From the Couch to the Circle: Group-Analytic Psychotherapy in Practice [1 ed.] 0415672198, 9780415672191

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From the Couch to the Circle

From the Couch to the Circle: Group-Analytic Psychotherapy in Practice is a handbook of group therapy and guide to the group-analytic model – the prevailing form of group therapy in Europe. It draws on John Schlapobersky’s engagement as a practitioner and the words and experience of people in groups facing psychotherapy’s key challenges – understanding and change. It provides a manual of practice for therapists’ use including detailed descriptions of groups at work; accounts of therapists’ experience and the issues they face in themselves and their groups. It is devoted to the group-analytic model and brings the other psychodynamic models into a comparative discussion to create an integrated and coherent approach. The book is divided into three sections: Foundations – aimed at practitioners using groups of any kind and working at every level providing supportive psychotherapy and groups for psychosis, trauma, people at risk, the elderly and children; The Group-Analytic Model – defines the group-analytic model at a basic and advanced level; The Dynamics of Change – aimed at group analysts, psychotherapists and psychologists providing short-term psychotherapy and long-term group analysis. The book is illustrated with figures, tables and clinical vignettes including incisive, instructive commentaries to explain the concepts in use. It is intended for those seeking psychotherapy to resolve personal problems or find new sources of meaning; for policy-makers in mental health; and for students of different models of psychotherapy and the psychosocial field. The comparative discussion about methods and models of practice will be of interest to the wider mental health and psychotherapy fields. The author draws together the inherited wisdom of group analysis since Foulkes’s time and makes his own lasting contribution. From the Couch to the Circle will be an invaluable, accessible resource for psychotherapists, psychoanalysts, psychologists, family therapists, academics, mental health practitioners and teachers in psychotherapy. John R. Schlapobersky is a Training Analyst, Supervisor and Teacher at the Institute of Group Analysis, London and Research Fellow, Birkbeck, University of London. He is in private practice at the Bloomsbury Psychotherapy Practice and works with individuals, couples and groups. He has trained generations of group analysts, teaches internationally and has many publications. This book is the professional life’s work of a leading British group analyst.

The role of a conductor in a group-analytic group has always appeared . . . similar to that of a poet or writer in the community . . . receptive to the current problems of his time and creative in expressing them . . . to bring them nearer to the consciousness of those concerned. (Foulkes 1975, 1986:157) Group-analytic psychotherapy offers an incomparable instrument for understanding the group mind or psychology of the individual in the group . . . (and though) much weaker . . . than psychoanalysis will need to build a more substantial theoretical superstructure out of the process of communication, of mirroring, of configuration and of translation. (Anthony 1978:10)

From the Couch to the Circle

Incredibly rich in clinical vignettes, steeped in heart, mind and scholarship and faithful to how group therapy heals, Schlapobersky’s From Couch to Circle beautifully depicts how ‘the troubled group that each individual has within’ is played out among the other group members. A simple testimonial cannot do justice to this monumental effort that is destined to become a classic in the field. Prof Jerry Gans MD, DLFAGPA, Harvard Medical School, Distinguished Life Fellow, American Group Psychotherapy Association. Author, Difficult Topics in Group Psychotherapy This unique publication offers the next fine turning point in group education and practice. It covers the wide range of methodology and the complexity of group experience moving from one stage of disciplined work to the next buoyed with intellectual excitement and a deft touch of humor. It draws fluently upon the three ingredients of group: process, theory and practice and will delight Modern Analysts encouraging both new entrants and the most experienced practitioners. Statistics, theory and typology are used with wit and daring as John takes us from the most personal narratives in case studies to varied interpretations of theory offering vivid contrasts between schools of analytic investigation. Few books can achieve the dynamic pace and thrilling results that he uses to carry the reader from one chapter to another. Phyllis F. Cohen, PhD; FAGPA; National Chair, Group Foundation for Advancing Mental Health; Former Chair Center for Group Studies, New York; American Board for Accreditation in Psychoanalysis; Former Chair, Center for Group Studies John has amassed a rich harvest in the skills by which he applies group analytic theory and technique – a narrative art. Science is in the tabulations, careful categorization of diagnoses, treatment results, and illuminating figures. This book will interest and inform readers seeking an introduction and mature practitioners who want to revise their own experience and ideas. Rarely do we read a single author text written with the authority that derives from such rich experience as a practitioner

