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THERAPY? What is it?
Group Therapy with Dave MacQuarrie

Everything that we discuss together is confidential unless you give me permission to disclose it. Certain exceptions do exist. If you inform me of the possibility of physical harm to yourself or others or of something illegal, I may be required ethically or by law to break this confidentiality. If you have been referred to me by another professional, I assume your permission to discuss/disclose your ongoing status with that professional.

As recommended by the College of Physician and Surgeons of Ontario and where practical, I record sessions for documentation of attendance and conduct via digital video (no audio is recorded).

At present, I am doing exclusively group therapy with minor exceptions at my discretion. Generally sessions are at a fixed time, 3 hours each week. After 4-6 sessions together, we may discuss how we are working together and what we expect of each other.

During our work together, I invite you to keep a journal, a diary of the emotional issues that concern you. Such a journal helps to identify issues more clearly and writing often allows exploration with less pain. In addition, I invite persons to do a detailed autobiography and family tree of themselves; our therapy work is in the present, yet influenced by the past, and hence familiarity of the past is useful.

One aspect of our work is to help you resolve immediate difficulties. In broader terms, therapy involves helping you learn to be more alive, more fully human in the present moment and to increase your satisfaction with living.

During our work together, it is my intention to explore issues, often painful issues. However I cannot know the effect of this exploration on every client; if stressful, I therefore invite people to say, "STOP" whenever they feel they need to do so. This means to me that the person is feeling overwhelmed and unsafe --- my commitment is that I will stop whatever process we are exploring so as to re-establish safety.

I do ask clients to be responsible for themselves. Especially I am likely to challenge people who say they want something and are not willing keep commitments to be in action for what they want.

Independent of this work or as part of it, I may suggest a variety of other processes, led by myself or others, as a means of obtaining a different insight into your problems. Specifically I request that you attend my weekend Anger, Rage and Violation workshop as a way to familiarize yourself both with my general philosophy and options as to how we might work together --- although called Anger, Rage and Violation, it represents a major introduction to emotional process work (and likely is equivalent to several months of therapy work).

As a physician, my fees are likely covered by OHIP. Certain aspects such as major reports, telephone consultations and missed individual appointments (not canceled 24 hours prior) are not covered by OHIP and may be billed to you privately. Generally I do not bill for missed group sessions unless there is a contract of attendance that I have made with you.

If you have any questions, please feel free to ask them at any time. Specifically, if you feel dissatisfied at any time, please discuss it with me; my intention is to provide the best service of which I am capable but I also realize that occasional conflicts are inevitable.

How to get the most from therapy

People are often uncertain what to expect from the process of therapy. I have found most people approach therapy with the notion that they will describe their distress and somehow the therapist will assist them to create a happier, more functional life or relationship. Partially true.

After 20 years of clinical experience, I have arrived at some guidelines that can make our work more effective. First, I do have some expectations of you. I am not neutral. I have evolved principles and concepts that I believe give us the greatest chance for success.

Your job is to create your own individual objectives for being in therapy. Like a good coach, my job is to help you reach them. I have many, many tools to help you become a more effective person - they work best when you are clear about how you aspire to be.

To create the life you really desire, there may be some difficult tradeoffs and tough choices for each person.

The first tradeoff will be time - it simply takes time. This time will encroach on some other valuable areas - your personal or professional time.

The second area that will be challenged is energy comfort - it simply takes effort to sustain improvement over time.

The third compromise is comfort - emotional comfort - going out on a limb to try novel ways of thinking or doing things, listening and being curious. At the beginning, there will be an emotional risk taking action, but you will never explore different worlds if you always keep sight of the shoreline. In addition, few people are emotionally comfortable being confronted with how they don't live their values or being confronted with the consequences of their actions.

The fourth effort is even more difficult --- that is, improving your reaction to problems. For example, if you are hypersensitive to criticism, it will take effort to become less sensitive (and practice being criticized) instead of hoping the other will stop ignoring or criticizing.

