"…the group uses its own resources …. The members of the group … are engaged actively in the therapeutic process and they are not merely “recipients” of treatment as they so very much wish to be.”
(Foulkes and Anthony, 1957, p. 82)
A few years ago I was invited to supervise group therapists in a large public clinic. All the group therapists were also dedicated and experienced individual therapists, as is customary in these clinics. I soon discovered that the groups were relatively small, and despite an abundance of patients and long waiting lists, the groups were diminishing. I realized that the patients in groups at this clinic had expressed dissatisfaction, and often requested individual therapy rather than group therapy.
In the supervision group we were trying to decipher the reason for this. The group therapists told the supervision group what had taken place in the group meetings, and then we found time for a reverie of personal associations of the other supervision group members (Berman and Berger, 2000). The patients in these groups were generally hardworking people, exhausted from life crises and long struggles. Some of them came from poor families and continued to experience poverty and economic and existential anxiety in the families which they built. There were men who could not bear the burden anymore, so it was carried by the women instead. There were women who had to bear the consequences of their neglected and now grown children, after years of over-working away from home. Most of them needed medical help. For some of them the group was designed to help avoid further hospitalizations due to brief psychotic episodes.
Our cumulative experience shows that at in some of the mental health clinics, including those which deal with treatment of severe post traumatic burnout, group therapy is a key factor in rehabilitation and recovery. Foulkes said that one of the insights which inspired him to found group analysis was his experience as an intern in a psychiatric hospital. During his night shift he sat with patients and saw how a spontaneous interaction between them created a rehabilitation processes. What explains the absence of therapeutic success and dissatisfaction of the patients with their treatment? In the supervision group we tried to find the answer to this question. Following reports of what had taken place in the group meetings, we heard a reverie of personal associations of the other members (Berman and Berger, 2000).
It was clear that the therapists felt compassion towards the patients in their groups and aimed to give their best to each of them. Usually the group meeting opened with a distress call from a particular patient who managed to talk first: "Yesterday I heard a motorcycle's backfire. It was like an explosion and all the trauma of the attack came back to me". The conductor immediately responded with an expression of empathy. The participant grasped this lead and described in detail the tough week he experienced: "My wife is not feeling well again. I told her to see a doctor but she doesn't want to, and she is also mad at me". A conversation between him and the conductor ensued, for about half an hour. The conductor turns to the other participants and invites them to respond. The participant who talked first receives two short responses - then, the two other participants demand the conductor's attention. One of them and sometimes each of them gain it. Usually, at the end of such a meeting one of the participants requests individual therapy or a referral to a psychiatrist for medication.
One of the female therapists in the supervision group said that a female participant in her group does not speak at all. She simply stares at the conductor from the moment the meeting begins. Her silent distress call is painful and powerful, and the conductor has difficulty looking away from her to turn to other participants, also waiting for her attention.
It seems that the conscious and unconscious wish of the participants is to establish a preferred dyad with the conductor as a form of an archaic wish for idealized relations with a parent. The patient-therapist dyad known to us from individual psychotherapy does not help and probably interferes with the creation of the "group". The "group" is based on a system of participants' relations and not on dyads. To be precise: the only possible dyads in the group are ever-changing dyads, which suspend the wish for a patient-therapist's preferred relations. In this sense, the "group" replaces the "personal".
In group Analysis the entire group is the therapeutic agent. “The group” is "The Therapist”. The first role of the conductor is to help the participants to create the interaction between themselves, and thus - to form a "group".
We can understand a participant's wish for a preferred dyad with the conductor: he is in distress, he feels lonely. He comes to the group with a prolonged sense of deprivation of attention. He wishes for empathy. Instead, he meets a group of "needy" strangers. He feels that the chance of having his needs fulfilled is threatened more than ever. The conductor becomes a disappointing object rather than a helpful one.
Group analysis offers an alternative option: While in individual therapy the good object (under positive transference) is mainly the therapist, in group analysis the good object is mainly the entire group (this can also apply to the bad object). The group offers a sense of belonging, which calms the anxieties of the participant and gives him time and a space. The changing identifications with others enable the participant to expand his self-experience. The resonance of the emotions within the group and the discourse about them deepens the participant's understanding of himself. The group invites the participant to giving-receiving relations in which he becomes a partner in his own and others' therapy. He can re-discover himself.