and teacher who enjoys and is able to utilize the work of his students. The writing of former patients gives the final stamp of authority to his work in ‘The last word’. Malcolm Pines, MRCPsych., Founder, Institute of Group Analysis London, Formerly Consultant Psychotherapist, Maudsley Hospital, St. George’s Hospital, Tavistock Clinic. Author, Circular Reflections Everyone working with groups will benefit from this book from whichever ‘school’ they come and at whatever level of experience. It is a mine of information about group analytic ideas and how to use them presented accessibly and with an appreciation of their complexity. Theoretical material is compelling and enlightening. The massive strength of the book is the case material that drives it with engaging and often moving examples and incisive, consistently instructive commentaries. John shows acute clinical sensitivity and virtues as a teacher, deploying the concepts to make sense of clinical material . . . and using clinical material recursively to flesh out the theoretical concepts . . . a terrific way to work. Prof Stephen Frosh PhD, Professor of Psychosocial Studies, Birkbeck, University of London. Author, Hauntings: Psychoanalysis and Ghostly Transmissions John’s masterful exposition of Foulksian group analysis and other models gives us their underlying theories, principles and clinical applications in a jargon-free, beautiful language. There shines through the man the writer is: intellectually inquisitive, emotionally engaged and deeply humane in his contact with and care for his patients. This spirit exemplifies a passage by Foulkes quoting a patient saying, ‘What is essential is not what you do but who you are.’ The book extends this spirit for experienced and new practitioners and for students who will find it especially useful. It is relevant and accessible to a wide audience of professionals including teachers, social workers, administrators and – dare one hope – politicians. Their reactions would be as welcome as those of John’s former patients in ‘The last word’. Liesel Hearst, Training Analyst, Institute of Group Analysis, London; Supervisor and Founding Trainer, Institutes of Group Analysis, Denmark, Norway, GRAS Germany and ZGAZS Switzerland. Co-author, Group-Analytic Psychotherapy: A Meeting of Minds In his wonderfully well-written textbook John Schlapobersky does a great service for the field of group psychotherapy – a remarkable synthesis of accrued clinical wisdom, cutting-edge knowledge and thoughtful clinical application. The author builds articulate, eloquent bridges between individual and group psychotherapy; between members and leaders within the therapy group; between European and North American models of group psychotherapy and, most importantly, between

depth theory and accessible technique. There is no better resource that brings together the worlds of group analysis and group psychotherapy. Prof Molyn Leszcz MD, FRCPC, DFAGPA. Professor and Vice-Chair, University of Toronto Department of Psychiatry, Co-author with Irvin Yalom, 5th edition, The Theory and Practice of Group Psychotherapy This book provides ‘the state of the art’ in group-analytic practice and thinking. A most experienced clinician shares his curative approach and interventions through a wide range of clinical examples in different, touching group experiences. It is a joy to learn from this master teacher – he is both a model for group therapists and a theoretical innovator. John’s interest in new formulations, new approaches and a humane way of relating to patients will help the reader grow. Students as well as experienced practitioners will find the text, the broad field it covers and the depth of its studies applicable to many of their own challenges in group therapy. Robi Friedman PhD., President, International Group Analytic Society; Former Chair, Israeli Institute of Group Analysis. Co-author, Dreams in Group Psychotherapy British group analysts have been waiting for a major contemporary textbook on group-analytic psychotherapy for many years and John Schlapobersky has written such a book. The term ‘magnum opus’ is highly appropriate for a work that is both theoretically robust and clinically rich. It will be of particular interest to those who work as therapists with victims and perpetrators of violence and I predict that it will become a book that no practicing group therapist will want to be without. Gwen Adshead, MB ChB; FRCPsych. Group Analyst; Consultant Forensic Psychiatrist, Ravenswood House. Co-author, A Matter of Security – Attachment Theory, Psychiatry and Psychotherapy This book sets new standards for the whole group-analytic community and anyone interested in the tradition founded by Foulkes. It integrates practical relevance and scholarship in a carefully elaborated presentation. John Schlapobersky is a staunch ‘Foulkesian’, fully aware of inconsistencies and gaps in Foulkes’s original texts, one of which is the key concept of communication. He breaks new ground here with chapters on the speech forms of the group-analytic process; silence in groups; and metaphors for a ‘language of change’. Readers in the German-speaking world will find especially informative how he documents the origins of group analysis in the German intellectual tradition to 1933; then locates its development in the context of British