A common yet unproductive pattern in therapy is making the focus be whatever problem happens to be on someone's mind at the moment. This is a reactive (and mostly ineffective) approach to working things through.

The second unproductive pattern is showing up and saying, 'I don't know what to talk about, do you?' While this blank slate approach may open some interesting doors, it is a very hit or miss process. Would you go to a business meeting without an agenda, especially if you were the  coordinator of the meeting?

The third major unproductive pattern is discussing whatever fight you are now in or whatever fights you had since the last meeting. Discussing these fights/arguments without a larger context of what you wish to learn from the experience is often an exercise in spinning your wheels.

Over time, repeating these patterns will lead to the plaintive question, 'Are we getting anywhere?' The likely answer is 'No!'

A more powerful approach to your therapy sessions is to do the following before each session:

1. Reflect on your objectives for being in therapy.
2. Think about your next step that supports or relates to your larger objectives for the kind of life you wish to create, or the partner you aspire to become.

This reflection takes some effort. Yet few people would call an important meeting and then say, 'Well, I don't have anything to bring up, does anyone else have anything on their agenda?' Your preparation will pay high dividends.

Brief Concepts

The following ideas can help identify areas of focus in our work and/or stimulate discussion between meetings. If you periodically review this list, you will discover that your reflections and associations will change over time. So please revisit this list often; it will help you keep focus during our work.

Attitude is Key

• Your attitude toward change is more important that what action to take.
• Effective change requires insight plus action. Insight without action is passivity. Action without insight is impulsive. Insight plus action leads to clarity and power.
• Everything you do works for some part of you, even if other parts of you don't like it.
• All significant growth comes from disagreements, dissatisfaction with the current status, or a striving to make things better. Paradoxically, accepting that conflict produces growth and learning to manage inevitable disagreements is the key to a better life and more harmonious relationships.
• You can learn a lot about yourself by understanding what annoys you and how you handle it.
• Problems occur when reality departs sharply from our expectations, hopes, desires and concerns. It's human nature to try and change others instead of adjusting our expectations. This aspect of human nature is what keeps therapists in business.
• Fear lets you know you're not prepared. If you view fear in that mode, it becomes a signal to prepare the best you can.
• Identifying what to do and how to do it is often easy to identify; the bigger challenge is to do it.
• The definite possibility exists that you have some flawed assumptions about other's motives. And that they have some flawed assumptions about yours. The problem is most of the time we don't want to believe those assumptions are flawed, certainly not my own assumptions!
• If you don't know what you feel in important areas of your relationship, it is like playing high stakes poker when you see only half your cards. You will make a lot of dumb plays.
• If you strive to always feel emotionally safe in life and get it, you will pay the price of becoming dull.
• Solutions, no matter how perfect, set the stage for new problems.
• Trust is the foundational building block of growth; you create trust by doing what you say you will do.
• We are all responsible for how we express ourselves, no matter how others treat us.
• Others are quite limited in their ability to respond to you; you are quite limited in your ability to respond to others. Accepting that is a huge step into maturity.

Tough Questions

• Asking good questions helps you uncover causes beneath causes.
• When a problem shows up, it's natural to think, 'What should I do about it?' A much more productive question is. 'How do I aspire to be in this situation?'
• If you want others to change, do you think about what you can do to make it easier?
• It is important to let others know what you think, feel and are concerned about? (Because they really can't appreciate what they don't understand.) But do not expect them to change simply because you have told then how you feel!!
• Can you legitimately expect others to treat you better than you treat them?

For optimal outcomes, please review these sheets every few months as our journey continues.

What is Therapy?

Most clients come to a therapist because they have some form of emotional pain. And they want to get out of pain!

That is appropriate and in many cases is the basis of the initial exploration that they and the therapist undertake. The pain comes with many names---marriage breakdown, anger, fighting with parents, alcoholism, and others. Seems like a huge problem relative to the size of the person.