But what about the conductor? In the opening quotation about the main theme of this chapter, the conductor is not mentioned at all. Why? Because in group analysis, despite his therapeutic experience, his professional understanding, his availability to his patients, his or her most important role is to help the group members to develop and recognize their own resources. The conductor's recognition of the participants’ contributions and their mutual empowerment should be prioritized. In contrast, in the opening example, the therapists tried to give their best to each of the participants personally. Prioritizing a patient-therapist relations disturbs the founding of the "group". The participants were trying to establish a preferred dyad with the conductor and invested in it at the expense of creating group discourse. As much as the participants' distress increases, this investment will inevitably fail. The participant who manages to speak with the conductor cannot be satisfied - because he will eventually be interrupted (in order to mange to respond to at least one other participant), and because his turn will not return during the next meeting. A participant who does not manage to speak to the conductor may feel frustration, rejection and jealousy. In a therapeutic group, in the sense that I offer here, patients may feel more self-fulfilled, helped, and develop the ability to help others. (Paradoxically, the dedicated and compassionate conductor may increase hunger and frustration as he tries to be more faithful to dyadic therapy). Analytic group therapy is not individual therapy in the presence of others.
The "Group Entity" According to Group Analysis
First of all, the "group" in group analysis is an open and continuous system of interaction between all the participants of the group including the conductor. As the group develops, the participants share and respond to one another, through being attentive to what arises within themselves - and as a result - share again. Schlapobersky (1993) suggests the term "discourse" for describing the transpersonal chain-like associations that characterize communication in the group.
The system of interactions enables belonging and participation "… Being a respected and effective member of the group, being accepted, being able to share, to participate, belong to the basic constructive experience in human life " (Foulkes and Anthony, 1957, p 27).
Another aspect of the interaction in the group is "exchange" (Zinkin, 1994). When group members talk to each other and are exposed to one another's way of life and reactions, they give and receive aspects of experience that were missing for each of them. In the group, participants are exposed to different feelings and attitudes about each other. Some of those feelings and attitudes are not congruent with their own perceptions of themselves. Participants' self-perception is continuously challenged in the group. As a result, one's ability to contain different feelings and opinions grows. In other words: one's ability to contain "otherness" in a therapeutic group is improving and bears a benevolent effect on his or her close relationships. Participants also discover that whatever one says about someone else reveals some aspects of oneself. With the assistance of the conductor, the common belief in objectivity is transformed to the experience of inter-subjectivity (Mitchel 2000, Benjamin, 1988), and the risk of judging people is gradually replaced by self-reflection and empathy. Together, participants discover the meaning of reciprocity. Following the exchange in the group, participants feel that they become partners in building its therapeutic value. Their identification with other members help them to internalize ways of dealing with life situations in different ways. The participant dares to try and experience new behavior, he receives recognition (excited at times) of aspects within himself that he was unaware of, and he receives gratitude for his contribution to the other participants.
The participant learns to decipher his projections and gradually re-attributes them to himself. It is important to mention Foulkes' concept of mirroring and "Mirror Reactions" (Foulkes, 1964, 33-34). Unlike Kohut (1971, 126-132), Foulkes refers to the Other in the group as a mirror to one's rejected self-aspects. Looking at this kind of mirror means knowing oneself better.
The more abstract aspects of the "group", in group analysis, concern the matrix. As a metaphor, we can say that cars drive on roads. As they each drive, all of them have relations between them. The whole system is called "traffic" (Foulkes and Anthony 1957). This is also the meaning of the concept "the matrix" as describing the system of group interaction as trans-personal. "The matrix is the hypothetical web of communication and relationship in a given group. It is the 'common shared ground which ultimately determines the meaning and significance of all events and upon which all communications verbal and non-verbal rest" (Foulkes, 1964, 33-34).
Today, after the discovery of mirror neurons, it is clear that Foulkes was ahead of his time when describing the trans-personal interaction as equivalent to any intra-personal occurrence. His concept of resonance accurately describes what is explained today by the operation of mirror neurons (Foulkes 1977; Berman, 2012). Mitchell, when speaking about emotions he writes about the human interaction in similar terms to the idea “matrix”: "Affect is contagious, and, on the deepest level, affective states are often transpersonal. Intense affects like anxiety, sexual excitement, rage, depression, and euphoria tend to generate corresponding affects in others. Early in life, on the deepest unconscious levels throughout life, affects are evoked interpersonally through dense resonance between people, without regards for who, is feeling what" (Mitchell, 2000. p 61).