psychoanalytic discourse; and then connects it with the development of group psychotherapy in the USA. Thomas Mies PhD., Training Analyst, Institute of Group Analysis, Munster, Germany; Editorial Board, Gruppenpsychotherapie und Gruppendynamik Group analysis has been waiting for a book that integrates the many diverse strands of the theory into a meaningful whole. From the Couch to the Circle is an important step in this direction. Ambitious and scholarly, the book draws on literature and research from the UK, USA and beyond to build a rich and nuanced construction of what group analysis is. This dense tapestry is animated throughout by vivid examples in vignettes and commentary that reflect the author’s unwavering commitment to group analysis and his considerable experience and wisdom, his passion and compassion. Beginners in the field, seasoned practitioners and curious non-professionals will gain both essential data and rare insights into a field that holds hope for the future of accessible and equitable mental health practice. Morris Nitsun, PhD, Consultant NHS Psychologist in Group Psychotherapy; Training Group Analyst, Institute of Group Analysis London and Fitzrovia Group Analytic Practice. Author, The Anti-Group In this substantial work John Schlapobersky turns his thoughtful and meticulous attention to embodying comprehensively the corpus of group-analytic literature. This will become a standard work for consultation as much as for reading, for study as for inspiration. It establishes group analysis as a seriously thought through approach to the practice of psychotherapy in groups. More than that, Foulkes and his early colleagues are properly acknowledged to have originated in and extended the theory and practice of psychoanalysis itself. The psychoanalytic couch and the circle of the group are close cousins. There is a special tension between them that arises out of their mutual dependence and rivalry that John shows has been turned to creative advantage by the long tradition of academic and institutional work. This book leads the beginner towards becoming a sophisticated practitioner and the experienced group analyst towards renewing his acquaintance with his own origins. Bob Hinshelwood, Psychoanalyst, British Psychoanalytic Society. Author, What Happens In Groups, and Research On The Couch Much of this book is teachable and would be a great introduction for American readers unfamiliar with group analysis. Theory alone is not enough; something has to catch fire. What is not teachable is exemplified in John’s vivid clinical narratives of how and why people who struggle, succeed, and sometimes fail, in group therapy. He describes Foulkes, founder of group analysis, as a towering figure who attracted and led through great personal creativity and charm, with a

gift for bringing ideas to life in the room. John supplies the equivalent Foulkesian life force in his deeply poetic clinical thinking and writing. Dominick Grundy PhD, Editor, International Journal of Group Psychotherapy ‘To make soup the cook doesn’t need to get into the pot.’ (Gorky quoted Schla­ pobersky, characteristically illustrating the role of the group conductor). This book is the most glorious potpourri of everything one wants to know and feel and experience about group therapy, group analysis, and group dynamics – and more. It magically combines, theory, science, clinical illustration, personal revelation, anecdote, apposite quotation, allusions from the literary canon, and social and cultural wisdom. Schlapobersky and his book – the literary analogue of a group at its best – are worthy successors to his predecessor giants: Foulkes and Anthony, Yalom, Skynner, Pines. Read him: for instruction, for joy, to live and laugh more fully, more contentedly, more dangerously – and become a better, braver, more compassionate, more confident yet questioning therapist whilst doing so. Prof Jeremy Holmes MD FRCPsych, University of Exeter, UK. Author, Explorations In Security Foulkes would have been as delighted with this new book as I am. E.J. Anthony MD, FRCPsych., Co-Author, Group Psychotherapy: The Psychoanalytic Approach

