INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 64 (4) 2014

RUTAN
45+ YEARS OF GROUP PSYCHOTHERAPY

Things I Have Learned:

45+ Years of Group Psychotherapy

J. SCOTT RUTAN, PH.D.

The noted humorist Dave Barry, in looking back over his life
and thinking of things he had learned, said one of the things he
learned was that “There is a very fine line between ‘hobby’ and
‘mental illness’” (1998, p. 182).
Following in Dave Barry’s path, I would like to look back over
the 45+ years I’ve been practicing group therapy and see if there
is anything to be learned by what I have learned over those years.

IN THE BEGINNING

I was born in 1940, a tumultuous time in the world. WWII was

just beginning, and the world seemed a scary place. It was also
the time when the practice of group psychotherapy began. Some
trace the roots of group psychotherapy back to Joseph Pratt
(1906/1969), who treated his tubercular patients in groups at the
Massachusetts General Hospital in Boston, or to Gustav Le Bon
(1895/1920) in France and William McDougall (1920) in Eng-
land, both of whom studied large group behavior.
The fact of the matter is that group therapy as a treatment mo-
dality really began in the 1940s in response to the vast numbers
of mental health issues in the soldiers fighting in WWII. Plato
noted in The Republic that “necessity is the mother of invention.”
The number of soldiers requiring psychotherapy so dramatically
outnumbered the psychotherapists in the field that a creative re-
Dr. Rutan is Senior Faculty, Boston Institute for Psychotherapy.

555
556 RUTAN

sponse was needed. In those days, we didn’t use the acronym

PTSD—we said instead they were “shell shocked” or “battle fa-
tigued.” So group psychotherapy was instituted purely as a practi-
cal means of providing service to more who were in need. There
is a famous memo from William Menninger, Director of the Psy-
chiatry Consultants Division in the Office of the Surgeon Gen-
eral of the United States Army during WWII, in which he wrote
to his physicians in the field, “Group therapy has been found
to be helpful. Henceforth you will practice it.” (And you must
remember, psychotherapy in those days was a highly individual-
istic, rather secretive and private enterprise conducted only in a
dyadic relationship.)
As these young, largely inexperienced doctors, nurses, and
medics began to work with their patients in groups, they began
to see that groups had particular effectiveness as a treatment mo-
dality. And thus group therapy came to be.
I began my psychotherapy practice in 1966 in the heyday of
the psychoanalytic movement. Actually, I began my practice just
after the heyday of classic psychoanalysis. The 1960s were marked
by the modification of classic concepts by more flexible theories,
usually referred to as “psychodynamic theories.” And many of the
modifications to classic theory were actually stimulated by the
flourishing interest in various types of group therapy and growth
groups, all of which documented the importance of relationship
in healing and change.

Life Was Simpler

In many ways, life was simpler for therapists when I began. Pa-
tients were plentiful. We were not bound by the dictates of the
best-selling work of fiction, The Diagnostic and Statistical Manual
of Mental Disorders. Rather, we clustered individuals into one of
three categories.
• Thought disorders: Those whose thoughts are disturbed; in
other words, our psychotics, our manics.
• Mood disorders: Those whose feelings are disturbed; in
other words, our depressed and anxious.
 45+ YEARS OF GROUP PSYCHOTHERAPY 557

• Character disorders: Those whose fundamental way of

being is disturbed; in other words, our borderlines and
narcissists and sociopaths.