I suggest that the "group" and the "personal" are two concomitant modalities of human existence. However, the significance of the individual varies greatly following the concept of matrix and the recognition of "the group entity". Foulkes says: “Personally I believe that the multipersonal hypothesis of mind is nearer the true nature of events… I found the old theory of perceiving this in terms of individuals and their interaction as individual minds enclosed in each skull, interacting in the most complicated fashion with the others that this theory acted as a great barrier to my understanding” (Foulkes, 1973).
The individual within the same matrix is like a nodal point of communication, as the neuron is a nodal point of nerve conduction. Since the individual in the group, as a nodal point of communication, affects and is affected all the time, he becomes an open system.
Hence arises the unique therapeutic benefit of group analysis: imagine that the personal difficulties with which a man comes to therapy stem from the fact that he is "imprisoned inside his skull". If he is lonely, or suspicious, or angry and attacking, or vulnerable and introverted – the cause for all of these may be personal aspects of seclusion. Therefore, the entry of man to an open system can be the basis for change. The contribution of group analysis is the patient's transformation from a state of intra-personal introversion into a state of integration within interpersonal communication and affiliation.
In addition to all of this the participant receives in his turn a unique time investment from the participants and the conductor. This time investment reaches its efficiency peak only after establishing the "group". Yet, the main difference between this focusing and individual therapy is that after every kind of this focusing, and sometimes even during it, the group returns (with the conductor's aid), to the group meanings through resonance and mirroring. All of what was said during the personal work with one participant enhances the work of other participants.
Moreover, group analysis encourages the conductor to recognize typical forms of group anxieties, and mechanisms of defense (like Bion's basic assumptions (1961), Hopper's basic assumption of Incohesion: Aggregation/Massification) (2009): "…bi-polar intrapsychic constellations are associated with two types of personal organization: one, the "contact shunning" or "crustacean" and two, the "merger-hungry" or "amoeboid"(Hopper, 2012, p.XXXVI) Another perspective are the categories of interpersonal pathology, like the Deficiency Relation Disorder, Rejection Relation Disorder, Relation Disorders of the Self or Exclusion Relation Disorder (Friedman , 2013). "Using the complementary optic of multi-personal dysfunctions will not only improve indications for psychotherapy but also facilitate optimal contribution of the different therapeutic spaces"(p.166).
The contribution of Bion (1961), although not a group analyst, could be relevant here: according to Bion, each participant may make and act upon a basic assumption. (1961, pp 116) Therefore, I suggest that we should decipher the words of a participant as representing the group unconscious. We can elaborate the meaning of Bion’s words and argue that when any participant becomes aware that his words also represent the inner world of others – his experience of affiliation and partnership increases.
The forming of the "group entity" is a process and is a professional challenge for conductors. In this chapter I would like to focus on the conducting challenge which is, in my opinion, the greatest of all: the difficulty to give up the therapeutic dyad and replace it with group conducting.
The Challenge of Giving Up the Therapeutic Dyad
Some of the most prominent psychoanalytic theorists oppose any deviation from dyadic relations in psychotherapy. Although Freud himself (1921) saw the importance of social and group psychology, he was skeptical about the therapeutic benefit of “group therapy”. (Freud, S. (1926). Letter to Trigant Burrow 14 November 1926. Quoted in: J. Campos (1992)). Winnicott (Rodman, 1987) also expressed his concerns about groups in general. He believed that the group might uniformity of thought, become "grouping of supporters" (pp 45) impose and thus cause the participant to use more of his false self at the expense of his true self. I think that he was wrong. Group therapy, in my opinion, encourages just the opposite: it helps the participant to dare to express his true self in front of others Kohut (1984) believed that empathy is indivisible, in that any shifting of the empathic attention of the therapist towards someone else – might result in an empathic failure.
