Welcome to Group

Group therapy, for me, is sort of like travel. Sometimes the experience is worse than you’d like to admit at the time, but it’s OK, cause you’re not doing it for the immediate experience. You’re doing it to have the experience, by which I mean to possess it. And once you possess it you can use it however would be useful to you.

In (I think) 2010 I went on a tour of the great national parks out west with two of my best friends. We were all broke, so to save money we brought a tent to camp out where we could and, barring that, we planned to sleep in the car. We ended up doing the latter more times than the former, and it was tight and hot and sweaty and awful and often the three of us barely slept. And I’m afraid that sleep deprivation is one of the easiest possible ways to make people touchy and combative. Naturally, we argued the entire two weeks, and one of my friends and I almost came to blows. The landscapes were incredible, everything I could have hoped for, and the moments when I was just taking them in were wonderful. But we fought so much and I was so exhausted that I would be lying if I said the actual experience was enjoyable.

But now? Now I can look back and enjoy the memories and process only the times we got along and had fun. It was a great trip! I set aside memories of the fights, I hold onto the sight of Devil’s Tower and the deep black fur of the bear that walked right up to our car, and I know it was a great trip. That’s not dishonesty. I wouldn’t even call it nostalgia. It’s just recognizing that the present, lived reality of an experience is not the only legitimate criterion for the value of that experience. You can take experiences now and process them later.

It’s the same way with group therapy: the actual process, if I’m keeping it one hundred with you, was not generally enjoyable, and in fact was aggravating fairly often. Most often group was just kind of boring. But in time I have learned to look back on it and to recognize that indeed, I was healing, and indeed, I was learning. It’s a perpetually awkward interaction between people who don’t know each other, and in many contexts patients shuffle in and out so it’s hard for familiarity and camaraderie to grow, and often enough people are there who don’t want to be there, and no individual moment seems to matter. But it’s also a way to let your problems out into the air among other people who have problem of their own, which simultaneously legitimizes your problems and puts them in perspective. And personally I found that, as with our trip out west, in time my initial discomforts and anxieties about it have been forgotten. What remains, I hope, will be the equanimity that grows when we are led to remember that all of us labor under our own special pain.

I want to emphasize, though, that it’s OK to find the actual experience of group therapy to be a big pain in the ass. This isn’t Protestantism; you can just go through the motions without believing, it’s OK. Group is a very strange thing. Therapy is a process that we associate with sharing our deepest secrets and most embarrassing pathologies with one person, legally obligated to maintain confidentiality, and yet we attempt something similar with a group of strangers we have no reason to trust. Nobody divulges everything in group, of course, and sometimes you’re directed not to talk about certain things. But to one degree or another, the whole process is built on your willingness to lay out explicitly the stuff that you’ve tried so hard to keep secret. It’s intentional oversharing, prescribed oversharing. And that can be both terrifying when it’s your turn and boring when it’s someone else’s. I’m just trying to be real about the process, as psychiatric medicine in popular culture ping pongs between being sensationalistic and prurient in some tellings and filled with sentimentality and phony uplift in others. Being psychotic is dramatic. Being treated for a psychotic disorder is boring. I’ve been in a handful of programs in my life and the vibe resembled nothing so much as the DMV, or the registrar’s office at a state college.

Here, I’ll do a little oversharing of my own. My mental process in group, at least as I remember it (it’s been a few years) goes something like this:

Well, here we go - I don’t know what I should say, I have nothing to say and way too much to say, I don’t want to rehearse, everybody else rehearses, I want to be real - Dr. Dickhead is explaining the rules in his dull monotone, like we haven’t already done this together a half-dozen times - Debbie’s on about her bad knee again; Deb, I sympathize, but no one here is a rheumatologist - Michael’s doing well, he’s so low-key, I don’t get why he’s in here - I should really get into rock climbing when I get out of here, it looks cool and those guys are in great shape - shit, shit, I was so far away and it was probably so obvious, I should pay extra close attention to Paula - you know Michael’s not a bad guy and I’m not his doctor, I shouldn’t question his diagnosis - Daryl doesn’t want to talk again, Dr. Dickhead says he should, what else is new - oh shit it’s my turn, shit, OK, here goes - shit I didn’t talk about most of what I wanted to talk about, and Michael kept talking over me and I hate that dude so much - Cathy’s not doing good, I should save her - oh, Christ, Craig, here we go, same old speech, yes yes Craig, your mother, yes, you were deprived, yes, you’re aware that we’ve all been through some shit right, oh here we go, he’s making the turn from the part where he talks like the world’s most beleaguered man to the part where he brags about how he became the country’s third biggest jet-ski dealer through nothing but gumption - oh good yes please quote Tom Landry again, thank you Craig - Michael just rolled his eyes at Craig, I knew I liked that dude - it’s Sara’s turn, everybody likes her and everybody’s scared for her, it makes you feel so powerless - half the people are crying and I’m not, am I a broken person, I don’t want to be the kind of person who doesn’t cry - OH FOR FUCK’S SAKE CRAIG, NOT NOW, THIS IS NOT THE MOMENT - thank you for your gentle wisdom, Dr. Dickhead - oh it’s Sid’s turn, he’s a gambling addict, he has the best stories - Paula wants to bone Sid, I’m pretty sure - my neck hurts - oh, shit, we’re done already, it goes so fast - no, thank you, Dr. Dickhead

