his feelings as a child, which may be more tolerable than his feelings as an adult.]

Raj: i don’t know. it was a long time ago. i guess there was this one time.

With the help of the group members, who became intrigued by his past and continued asking him questions, Raj eventually recounted one specific day. he described going to the front room early to get a seat right across from the front door, and he eagerly waited for his family to visit. Each time the door opened, he imagined it would be his mother walking through. Each time, it would be someone else’s family, and he would watch them reunite. it was never his family, and it would happen more than a dozen times.

Raj: Eventually, i just stopped waiting for them to come. on the weekends, i would stay in my room and focus on my school- work. This ended up to be a good thing since i did so well. [Although Raj is positive about the outcome of the experience, his face becomes red, and he appears uncomfortable with the feelings that are coming up. He looks sad. The group is present and engaged.]

Leader: Raj, for a moment i saw something in your eyes, and it looked like you felt sad just now. is that how you felt?

Raj: i never really thought about this time in my life as sad. i was sad. i have not really gone back there in a long time. [Pauses] i just don’t want to focus on sadness now. i don’t see the point. it doesn’t change anything.

Steve: i can really relate to that. i also ask myself, “What is the point?” sometimes. “Why do i need to focus on feeling angry or sad?”

Leader: So what do you tell yourself, Steve, when you ask yourself that?

Steve: it has taken me a long time to realize that shutting off my feelings from when i was growing up made sense when i was a kid, but now it has pushed others away and kept me alone. it is hard to believe that these feelings can have a purpose. i remember

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the first time in this group when i shared my experience of my father’s alcoholism and how that triggered all of this anger i had pent up for years. At the time, i could not see how that anger was influencing all of my relationships especially with my own kids. [Steve is a member who is also high in avoidance but less so than Raj. He is able to empathize with Raj’s deactivation of emotions, but he is also able to offer a different perspective on how disavowal of painful feelings can have a negative impact on current relationships.]

This clinical example highlights how group members can help each other process and explore emotional reactions. Although Raj quickly moves away from his sadness, he is able to acknowledge the sadness he felt as a child for the first time in group. he also raises his experience as a child who is sitting with painful emotions without a caregiver to comfort or soothe him. Raj indicated that he learned to focus on schoolwork to avoid being overwhelmed with his intense feelings of longing, disappointment, and anger. This was adaptive as a 5-year-old struggling to survive repeated disappointments. This detachment and withdrawal from emotions is not adaptive in his current life, however. Steve, another more dismissing-avoidant group member, is able to empathize with Raj and express his own struggles with identifying and tolerating emotions and how this influences current relationships. More important, during this session, Raj has moved from being judgmental toward nancy for expressing emotional vulnerability and neediness to focusing on the root of his own disavowal of needs. he also offers the group an opportunity to connect with him and his struggles to avoid his feelings.

Encouraging Interpersonal Feedback

When working with dismissive group members, it is helpful to encourage the group not only to challenge their avoidance but to recognize their risk taking. As Raj revealed more in the session, group members seemed to be more engaged with him. They appeared interested and thoughtful as he was describing his experience. Raj’s disclosures had an important impact on the members, who then started to share their painful experiences to connect with him. The group members, like Steve, shared their own past that related to Raj to demonstrate their understanding of the use of avoidance to manage more painful emotions. Although members were able to relate, the experience of increasing intimacy caused Raj to withdraw again. he felt the support group members offered was not always helpful, and he was ambivalent about being similar to the other group members. The compassion he was receiving felt uncomfortable to him, and he did not want to be weak and needy. The leader aimed to help Raj use the group feedback to foster some insight into how his

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avoidance was perceived by other people and how this may have an impact on him outside the group.

Leader: Raj, i wonder what your experience of the group has been like today?

Raj: i don’t know. it is very different from what i expected. People seem to like it when i talk about this side of me from the past, but i’m not sure i see the point in the long run. if i were you, i would want to hear how i can help address your problems, not how i was feeling sad when i was young.

Nancy: To be honest, this is the first time i have ever felt like i knew you. i think this is the only time that you have shared anything about yourself. You always give advice, like a professor, and you do it as though you have it all figured out. You have the answers.

Leader: nancy, how does that make you feel?

Nancy: it makes me feel worse. i feel like you think you’re better, and it makes me feel angry. i’d much rather hear about your struggles, too. hearing about your experience has made me feel like we’re not so different after all.