As therapist, I do not know how to solve big problems; I can only handle small problems. So the exploration often becomes like a connect-the-dots puzzle; only at the beginning of the exploring we do not know what the dots are or where they are. Each session we may find a dot or two (small problems); useful, but only after a few weeks or months, do the connections between the dots start to make sense. Patterns begin to emerge and along with this come new possibilities, eventually leading to a deeper appreciation and resolution of the problem.

In most problems of my own life (to use myself as an example), I would like the world to change so that I do not hurt. Unfortunately this will not happen---at the very least I do not know how to change others so that it will.

At the same time, in most problems of my life, I do not recognize the ways in which I contribute to my own problems. As a child (usually), I have learned ways of being (thinking and feeling) and of behaving (doing) that kept me safe, as a child in a big scary world. As a child, these ways worked---but now as an 'adult', they no longer work effectively. The people with whom I interact are different; the situations of my life are different. New ways of being are required and I continue to do the old ways. This is the process of being an adult human being at an undifferentiated level, which is where most of us start.

The essential questions at this point are therefore:

• What is happening in my life that I hurt?
• How do I contribute to or create my own pain?
• What am I gaining by my 'negative' state?
• How am I willing to be different so as to allow others to be different also?

At a deeper level, what this is about is my becoming more aware of who I am and making better choices for myself, of knowing where I stop and the other person(s) begins. This is the process of developing an Ego, of personal boundaries and personal power, of high self-esteem (essentially all the same processes under different names).

And at a deeper level still, therapy becomes an exploration as to the nature of life, of transcending my Ego, of surrendering to life. Therapy is then a transition to spiritual journey, of humility, compassion and respect for all life. Often associated with religion, it is simply a deeper stage of life and need not involve belief systems, especially not religious dogma!

Pretty heady stuff---but what does it mean to be in therapy? What are the issues (the dots) that we together can work on in therapy?

For the most part, therapy is an exploration of being alive, of how you, the client, live your life, perhaps at many different levels simultaneously.

There are two big groups of issues:

• Those that you the client initiate --- anything with which you are dissatisfied.
• Those that I as therapist initiate --- anything that is part of being human.

So what does you do here? One approach could be:

• First, identify 'anything'---some component of your life with which you have pain or frustration or simply questions of what is happening to you. The more emotional intensity/anxiety involved, the more likely that the issue is significant.
• Second, identify what you already know about 'anything'---at this stage your description will be incomplete. If you could describe it completely, likely it would not be a problem; if you think you know what the answer is, likely you do not have the complete answer (else the 'anything' would be resolved).
• Third, identify what you would like to have different in your life around this issue, however impossible that might seem. It may be practical or not.
• Fourth and most important, be prepared to be stuck! If you could do steps 'a-b-c' in a way that did not lead to stuckness, you likely would not have an issue or, more commonly, are avoiding an issue but keeping it out of awareness.

Therapy is the process of examining what happens with steps 'a-b-c-d', of how you the client do the above, especially step 'd'! It is also an emotional process, not an intellectual process.

What might happen with this?

Maybe you will get stuck and we will examine how---what has actually happened to you at this point that you feel confused, angry, sad or whatever. Or maybe we will simply identify some human characteristic at this point. Then we will explore further to seek resolution of the issue in some manner, especially to seek greater awareness of what is happening. Increased awareness of your experience is the basis by which you make new emotional choices in your life.

I work with clients in group settings, largely because the growth process is then much more active. Usually, I work with one individual at a time but often ask the working client to interact with others, both to encourage emotional experiencing and to augment stuckness.

The interactions between us are usually verbal, usually with action of some kind. Often I may ask you to pretend, to fantasize or to act out a fantasy, or I may ask you to hold a pile of books or other objects or to draw a picture. In all of these are examples, I will be asking you in some fashion to have a larger experience of whatever the issue is for you.

In this work, I often encourage release of emotional energy. In saying this, I need to be very careful that you understand what I am saying---this is a society in which energy release is very frequently misinterpreted.