Let us recall the example I gave at the beginning of the chapter: One of the participants does not speak at all. She expresses her distress by staring at the therapist-conductor. What does the therapist feel in these moments? She feels great distress. She fears that any shifting of her gaze from the participant's gaze might be interpreted as abandonment by the participant. On the other hand, she knows that in due course she may cause the same feeling in other participants, who are waiting for her attention. In her counter-transference, she shifts from feelings of compassion to feelings of guilt. As a result, she may experience disappointment in her professional contribution as a group therapist. Indeed, even experienced group therapists who feel that their contribution is not successful are hesitant in using it again.
The group therapist who establishes the dyad of individual therapy in the group might deny his narcissistic need that may lead him to an omnipotent intention of satisfying the participant's narcissistic wish. An individual therapist, experienced as he may be, cannot satisfy the emotional and developmental needs of all participants at a weekly meeting. He cannot do it alone. Only with the combined therapeutic help of all participants in the group, only with the "group as a therapist", a meaningful psychotherapy may be possible. Omnipotent input of the conductor may bring the group to a narcissistic regression: the participant's narcissistic needs lead to an over-dependence, incapability and over-neediness.
The success of group therapy depends on a certain overcoming of the narcissistic wish and regression of conductor and patient alike. A conductor who knows his limitations can more easily recognize the ability of the group members to participate in creating the group's therapeutic value. This is no different to a mother's ability in seeing her child as more capable of coping, as not so lost, and as a partner in their own growth, and even as someone who helps her in fulfilling her role as a mother (Winnicott, 1963).
In Bion's (1961) view every dyad in the group is a function of an unconscious group cohesion around the basic assumption of pairing. According to the basic assumption of pairing, the group as a whole unconsciously produces within it a pair of members that engage in tight discourse. In these moments there is an active and self-centered pair, while the other members are silent and passive. The content of the discourse does not count. Pairing as a structure does. According to Bion, the unconscious wish of the group is that this pairing will give birth to an imaginary alternative to the group therapist. The illusion of the participant that salvation can come from any source other than himself, may result in a developmental arrest, which might prevent personal transformation. In Bion's view, only by turning to internal resources, while renouncing wishes for dependency, and overcoming difficulties and fears can patients benefit from psychotherapy.
The conductor is also subjected to unconscious group process. Therefore even a dyad of which the conductor is a partner is also under the influence of the basic assumption of pairing.
In this sense Bion and Foulkes talk in a similar language. Bion deals with building a working group through giving up any dependent illusion and replacing it by turning to internal resources. According to Foulkes the conductor is transformed from a focused idealized central figure to a partner in the group. The conductor deals with the active role of the participants, and in their partnership of creating the "group", he is included.
It is most likely that the conductor's avoidance of participating in the therapeutic dyad may be challenging, since it may evoke at the beginning, hard feelings in the group. It may stimulate insults and introversion. It may provoke anger and protest. The conductor must be able to endure it and contain these possible group reactions for the sake of the profound therapeutic benefit that may be achieved later. If the therapist prefers the creation of the "group entity" rather than investment in dyads, he/she can be empathetic with the difficulty that he/she imposes on the participants' by frustrating their wishes for dependency and exclusivity. He can understand their anger at his refusal to participate in their wish of salvation coming from the outside. After all, people who come to us for treatment may feel that their own attempts to change have failed in the past. They fear to fail again and hurt their self-esteem further. They may also fear that other participants have failed, like them, and can hardly be trusted as partners. The empathy of the conductor to the inner world of the participants and his understanding of their personal and collective transferences is very important at this point (Hopper, 2006-2007).
Comments on Technique
The avoidance of participation in the dyad does not require the conductor to remain silent - in the face of a participant's request to share his distress. The conductor can refer to the participant - briefly and with empathy. Yet, it is important that the conductor immediately appeals to other participants and avoids remaining in tight discourse with the particular participant. Appealing to other participants is intended to encourage them to share whatever arises in their mind in the light of the words of the participant who talked first.
The invitation of sharing on all that is said in the group is categorical, and is always in its place. Many therapists fear that turning to other members, especially when a participant is presenting his distress, may be experienced by him as a rejection. Moreover, other participants in the group also may protest if they feel the conductor has abandoned one of their friends. But in my experience it is not the case. Sharing feelings and thoughts helps the patient feel included and supported. Often, he inspires their wish to share. He also hears about their similar and different feelings and attitudes. And finally, the conductor can always go back to the patient to check if he really felt abandoned, and add a contribution.