Steve: Exactly. i really appreciated you sharing what you did even if you don’t think it was helpful. i think i understand why you focus on your work so much. i used to think you just didn’t care, but i think you focus on solving problems because you learned as a kid that feelings are not helpful. i also struggle with that, so i get it.

Raj: So you want me to talk more about my childhood?

Nancy: no, i guess what i am saying is i want you to talk more about yourself and give less advice. Just be you in here.

Leader: nancy, can you share more with Raj about your experience with him earlier in the session versus now?

Nancy: Sure. i guess i was annoyed when he said i should not be so dependent on my boyfriend. [The leader motions for Nancy to talk directly to Raj.] i should be more like you, independent. Like you have been since you were 5 [talking to Raj]. i felt like you were being critical of me. But now that i have gotten to know more about you, i see that there is a reason why you don’t want to depend on people. You don’t want to be disappointed. i relate to that, and i don’t want to be disappointed either.

Leader: Raj, what do you hear nancy saying?

Raj: i didn’t know i came across as perfect. i don’t think i’m perfect. [It is hard for Raj to take in the positive feedback.]

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Mary: i don’t think you realize that when you give only advice, you come across as having all the answers. it feels like you’re perfect or better than us.

Raj: Do others think that way? [Several group members nod their heads in agreement.]

The intervention described was the first time Raj acknowledged any feelings, described anything personal in the group, and was able to hear group members’ feedback. This was a major and important step for Raj, who continued to courageously struggle to take in the group’s feedback over time.

We can see the importance of using the past to enhance our understanding of the here-and-now interactions in the room with a more dismissing-avoidant group member (Bowlby, 1988). Before this session, the leaders and members continually provided feedback to Raj, but the feedback was not penetrating his defensiveness. he was not able to access his feelings with ease, and every bone in his body was rejecting vulnerability. The group’s confrontations never seemed to affect Raj, and this only served to frustrate the group members. To foster a new pattern of interpersonal interaction and emotion regulation, the leader engaged with Raj with more curiosity to foster a new experience.

The leader invited him to explore the roots of his deactivation and take a closer look at his reaction and eventually his underlying feelings. once the details of his childhood became more apparent to the leader and the other members, the group became more accepting of him and could understand his behaviors in the group. Eventually, the members’ reactions began to become a more salient factor in the process as they expressed empathy for Raj and also feedback as to how his vulnerability was more attractive to them compared with his superiority. not surprisingly, Raj did not trust the positive feedback he received from group members. This is consistent with work by Brennan and Morris (1997), who described how more dismissing-avoidant individuals tend to reject other’s feedback in general, especially positive feedback that activates their dependency needs. Future group sessions focused on helping Raj continue to gain insight into his ambivalence to emotional closeness in the group and the way he came across to others. Although the interaction did not alter Raj’s attachment behaviors immediately, it initiated a process in which Raj could begin to develop a more cohesive narrative of himself, learn to slowly tolerate emotions, and gain insight into how and why he pushed others away.

ConCLuSion

group therapy has the unique power to facilitate incredible growth for members who come to the group with a long history of interpersonal avoid- ance and emotional detachment. group therapy provides these patients with

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interpersonal feedback that calls into question their devaluation of others and idealization of themselves. The group members have the power to confront these dismissing-avoidant interpersonal strategies if the leader helps them explore the underlying motivation behind emotional detachment. For some group members high in avoidance and low in anxiety, interpersonal feedback with regard to their defensiveness can engender insight, but for some group members within this avoidant dimension, receiving challenging interpersonal feedback will only provoke more defensiveness. The group leader’s task is to know when to allow the group to challenge the more dismissing-avoidant group members and when to try a different strategy. These members are at risk of being a scapegoat if the interpersonal feedback does not penetrate the defensiveness. The leader must facilitate empathy and mentalization to foster insight within the group. To do this, it is important for the leader to facili- tate a different interpersonal experience by slowly making space for these individuals to reveal the underlying motivation for their self-sufficiency. Providing this window into the more dismissing-avoidant group member’s feelings facilitates empathy in the group and connects this member with others, facilitating cohesion.

As we look back on the case of Raj, we see how he was slowly able to gain insight into the impact of his actions on others in the group when he was seen in a different light. Raj was able to expose a different part of himself in the group, and other members were able to see how he needed to protect himself from the feelings he had as a child. only after the others really saw him were they able to provide helpful feedback that could be digested by and meaning- ful to Raj.

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