I hope that doesn’t make me sound like a complete asshole. I know that each of these imaginary characters is entitled to the same understanding that I have asked for from the world. I know I should not be so hard on “Craig.” And, to be clear, I would never vocalize any of this stuff. I’m just trying to make you understand that for me the process of therapy, in group or one-on-one, is a constant war with a conscious mind that tells me that nothing is happening, that it’s all pointless, and that if I can see someone trying to rewire my brain, it can’t possibly work. But then I look back and I find that the people who may have once annoyed me left an indelible imprint on my heart, even in our brief interactions. And, in time, I come to accept that I was not the weirdest, coldest, phoniest, least deserving, most inarticulate person in the room, that the doctors and the patients took me as just another hobbled person trying his best to put his life back together once again.

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I truly dreaded the stock photos I would find when searching “group therapy,” and I was not disappointed. Let’s do “what group therapy is not” with some of those.

It’s never this dramatic. Nice watch, though.

I’m sure group sometimes gets done outside but I’m guessing it’s just about always at one of those private no-insurance places that charge three grand a day for a bed.

People will occasionally hug or give a pat on the back, but it’s not a very touchy environment. Psych patients have a tendency towards germaphobia and sometimes the institutions have explicit no touching rules.

It’s not an Activia ad.

It’s not an opportunity to trade respiratory infections. Being able to smell every member of your group at once is probably not conducive to growth.

I looked at dozens of these and for whatever reason the people who style these stock photo shoots seem to think that psychiatric patients all dress like they’re trying out for the Land’s End catalog. So many muted pastels and formless neutrals. Sweaters like the lesbian guidance counselor at your high school would wear. Billowy shirts with giant sleeves, for the ladies, and drab button-downs two sizes too big for the dudes. I guess it’s not germane to our business here today, just weird.

Group therapy is not where you, the edgy bad boy protagonist, fight against the man. (In this instance by having weird hair stuff going on and blatantly breaking our rules about dressing only in clothes bought at the Gap in 1997.) For one thing there’s a decent chance you’re operating under a fat dose of quetiapine. Also your culture lied to you and mental institutions are not places where it’s cool to resist conformity or whatever. You’re not gonna be in a battle of wits with Nurse Ratched, you’ll be writing bad poetry and watching Murder She Wrote in the common room. Fight the power someplace else.

The guy on the left is vaguely menacing, right? I’m not making that up? Clothes are right in our cool and unthreatening color wheel sweetspot in this one though. Also, again with the touching! My experience is limited, I grant you, but I’m telling you I don’t think most people in group are looking to get touchy. It’s just not the vibe most of the time.

All of these neck-down shots - and there are very many in the stock photo galleries - are actually kind of appropriate. There’s a lot of studying the floor, in my experience. I’m pretty extroverted and I love to be social, most of the time, but something about group therapy can make it hard for me to look people in the eye. Then again these people appear to be holding a séance so maybe I would be too busy communing with the spirits anyway.

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Group therapy is not strictly an inpatient thing; I myself have done a little outpatient group therapy. (This is often part of an IOP, or intensive outpatient program.) But I have to guess that most people only ever encounter it in an inpatient setting. Which means that it’s behind the same high hard wall of American psychiatric medicine I have complained about in the past, the useless binary that divides the options into outpatient experiences that are not enough and inpatient institutions that many people fear will be too much. Underwhelming or frightening, inadequate attention or total submission to the surveillance of a complex and bureaucratic system, take your pick. There is a divide into two parts in the way we distribute psychiatric care, in this country, and between those two parts there’s this great big hole, and a lot of people fall in and suffer for it. Of course the rich have no such problem, and they can get a type of treatment tailored to their every need at institutions that have all the amenities of a luxury spa and are advertised that way.