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From the Couch to the Circle

Group-Analytic Psychotherapy in Practice

John R. Schlapobersky

First published 2016 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN And by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2016 John R. Schlapobersky The right of John R. Schlapobersky to be identified as author of this work has been asserted by him in accordance with sections  77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Schlapobersky, John R., author. Title: From the couch to the circle : group-analytic psychotherapy   in progress / John R. Schlapobersky. Description: Hove, East Sussex ; New York, NY : Routledge, 2016. Identifiers: LCCN 2015021331 | ISBN 9780415672191 (hardback) Subjects: LCSH: Group psychotherapy. | Group psychoanalysis. |   BISAC: PSYCHOLOGY / Movements / Psychoanalysis. |   PSYCHOLOGY / Psychotherapy / General. | PSYCHOLOGY /   Mental Health. Classification: LCC RC488 .S25 2016 | DDC 616.89/152—dc23 LC record available at http://lccn.loc.gov/2015021331 ISBN: 978-0-415-67219-1 (hbk) ISBN: 978-0-415-67220-7 (pbk) ISBN: 978-1-315-67009-6 (ebk) Typeset in Times New Roman by Apex CoVantage, LLC

Dedication

This book is dedicated to the memories of James Anthony, Helen Bamber and Bryan Boswood, who passed away whilst it was being written. They were inspiring colleagues and mentors who became dear friends. It is dedicated to three groups of living people. First it is dedicated to the next generation of my own family: my daughter Hannah; grandchildren Maia and Leo; stepson Josh; nieces Kate and Diana, Alice and Jane; nephew Simon; and stepnephews James and Andrew; to their children and children to come. May the work described here help to make the world a better place for all our children. It is dedicated to those I have known in teaching relationships, including students and supervisees in training programmes and institutions in different countries. The Training Convenors of my own institute, the Institute of Group Analysis London, who I have worked with down the years merit special mention. We worked together to develop a curriculum, write a handbook and establish an MSc programme with our academic partner, Birkbeck College, University of London, now in its 18th year. The introduction to this book by the former head of the Department of Psychosocial Studies at Birkbeck College, Prof. Stephen Frosh, gives one tribute to this work. Another is in the citations and references to our graduates’ theory papers and dissertations written during their training, some of which now inform the literature and many of which have been quoted from with their permission. It is dedicated with a full heart and deep appreciation to those who have attended my groups – therapy and experiential groups – and the groups of my colleagues and supervisees. Your lives populate the pages of this book. I have drawn on your stories and taken liberties with them and your identities, to re-arrange them and so protect your confidentiality that would allow an authentic portrayal of our work together. This protocol is in line with the code on confidentiality set out by the Institute of Group Analysis and International Psychoanalytic Association. I have made every effort to reach you, secure your consent to this publication or make amendments to meet your concerns if experience described here was likely to be recognisable. Where called for, vignettes have been amended or removed. I did not anticipate the active co-operation shown by those approached. Many of you have participated by providing memories that augmented my own records,

xii Dedication

allowing me to edit the vignettes and shape them more authentically. I thank you all. The work goes back many years, and there may be some who think they find themselves here who have not heard from me first. Similarities in this material to the actual therapy of anyone – alive or not – is accidental. I trust readers will find that the accounts are set out here on professional terms, first to honour the work we have done together and second to serve the field in good faith. For this I thank you twice.