Those were exciting days. The general public believed in psycho-

therapy and they flocked to it. Insurance did not interfere with
the process because mental health issues were considered educa-
tional not medical in nature (even though the early practitioners of
group therapy were MDs, medics, and nurses on the battlefield).
If I began my practice as classic psychoanalysis was fading, I
began in the halcyon days for group therapy:
• In 1969, one of the most popular movies of the day was
Bob & Carol & Ted & Alice, which featured two couples who
learned in their encounter groups to be utterly honest, and
they practiced absolute honesty on a weekend…with disas-
trous results.
• In New England, NTL (National Training Labs, fathered
by Kurt Lewin and Ken Benne) were very popular and
were primarily focused on making groups more efficient.
They did a lot of work with businesses.
• In Chicago, Carl Rogers was very involved in sensitivity
groups, where the focus was on sharing feelings with oth-
ers.
• By the 1970s, the Werner Erhard Sensitivity Training
Groups (EST) were flourishing. EST was based in Esalen,
California, but Encounter Groups were happening every-
where.
• Gestalt (Fritz Perls) and Transactional Analysis (Eric Ber-
ne) were enormously popular, and both were group based,
though in both cases the group was more an audience for
individual work than a real group.

I do not know of a group therapist in those days who could not

easily fill a therapy group. For many years, I ran 10 groups a
week. As I gained more experience and became seen as “senior,”
I and all my senior colleagues could guarantee that if we accept-
ed a student as a supervisee, we could make sufficient referrals to
fill his/her practice.
558 RUTAN

My Introduction

I was introduced to group therapy in an ideal way—as a silent ob-

server. I had the rich opportunity to observe three very different
group therapists, sitting as a silent observer in their groups for a
year each. I learned a great deal from those experiences. Four of
the most important things I learned were:
• The ability to bear strong affect without having to act.
• A variety of leadership styles can be beneficial. (Groups
are like tapestries.)
• The group itself is the healing agent and the leader’s role
is to make it a safe enough place to become so.
• A good group therapist is not a group leader, but rather a
group follower. “I have to follow them, I am their leader”
(attributed to Alexandre-Auguste Ledru-Rollin).

This was such a powerful learning experience for me that I have

been observed by students in group therapy for decades. At first,
all my private groups had a single observer who agreed to at-
tend for a year. Then, as I began to have more mental health
professionals in my groups, that became untenable. But I’ve had
ongoing groups that are observed for over 40 years, the first 20
with Anne Alonso at the Massachusetts General Hospital, and
the latest for over 20 years at the Boston Institute for Psycho-
therapy with Sara Emerson, then Nina Fieldsteel, and currently
Annie Weiss. It is not because I believe observing me at work is so
special, but rather because the opportunity to see ongoing group
therapy is so special. More can be gleaned from the gaffes I’ve
made than from the moments where I actually think I know what
I’m doing.

My Historical Roots

I remember from the very first moment that I sat in a therapy

group as an observer feeling, “I am home!” This was a modality
that felt real and alive and powerful.
My father was a musician—he was the timpanist for the Chi-
cago Symphony in the 1930s, but his first love was jazz. I can
recall many evenings when musicians would end up at our home
 45+ YEARS OF GROUP PSYCHOTHERAPY 559

late at night and early into the morning, after their “gigs” were
over. And they would play. Some great musicians were in those
late night improvised jam sessions. One thing I learned from that
experience was that the most famous or even the most talented
musicians did not necessarily make the best music. For those late
night sessions to produce really amazing music required a kind
of cooperation, sharing, and interplay between the participants.
Perhaps it was the young boy’s spellbound observing of those
lively “groups” that set the stage for me to feel so comfortable
in groups. Or perhaps it was the various sports teams or music
groups that I was a part of as I grew up. Indeed, we all participate
in many groups, beginning with our families, and I suspect our
experiences in those groups influence how comfortable and opti-
mistic we are about therapy groups. Whatever it was in my case, I
knew group therapy was going to be a very important part of my
professional life.
But you cannot just put together a group and assume it will be
helpful. There has to be a theory to guide you, since our theory
is our roadmap to our technique.