There are great psychiatrists and great therapists out there. And a lot of people get good outpatient treatment and their lives get better because of it. (Eventually, I became one of them.) But too often our system presents people with no options for immediate and urgent care if they’re not perceived to be an immediate physical danger to themselves or those around them. Many doctors in our system seem to believe that inpatient treatment is only appropriate for the acutely psychotic patient. But there are those who need 24-hour support and monitoring even if they can maintain some level of lucidity, and that’s to say nothing of the fact that psychosis is not binary, or even really coherently scalar in a conventional sense. If you present as someone who does not meet the standards for hospitalization (according to a checklist put together by a lawyer who only cares about avoiding indemnity), then your reward for recognizing that you badly need help and seeking it in an emergency context is some bored and condescending asshole saying “the appropriate place for you is outpatient care.” Theb they show you the door. Then you have the pleasure of trying to navigate our medical insurance system while enduring a psychiatric crisis.

What if we lived in the kind of society where certain types of psychiatric medicine, the types that are now typically only afforded when people have already reached crisis and hurt themselves and others, were available on a preventative basis? I read all over the place that additional expenditures in preventative medicine could more than pay for themselves through avoiding later acute care. I don’t know what the actuarial charts look like, for psychiatric medicine specifically. But I do know that, as comprehensively humiliating as inpatient care can be, it can also present precisely the nurturing space that the suffering need, and it makes me sick in the heart to know that many people need priority care and constant monitoring but have no way at all to enter a facility, short of triggering the involuntary commitment process. And involuntary commitment can ruin your life.

Outside of the bigger picture, I think group therapy could be a great alternative for people who may well have never considered it, and who would have no practical access to it. There are ways to get access, true, if you live in the right place, if you have the right insurance, if you can get the right referral…. But there’s no obvious process for most. We could use more options for therapy in general. Getting into traditional one-on-one therapy can be very challenging. To quote myself

I have had deeply imperfect access to mental health care over the past two decades, given that this is the American medical system, but I have had superior access to most people. And I still have consistently struggled to get into therapy. I should have been in therapy constantly given my mental illness and my biography. But I’ve barely been in it at all. Consider immediately after my last hospitalization. I was highly motivated to get a therapist. I had time away from work to look. And I had access to NYC union health insurance, which is well-known to be strong despite years of erosion of benefits. What’s more, New York has one of the highest therapist/analyst/mental health professional densities in the world. I don’t have kids and my schedule was more flexible than that of most.

And yet trying to find a therapist was a nightmare. A truly discouraging number of places didn’t take my insurance or take insurance at all. Out of pocket costs that were cited were like $300 and up. Tons and tons of promising-seeming options were not taking new patients and several told me there were months-long waiting lists. Also, several told me that they were “not the right therapist to meet your needs” when I told them about my bipolar disorder and recent psychotic episode.

That last bit is particularly frustrating. Conventional psychoanalytic or CBT therapists often feel unqualified for working with people with serious mental disorders, and can decline to treat any patient they wish. Even some prescribing psychiatrists only seem comfortable pushing Vyvanse on unruly teens and Ativan on disgruntled wine moms. My complaints are not merely anecdotal, either. This report from the National Alliance on Mental Health details how hard and expensive getting mental healthcare can be.

I haven’t been in group therapy in years, and it’s hard to imagine what might happen for that to change. Unfortunately it would most likely happen if I was again admitted to a psychiatric facility, which I mostly dread and, on strange and quiet occasions, wish for. I’m in a bipolar support group, and it means a lot to me, but it’s not therapy, a point which the organizers are careful to make clear. I’m OK though. I worry for others. What I wish was that people who have been in one-on-one therapy for years and feel that they’ve run into a brick wall, or who dread searching for another new therapist, might have the opportunity to try group, as it’s a profoundly different thing. More discursive, obviously, but also less solipsistic, and an experience where the bargaining you do with yourself is more obvious and thus more honest. And it’s a constant reminder of what’s on the other side of this. Because the goal, one hopes, is the promise of a more humane treatment of others, and through them ourselves, as expanding our capacity for compassion reminds us that we need it as badly as anyone else. That’s the point, of group therapy and all other forms of psychiatric treatment, to forgive ourselves so that we might be better able to forgive others. Because we all deserve a little more patience, to be a little better understood.

Even Craig.