Energy release is NOT an excuse for you to hurt yourself or others. And there is some risk of self-harm, similar to any vigorous sport.

My basic acronym is 'No SAD' --- I will not intentionally scare (S) another human being, I will not attach (A) another biologic creature and I will not destroy (D) with my energy (usually my anger) that which I would not destroy when peaceful. This acronym gives me both safety and the scope to use my body and my voice as necessary to explore my internal state, releasing the energy that generally is so painfully stuck.

We as humans are not stuck in our conscious minds---if we were, it would be a simple matter of making new decisions and sticking to them. We are stuck in our other-than-conscious minds and in our bodies.

So, what happens? We start into an issue and get stuck. Often we are stuck, about to cry, choking on our voices, angry and stuffing our anger, shamed and feeling like a six-year-old again---many many reactions occur. There are many ways to handle this therapeutically.

It is my personal experience in my own therapy, my professional training and my therapeutic approach to respond to this with energy release, if appropriate for the client. So in a general sense and in the moment of emotional intensity, I may suggest processes for energy release, always on a voluntary basis.

Four aspects of these interactions are important for me. First, it is my personal belief/experience that this way of working is incredibly powerful in allowing growth, far more powerful than individual talking. Second, I am attempting to find a balance between augmenting the experience without overwhelming the client. Both the group setting and the mandate of each client to say "Stop" are very important in maintaining an atmosphere of trust in this work. Third, in this work, we are working at an emotional level. It is my personal belief that to over-intellectualize the need for energy release actually takes away from the benefits of the process.

Fourth, there are risks to this. There is some possibility of physical harm, again similar to that of any vigorous sport. You the client have a responsibility in choosing to act on my suggestions or you may know yourself of your need for physical release. I as therapist attempt to ensure safety and I can only guess at the risks for you. I ask you to be cautious if you are aware of problems or of risks to self at that moment.

Having started work on an issue together, likely we will then examine whatever experience has occurred. How is this (the feeling or human characteristic) familiar in your life and how have you learned to behave/feel in this way. How is it related to who you are as a unique human being? How is it related to unfinished business from your past? How was it protective of you in the past?

You still have this experience, this way of being---now! How does it protect you---now? What do you gain from it---now? What is its positive intent for you? (All human behavior is sustained in the present and has a current benefit, a positive intention for the individual, and a cost, an undesirable component or consequence. The benefit always exceeds the cost although we usually keep the benefit out of consciousness.)

Having gained some new awareness you are now in a better position to make choices. Perhaps you want to keep this way of being---therapy is not intended to make you do anything you do not want to do. Life has choices! Therapy is about consciously living our choices.

If you want to change this pattern, then we will examine alternate ways of being, new behaviors! What might be their benefits and their costs? How might they be instituted? Some of these new ways of being might be at a cognitive level; others might involve more direct emotional experiencing. The basic intent of all this is for you to reach a state where you authentically feel better with yourself and your life.

This is a lot to cover, so often the time goes quickly and we leave a lot of open ends at the end of the group. Sometimes I will suggest a task for the intervening week, a way of practicing the learnings of the session. As well, we have the opportunity to take up the issue again at a later time.

What is important in all this?

First, it is likely very risky! To use myself as another example, in my own struggles with important issues, I feel very vulnerable, afraid of criticism or judgment, afraid that I will break the rules, afraid that I will be abandoned. Perhaps these are feelings that I want to avoid or censor. Perhaps I have never before been aware of them. In any event, I need to trust my therapist---and this takes time to develop!!

I also need to trust the atmosphere/space where I am working, be it on an individual basis or in group. In group, I need to trust the other individuals with whom I am working. Trust is not an all-or-none phenomenon; it builds slowly and requires my risking being known by others and my learning to know others. If I had ideal trust (as client) at the start of my own therapy, I probably would not need to be doing therapy! As therapist, a big part of my work is to allow/assist trust to develop.

