Two Clinical Case Studies:
Understanding and Responding to
Premature Termination in Group Psychotherapy

Gil Spielberg, PhD
Jean G. Gitlin, PhD

For more than 30 years, the issue of premature termination has been discussed in the group psychotherapy literature. It is our belief that patients who are in danger of terminating abruptly fall into two broad categories. The first category is composed of people who leave prematurely as a result of a painful and desperately driven basic organizing principle outside their awareness. Unless these organizing principles are appreciated, the attendant anxieties tend to result in the therapist and patients within the group finding themselves engaged in endless rounds of enactments merging from one painful and frustrating interaction to another. The second category of patients who terminate without notice is those who are protecting a fragile self against the experience of further fragmentation.

From a self-psychological perspective, preservation of the self is the most important issue to confront when evaluating the success of an individual’s engagement in and commitment to group therapy. If there is lack of attunement to the patient’s needs on the part of the therapist and group, traumatizing fears and or experiences may result in a failure to establish the required functions for preservation of the self, and premature termination is the likely outcome.

In our paper, we hope to illustrate these alternative understandings of the potential dropout with examples of a combination of interventions which proved helpful. In our first case study, we discuss a patient whose motivation for premature termination was driven by an

attempt to escape from the effects of problematic unconscious self-protective organizing principles. With our second example, we illustrated the group process as experienced by a patient with uncontrollable fragmentation anxieties.

Nina, a divorced woman in her mid-forties, had completed 18 months of once weekly individual psychotherapy three years prior to her first consultation for group therapy. During the preliminary session, Nina stated that she was reluctant to become a member of a therapeutic group. And, for the first few months, Nina resisted all efforts to become an involved member. She arrived late for session and acted in an evasive or hostile manner in the therapy sessions.

Nina’s non-verbalized refusal to reveal herself or comply with aspects of the previously discussed group contract set her apart and mobilized considerable aggression towards her. It appeared that as she defended herself with ever greater guardedness and hostility, a cycle of rejection and struggle for control ensued, all without accompanying emotional exploration. The likelihood of Nina repeating aspects of family life without therapeutic benefit was high. In spite of my (G.S.) attempts to help Nina understand her unconscious fears and overcome her resistance, my overtures were rejected. As the therapist, I led an open discussion of members’ concerns and feelings about the group, and Nina eventually became a focus. The situation lasted for close to ten sessions before she abruptly dropped out, much to the relief of the other members.

Sixteen months later, Nina called wishing to resume group treatment. I asked Nina what changes would be helpful for me to make with her. She thoughtfully replied that I had allowed too many attacks on her in the previous group. I agreed with her and continued to inquire about her thoughts, feelings and experiences in the group. Nina responded to my continued interest and empathic inquiry with tentative openness and some modest self-reflection.

However, once again within the group context, she initiated her defensive behavior. Since I was aware that the situation could escalate with hostility directed toward Nina, I intervened and assumed a more active role. I took my cues from Nina by observing her need to defend herself against the perceived threat of members’ inquiries, and I turned the direction of investigation to the group. By doing this, I supported and sided with her own efforts towards self-preservation.

Slowly, she became responsive to inquiries by group members, and it appeared that she was becoming more attached to me. Since we were not having contact outside the groups and there was a great deal I wished to learn about her, I suggested that she leave me messages about her experience in the group after the sessions. She agreed, and for several months, Nina and I communicated on an irregular basis through our respective answering machines. Sometimes her comments triggered genetic associations to issues that which occurred within her family of origin. Through repeated positive interactions, I slowly became a comforting and respected presence in her life within the group. As she felt protected by me and safer in the group, Nina became open to new emotional experiences.

Lois was a 43-year-old single woman and someone for whom group participation endangered a fragile self-cohesion. In this situation, premature termination may be sudden and can be viewed as an

attempt to modulate intense and overwhelming anxiety associated with self-state disintegration.

During the initial individual sessions, Lois described herself a veteran of the mental health establishment, having been in therapy since age 19. She talked despairingly about herself, her lifelong antisocial tendencies and her lack of trust in people. She characterized her relationships as hostile and painful, attributing the cause for these feelings to the conflicted relationship she had with her mother. Additionally, Lois revealed that she had a severe depressive episode which caused her to terminate her college studies. Several hospitalizations and antidepressant medications helped stabilize her fragmenting sense of self, but her relationship with people continued to be unsatisfactory. Understanding that Lois’ issues might be more effectively handled in group therapy, her therapist, while still seeing her on an individual basis, referred her to me (G.S.).

Following several preparatory individual sessions, Lois entered the group. Even though they had been expecting someone new, the ongoing group members were confused by her behavior in the initial meetings. Lois would interrupt others with hostile comments or tangential concerns but seemed to be unaware of the triggers to her quickly developing anxiety and rage. Group members probably would have found some way to offer the newcomer’s grace period, if not for Lois’ outbursts of anger. A vicious cycle was created as most people responded to her hostility toward them with a combination of anxious helpfulness, frustration or fear and some initiated attacks of their own.

My usual armamentarium of interventions was proving useless as I learned that interventions which would help to develop a mirroring self-object transference triggered Lois’ anxiety. Her anger would mount, yet I began to understand that it was discharged in the anxious hope she would not destroy me. At this juncture, due to insufficient understanding of the transference

configuration, little assistance from Lois to explore and increasing anxiety from within the group, the situation was deteriorating.

Somewhere in the midst of the chaos, which was threatening to engulf the harmony of the group, I found myself invested in and attached to Lois. I recognized in her a tenacious spirit and an unusual mind, which was not content with the status quo or the comfort of conformity. I decided to change the type of interventions that might enable Lois, together with other members, to remain engaged in the group process. Whenever I saw that Lois was becoming physically agitated, I invited her to walk a bit, leave the room if she had to and reminded her that she was free to move about the room if she felt the need. Also, each week I now provided her with a pen and several pieces of stationary. I encouraged her to write down whatever she felt was important. Soon she became the official historian of the group, and members began to count on her. She seemed to regard me with a mixture of respect and trust, and we now had a platform for exploration within the group arena. Premature termination had been avoided.

In our view, the underlying cause of premature termination is often a result of a history of self-object failures unexpectedly being repeated within the potentially re-traumatizing environment of the group. Within these often unknown patient reactive states, the “good enough” intervention is not easy to access. Even when the patient/therapist pair is well established and emotionally known to each other, the optimal response (Bacal, 1998) is frequently developed after previous failed responses. For those patients for whom verbal interpretation is not yet a therapeutically useful pathway, other intervention strategies must be employed.

In this paper, we have cast the act of premature termination as an attempted last ditch solution to a painful internal state. Verbal interpretations alone tend to be insufficient in bringing about the development of the self-object experience which allows vulnerable patients to profitably remain in group. In these kinds of cases, alternative forms of interventions have proven to be the optimal response. With a greater understanding of the possible treatment crises which underlie premature terminations and a greater repertoire of interventions, it is hoped that a larger number of patients who can benefit from group will have the opportunity to do so on a sustained basis.