PSYCHODYNAMIC THEORY

As I said, psychodynamic theory was the theory of the day, and

most early group therapists tried to meld that theory and prac-
tice together. Even Gestalt therapy and transactional analysis
were founded by psychoanalysts who, despite evolving quite spe-
cific techniques, still adhered to fundamental psychodynamic prin-
ciples—for example, believing in the unconscious.
Nonetheless, despite the immense popularity of both group
therapy and psychodynamic theory, the two did not play well to-
gether. There was a tension between psychoanalytic theory and
group therapy. Analytic theory valued transference above all else,
and many analysts felt pure transference was compromised by
the multi-person field in group therapy. Further, the sterile ex-
pert-object atmosphere of a psychoanalytic dyad did not translate
well to the highly personal context of a therapy group. It is very
difficult to remain a “blank screen” in a therapy group (like a
chameleon climbing onto scotch plaid).
560 RUTAN

Ironically, as I mentioned above, in some ways it was the spec-

tacular growth of group therapy that forced a rapid review and
modification of some major aspects of psychoanalytic theory.
Those of us who practiced group therapy were immediately
aware that transference was not dented at all in a multi-person
field. What really happened was that we got a broader view of
transference; not only did we have occasion to see how our pa-
tients might misperceive us (the parent or authority) from their
past learning, but we also got to see how they misperceive others.
That is, we not only had access to their vertical transferences, but
to their horizontal transferences as well.
Let us examine some of those primary tenets of psychoanalytic
theory and see how they play out in group therapy.

The Unconscious

Ah, the unconscious—the touchstone of psychoanalytic theory.

All theories begin with a leap of faith. For example, the empirical
method begins with the leap of faith that repeatability equals truth.
Psychoanalytic (or psychodynamic) theory begins with an even
larger leap of faith—there is an “out of awareness” world in all of
us, a world where important memories and feelings are stored
lest they otherwise overwhelm and damage us.
By its very nature, this unconscious world is hidden from us, so
the task of discovering it is no trivial matter. Classically, it was be-
lieved that an utterly dispassionate analyst was required, an inde-
pendent expert who would analyze the patient. The therapist was
considered an uninvolved scientist studying his or her subject.
There are a few windows into the unconscious.
• Transference [Janet Malcolm, “We must grope around for
each other through a dense thicket of absent others” (1981,
p. 6).]
• Slips of the tongue
• Dreams [The Talmud, “A dream unexplored is like a letter
unopened.”]
• Free association (group process), which suggests that as-
sociations are anything but free!
 45+ YEARS OF GROUP PSYCHOTHERAPY 561

The Problems

There were also problems attendant to the flourishing of classi-

cal psychoanalytic principles, which, as Eli Zaretsky (2008) noted,
were suffixed with religious-like charisma and zeal. Unnoticed at
first was a rise in narcissism and self-absorption. Now one was
understood as less a member of a family, or indeed as a member
of society, but rather as a distinct individual with a complex in-
trapsychic world that often took priority over social obligations
or roles.

The Modifications

The 1960s and 1970s were exciting times in the psychodynamic

world. There was a tremendous infusion of new and dynamic
modifications to classical theory. The work of Jerome Frank, Har-
ry Stack Sullivan, Otto Kernberg, Hans Kohut, Jacques Lacan,
Sandor Ferenczi, and many others began to recognize the impor-
tance of the therapeutic relationship and impossibility of a thera-
pist remaining aloof and being merely an unbiased “analyst.”
Thus began the exposure of what had largely been a “psycho-
analytic secret”—that analysts were for the most part not nearly so
“uninvolved” as they purported. Freud took his patient Ferenczi
on family vacations and on occasion loaned his patients money.
He routinely invited his dog into analytic sessions, though never
discussing that or considering that it might have some meaning
to his patients.