Conflict and misunderstanding does arise between therapist and clients; my hope is that at any time there is enough trust that we can discuss and negotiate new options for both of us, so as to allow our work to continue.

Second, I need to explore who I am. I need feedback, someone to be a mirror so as to show me who I am. I also need to be challenged occasionally (both as client and as therapist); else I start to believe my own truths excessively. I need to identify my own patterns and take note of what I gain from them as well as what they cost me. When I take responsibility for them, I have the choice to continue them or not! When I simply allow the therapist to identify my patterns for me, I don't have to choose!

Therapy is about learning, learning who I am and what is the nature of being human. There is a cliche that 'The hardest thing to learn is what I don't know because I don't know that I don't know it!' For me, there is much truth in this cliche, especially at the emotional level---frequently it is not safe for me to learn truth.

There is also a price tag to truth---to learn new emotional experience is often hard painful work and may well bring me into conflict with others, conflict that I wanted to avoid because of its pain to me or the other. For me, this cost to learning is compensated for by the long-term gains of being more fully alive! And more available to be in relationship with others effectively!

Third, I need to risk! A big part of therapy is to take on new behaviors as an experiment, to see if they fit. A truism of therapy is that 'I can act my way into a new way of thinking; I cannot think my way into a new way of acting!' This requires a certain amount of courage and endurance!

At some point in therapy, I need to start doing new behaviors, otherwise I am simply exploring (in thought or emotion) old ruts, old ponytracks!

There are a thousand ways I could be! Maturity means that I access these ways and it also means that I do so with integrity and commitment. At this point, I fully enter the process of spiritual journey; at some point in this, therapy ends and I simply join other journeyers.

If we are unable to work together using the above processes, what else might happen? I do not believe that it is possible for me to work with every person---therapy is simply too much of an art. And in so stating that, I neither make you nor myself wrong if we are not able to work together. To compare therapy to a grocery store, it sometimes seems like the client comes to the grocery store wanting to buy a TV set; grocery stores do not sell TV sets! Part of therapy is learning what I want in life and how to get it (especially that I need to be active so as to get it)!

To some extent, that is fine---simply an 'anything' as above. But if after a few months, we are no further ahead, then I will be honest as to what I perceive happening and suggest some alternatives. Maybe you the client need a different therapist, someone who works in a different way. Maybe you need individual therapy. Maybe you need some form of map as a guide to what you want. One type of therapy map is a communication course; there are many other maps.

All of this is negotiable; I simply want to work in a way that is satisfying both to you, the client, and to myself, the therapist. I am also more than willing to discuss any part of this statement so that you arrive at a stance where you have choice!

Modified slightly from Fred Richards, in 'The Helping Relationship' by Combs and Avila:

The path of psychotherapy is a journey in which two or more persons seek to discover one another and share one another's personal truth. To do this we will learn to risk disclosing who we are, to reach out to one another, to experience ourselves for who we are at the moment.

I cannot force you to change and grow. I will not tell you how to live. I will, however, invite you to grow, to become more aware, more loving, more able to live a richer, fuller life for which you accept responsibility.

Again, I will neither take responsibility for your life nor protect you from the pain and suffering of living. I will *help you* in your effort to change the perceptions and behaviors contributing to the unnecessary pain and suffering in your life. In regard to the pain and suffering that comes with simply living, I will *help you* to face it, accept it, and use it to grow. Sharing this effort with you will most likely help me to more creatively deal with the pain and suffering in my own life.

I will be present with you. I will be as honest, genuine, and real as I can muster the insight and courage to be. I will exert my will to not hide from you, even [if I feel an urge to do so when feeling helpless, confused and afraid].

I will be with you as long as I see you trying to grow. When I experience you as no longer trying to grow, I will share this with you. I will tell you my time left in life is precious to me and that I choose not to be with you. It is possible that for you my usefulness has ended and you perhaps need to *seek help* to grow elsewhere. We will talk about this impasse and hopefully not diminish our relationship when deciding whether or not to continue on the journey together.