As mentioned, the only possible dyads in the group are ever-changing dyads. One of the members of Foulkes’ mythological therapeutic groups said that while she spoke, Foulkes' gaze was wandering over all the participants in the room. He was always attentive to their resonance responses. Indeed, this is the recommendation for the conductor: always see all the others.
Additionally is Bion’s contribution - about the participant as spokesperson of the group’s unconscious mentality. According to Bion, each participant speaks of a theme common to all. Therefore the conductor can offer to the group the fact that the words of each participant in the room reflects the inner world of the rest of them. He is a spokesperson for the group as a whole.
Also important is the way in which any contribution from a participant in a group reflects aspects of the contextual society in which the group is embedded (Hopper & Weinberg, 2011).
Consider this very brief clinical vignette which illustrates these points:
Ann says in the group: "I cannot say it here, because I'm sure I'll be criticized for this, but the truth is that I do not want kids."
The conductor suggests: "Let us check what feeling it arouses between us. Maybe this feeling is also familiar to others."
Jonathan: "I totally agree with you. I think people give birth to children without asking them if they want to be born. It seems to me like an injustice in advance. I doubt if I will ever have children."
Gale: "I'm glad you say that. I gave birth when I was 20. I do not know why. I never heard my own voice. I did not know how to hear it. After a few years I realized that it was too early. I missed the good years when I could have been feeling my life. I love my kids. I cannot see myself without them today. Maybe I'll have time to live when they will grow up."
Silence. The atmosphere in the group is pensive and perhaps even sad.
Dana: "It's not just children. I want to have the freedom to think about what I want and what I do not want. It's about work. It's about marriage. I do not want to live like an automaton or according to what my parents were expecting."
David: "It's not just the parents. These are social conventions. I killed people in the army and I was almost killed myself. My friends were killed. For me social pressure is like a prison. I was never released from this prison".
Near the end of the session the conductor said: "It seems that What Ann said aroused a lot of similar experiences about what society may impose on each of us and how difficult it may become to choose one's own way. And to you Ann I want to say that I think you could experience here the possibility of acceptance from people in the process that you are going through".
Following the conductor's invitation, each of the participants expresses something very personal, a clue to an important aspect of their inner world. Over time each of the speakers would be able to continue their personal work. In the absence of the conductor's invitation to share - this important matter might not arise.
The Israeli Point of View
Besides individualism (and also narcissism), it seems that something in the mutual neediness, the importance of exchange, and the necessity of the investment in the group – is clearer to us, Israelis, at the beginning of our lives. To be precise: from the moment when each of us begins to be exposed to our social and political situation as Israelis. Moreover, "mutual responsibility" is a value in Judaism. Group analysis can add a professional contribution to this social and moral value.
We came from the ruins of the Holocaust, from diasporas and physical and emotional dangers. Israelis, Jews and non-Jews, are familiar with the experience of minority and the threat of exclusion and oppression. Even today we live in a reality in which there is a danger of attack and extinction from real enemies.
It seems to me that in this situation we have developed an understanding of the importance of the "group entity". We realize, probably, that belonging to a group gives security - no less than belonging to a family or a relationship. We need the group and the group needs us. I believe that there are two types of group affiliation. The first - based on the division of "Us and them" (Berman, Berger & Gutmann, 2000), which strengthens us and comforts us in threatening situations. Yet, in this sense, we belong to a polarizing society, which easily splits between groups and sub-cultures.
The second type of group affiliation is based on our wish for mutual and open universal affiliation. We understand relatively easily that the foreigner can become a relative and not necessarily an enemy. We tend to believe in the existence of a common language and contribute together to its constant creation. We use the group to learn to communicate more effectively and even to believe that a trans-societies' affiliation can, eventually, rescue us from the siege that threatens us from time to time.
Yet, in addition to the very real contribution of Israeli cohesion, it is advisable that we belong to an open society. Group analysis is based on the recognition of the personal, social and professional value of the inclusion of others. I believe we should be inspired by it.
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Entitativity is the degree to which members of a social group are perceived as a
coherent unit (Campbell, 1958:14)