Use of Self

Perhaps the most exciting changes in technique in our field re-

volve around how we use our “self” in the process. Certainly, this
is vastly different than Freud conceptualized the role of the ther-
apist. There has been a rigorous attempt to bring the “psycho-
analytic secret” into the open. That secret is that even the most
conservative analyst does care for his or her patient. If not, the
patient will not get well.
Early in our careers, we tend to follow rigorously the dictates
of our supervisors and teachers. I remember being amazed at
562 RUTAN

how my supervisors seemed to have marvelous phrases and meta-

phors to capture what was going on in therapy. And I remember
using a particularly catchy phrase that a favorite supervisor had
mentioned regarding one patient, with all my patients the follow-
ing week. It seemed to work with all of them.
And I remember a cataclysmic failure on my part due to follow-
ing too rigorously what I thought to be the teachings of my first
group supervisor. The first group I ran was at the Boston Uni-
versity Counseling Center and was composed of college students.
On my way to the second meeting of the group, I was crossing
the street and up beside me walks a lovely young coed member
of the group. She greets me cheerily… and I’m paralyzed. First,
she addressed me as “Doctor” Rutan, when I did not yet have my
Ph.D. And for some reason I was embarrassed about admitting
that. Second, I seemed to remember being taught that I should
show absolutely nothing of my true self since that would interfere
with transference developing. And we all know we want to grow
huge transferences. And finally, just to top things off, she was re-
ally attractive (and I was a late-20s male).
So, attempting to follow instructions as a good psychodynamic
therapist, I said nothing. I just looked straight ahead. And the
young woman, exhibiting far more maturity than I, had the good
sense to never attend another group meeting.
It is important in understanding Freud to keep in mind both
his progression and the world in which he lived. His was an era
reveling in empiricism, and for Freud’s revolutionary theories
about personality to gain any acceptance they had to be couched
in empiricism. Thus, it was natural that Freud viewed the task
of the analyst as a scientist, an acute observer. The primary ac-
tivity of the analyst was to offer interpretations of the patient’s
free and uncensored associations. In a sense, interpretation for
Freud is translation, translating the seemingly chaotic renderings
of free associations into meaningful constructs about the uncon-
scious world of the patient. As Freud said, “The doctor should be
opaque to his patients and, like a mirror, should show them noth-
ing but what is shown to him” (1912/1958, p. 118).
Clearly the purely analytic model of the therapist was a dif-
ficult fit in group therapy, though some did use it. Alexander
Wolf, the first Distinguished Fellow of the AGPA, essentially did
 45+ YEARS OF GROUP PSYCHOTHERAPY 563

Figure 1. Leadership Axes.

Reprinted with permission from J. S. Rutan, W. N. Stone, & J. J.
Shay (Eds.), Psychodynamic Group Therapy (5th ed.), p. 178. © 2014
Guilford Publications.
individual analysis with the members of the group…like a chess
master playing eight games at the same time. At the award cer-
emony for his Distinguished Fellowship, he said, “Frankly, I have
always preferred man over mankind.”
Others, notably the “group-as-a-whole” therapists, who follow
in the steps of Wilfred Bion and the Tavistock Clinic in London,
adopt a very distant role as leader. I have come to see a variety of
leadership axes that leaders employ (Figure 1).

My Path

• Focus on horizontal transference, not vertical transference.

It has been my experience that our patients come primar-
ily because of difficulties building and sustaining relation-
ships. True, some of those difficulties stem from vertical
transferences (e.g., gleaned from parents), and thus we do
work to clarify those feelings as well. But the true focus,
especially in the interpersonal world of group therapy, is
on peer relationships.
564 RUTAN