I will not meet with you to help you become what is called a normal, adjusted, self-satisfied person. Nor will I *help you* to whine and wallow in the misery of your own making. I too have a tendency to do both of the above, so I will lovingly *provoke you* to share with me the effort to be more. I will *help you* to take charge of your life and to reinvent it if necessary.

I will invite you to tell your story, as honestly and truly as you are capable of telling it now, perhaps more intimately than you have ever disclosed it to another human being. I will not share your story with others unless you request I do so. I may decide to tell you part of my story when I believe it is appropriate and helpful to do so.

I will say hello to you as honestly as I know how, but my commitment is to encounter you in such a way that you will someday decide to say goodbye. It is my hope we will say hello and goodbye as authentically and humanly as persons like ourselves are capable of.

In a sense, I will *help you* to die, to leave behind outgrown and worn out ways of being, believing, and behaving in order that you can renew yourself and become a new person. To surrender and let go of the old and embrace the new is often a painful and joyful experience. I will not run away from the fullness of either your pain or joy.

I have myself learned that much of our suffering and misery, when seen and understood, can evoke laughter. There are times I may laugh at both you and myself. There are times when you may laugh at yourself and me. Hopefully there will be times when we can laugh together. If we can share this laughter, there's a chance we will help one another free ourselves to grow and live.

These pages are to inform you of some of the options and possibilities that may occur during our time of working together. Please review them every few months as our journey continues.

Norms of my Groups:

To the best of my ability,

1. I will attend full sessions, arriving promptly for the beginning of each session.
2. I will adhere to the ground rules listed below.
3. I will give verbal or written notice of my intention to be absent from the group for more that three consecutive sessions.
4. I will attend a final session (for discussion, feedback and closure) during which I indicate (at the check-in of the group) my intention to leave the group on a permanent or semi-permanent basis.
5. If I am unable to keep these norms with the group, it will be assumed that I have terminated with the group.
6. Dave will provide group attendance records every few months so as to explore attendance as necessary. Such list will include first names of group members, phone numbers (e-mail if available) and attendance records.

Purposes of my being in a Therapy Group

1. To challenge myself and others regarding what shows up in the performance of my life.
2. To learn the skills of dealing with the pain of life.
3. To do the work of growth to manage these issues.
4. To celebrate life, both its pains and its joys.
5. To practice the following ground rules (to the best of my ability, not to perfection).

Cautions to my being in a Therapy Group:

Be careful!! --- you may get what you ask for!

1. With significant change work, there is an inherent risk of temporary confusion after a session.
2. With significant energy release work, I may not be in good physical shape. I need to be careful.
3. With significant change, other persons will probably object to my change, even my healthy changes.

Ground Rules for my being in a Therapy Group:

1. I will not scare, attack or destroy inappropriately (no SAD, absolute ground rule).
2. If told to 'stop', I will stop (absolute ground rule).
3. I will keep confidential what I hear --- I am free to tell my own story.
4. I will practice listening to others --- seeking what meaning is occurring in their lives.
5. I will practice listening to myself --- seeking awareness of my own truth.
6. I will speak I-language, not U-language; I will not 'should' myself or others.
7. I will deal with my energy directly to the best of my ability, rather than by avoidance.
8. I will risk being known, revealing my limitations so as to expand my options.
9. I will not drive myself from the property when unduly upset with the events of the session. If I or anyone else believes myself to be unsafe in driving, I will agree to alternate transportation.

To all my clients...

Please be aware that the nature of my practice is that of psycho-education and long-term psychotherapy. If my clients are in crisis, they are free to call me at any time (519-942-0860) but be aware that crises usually occur because of poor long-term management of life issues. I am not a crisis management center nor do I have a backup service for my therapy clients.

If you are unable to contact me and you are in crisis, please go to the nearest emergency hospital so as to access appropriate crisis services.