• Patients come with solutions, not problems. Depression,

anxiety, eating disorders, substance abuse, and even psy-
chotic episodes, understood from a purely dynamic per-
spective, are not the problems; they are the solutions. And
our job is to join with our patients in the detective work of
discovering what problems are so grave that they required
such costly solutions.
• Focus on intimacy, not conflict and/or aggression. For
Freud, sex and aggression were keys to personality growth,
development, and pathology. But he and his followers
focused much more on aggression and dysfunctional sexual-
ity. And nowhere was the primal drive for intimacy given
full credit or attention. Modern patients have much more
trouble with intimacy than with aggression.
• It’s all about the relationship. Lester Luborsky documented
in 1985 that the ability to form a relationship with a
patient is the major criterion for predicting a successful
outcome.
• Your “self” is your most important diagnostic tool and
therapeutic divining rod. Don’t rob your patients of your
raging or sexual or bored feelings—they worked hard to
invite them. (How you use those feelings in the service of
the therapy is delicate, but don’t deny the feelings.)
• Patients are always doing their best to be in relationship,
not out of it. This is the key to building empathic relation-
ships with hateful patients. (I often consider such patients
as using the “skunk defense.” The skunk is not an inher-
ently stinky animal; it stinks up the joint when it is fright-
ened and feels endangered.)
• The notion of “resistance” has been largely misunder-
stood, in my opinion. No patient resists therapy, or
growth, or success. They resist expected pain. And, again
using your “self” as a diagnostic tool, one of the clearest
signs of resistance is boredom or frustration in the ses-
sion. Don’t chase that feeling away. Listen to it and learn
from it. (Devise your shopping list or compose a new
article while you’re sitting there.) Remember, this is like a
 45+ YEARS OF GROUP PSYCHOTHERAPY 565

Geiger counter telling us that we are on important ground;

the patients or group are feeling fearful and thus putting
on the brakes.
• I have also learned that it is dangerous to practice in
isolation. Our patients become too important to us; they
become our social network. Therapists need community.
Those who are in solitary private practice have to work
that much harder to find a community—peer supervision,
a vibrant local association.
• We do not know more than our patients about what is
good for them (except in very few, very rare instances).
Advice giving is rarely helpful. Guiding people to be aware
of underlying motivations for behaviors and/or percep-
tions is far more helpful.
• Do not concern yourself with “secrets.” They are bor-
ing. What is really interesting is why some things are kept
secret.
• And as a striking note of reality, the younger profession-
als reading this today will be presenting, in 40 years, what
they have learned in the past 40 years. And they will
START with where I am ending. This should lead all of
us to have a deep humility about what we think we know
today.

To make this point more dramatically, here’s one of my very fa-

vorite quotes, from that wonderful cultural icon, Men in Black, in
which a man discovers that aliens exist:

1,500 years ago, everybody knew that the Earth was the center of
the universe. 500 years ago, everybody knew that the Earth was
flat. And 15 minutes ago, you knew that people were alone on this
planet. Imagine what you’ll know tomorrow.
—Agent K

How does this relate to building sustainable groups? I’ve found

that if I keep those guiding principles in mind, and if I have a
clear and mutually agreed upon set of group agreements, then I
can form groups that will become cohesive, which is the mark of
a working group.
566 RUTAN

References

Barry, D. (1998). Dave Barry turns 50. New York: Crown.

Freud, S. (1958). Recommendations to physicians practicing psychoana-
lysis. In J. Strachey (Ed. & Trans.), The standard edition of the complete
psychological works of Sigmund Freud (Vol. 12, pp. 109-120). London:
Hogarth Press (Original work published 1912).
Le Bon, G. (1920). The crowd, a study of the popular mind. New York: Fis-
her, Unwin. (Original work published 1895)
Luborsky, L. (1985), Therapist success and its determinants, Archives of
General Psychiatry, 42, 602-611.
Malcolm, J. (1981). Psychoanalysis, the impossible profession. New York:
Knopf.
McDougall, W. (1920). The group mind. New York: Putnam
Pratt, J. H. (1969). The home sanatorium treatment of consumption.
In H. Ruitenbeek (Ed.), Group therapy today (pp. 9-14). New York:
Atherton Press. (Original work published 1906)
Zaretsky, E. (2008). Narcissism, personal life and identity: The place of
the 1960s in the history of psychoanalysis. Psychoanalysis, Culture &
Society, 13, 94-104.

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