Contents

List of vignettes List of tables List of figures Foreword: Stephen Frosh Tribute: Malcolm Pines Historical Preview: E. James Anthony Acknowledgements

xv xviii xxi xxiii xxvi xxvii xxxiv

Introduction1 SECTION I

Foundations29 1 Aims and vocabulary of psychotherapy

31

2 Psychotherapy’s three dimensions: Relational, reflective, reparative59 3 Personal and group development

84

4 The language of the group: Monologue, dialogue and discourse in group analysis

112

5 Speech and silence in psychotherapy

135

6 The range of applications in ten studies: Duration, frequency, setting

158

7 Methods applications and models: The group-analytic model and its contemporaries

200

xiv Contents SECTION II

The group-analytic model221   8 A group’s three dimensions: Structure, process and content

223

  9 Structure: Dynamic administration, composition, selection235 10 Process: Concepts and applications

247

11 Content: Key questions about narrative, discourse and the voice of the symbol

278

12 The conductor: Convenor, therapist and group member

301

SECTION III

Dynamics of change325 13 Four domains of communication: Current, transference, projective and primordial

328

14 Lost or found in the transference? Transference, countertransference, projection and identification in groups

359

15 Longing and belonging in the intermediate territory

393

16 Metaphors and metamorphosis: Symbols, transition and transformation

418

17 Location, translation, interpretation: The heart of the group-analytic model

440

18 Conclusion and the last word

459

Index

475

Vignettes

  0.1  About Heaven and Hell 5   0.2  Survival and reciprocity 5   0.3  Sipology with soap and bubbles 6   1.1  The seer’s eye in the mirror 33  1.2  Empathic mirroring 34   1.3  Why are we talking about sausages? 36   2.1  My brother, what have they done to you? Some relational moments68   2.2  The ‘normals’ in our space capsule 70   2.3  About mayonnaise on the chin 71   2.4  The persecutor and the jangling keys 73   2.5  Separating a mother and baby: The cries of the cow and her calf 77   3.1  Key phases in the progress of individuals through a group 102   4.1  Who are you talking to? 117   4.2  A good father and an abusive father 119   4.3  How dare you dream about me killing your father! Projection and projective identification 121   4.4  Envy against progress in the group 123   4.5  An empty house without sexual feeling: Desire can bring the roof down 128   4.6  Do we discuss the nightmare or ‘the nightmare?’ 130   5.1  Who says it doesn’t work? 137   5.2  Love me or fuck off 141   5.3  You cry for what you’ve lost and me for what I’ve never had 142   5.4  The girl who lived in the heart of stone 145   5.5  A male megaphone silent in protest against a newcomer 149   5.6  Springing a trap 151   8.1  Challenges at the broken boundary: Structural interventions establishing authority 228   8.2  Poor attendance and the baby at the breast: Process-based interventions looking for meaning 229

xvi Vignettes

  9.1  The story of the wooden spoon 241 10.1  Resonance and valency: The isolate and the avoidant 256 10.2  Mirroring and resonance: One person’s tears as a votive offering to another’s hidden grief 258 10.3  Desire as a conscious condenser of accessible emotion 260 10.4  Unconscious condenser: He’s not a fucking professor, he’s my father! 261 262 10.5  Amplification and condensation after exposure 10.6  Signal (simple) resonance 1: Where fear and opportunity crawl the streets 264 10.7  Signal resonance 2: Where sheep may safely graze 264 10.8  Complex resonance: The wounds of injured experience that speak without words 265 10.9  ‘Familiarity is the kingdom of the lost’: The woman who found a newcomer in her group: Resonance, condenser and amplification at work in therapy 267 10.10 The story of four fingers linked to describe partnership – process dynamics at work in the round during therapy 270 11.1  People’s voices come alongside one another, followed by their stories 283 11.2  Anger and its monsters: Language, imagery and thematic development in the content of a therapy group over time 289 11.3  The woman whose birth saved her mother: Content and thematic development in a short experiential group 296 12.1  Late-night vigil – waiting for parents to return: The conductor 320 at work 13.1  Learning containment: The current domain 329 13.2  Fighting with the ‘wrong’ sister 330 13.3  Something new ‘cooking’ in the group: Projection and change 332 13.4  The living will not be buried with the dead 333 13.5  The triumph of hateful failure in a masochistic protest 336 13.6  The longing to be a ‘princess’ inside and outside the group 341 13.7  The work of the ‘crying group’: Analysis of 25 subjects, their figurations and the four domains 346 14.1  Reading Fraud and Junk 362 14.2  Who took my place and when was it taken? Location, translation and interpretation of vertical and horizontal transference378 14.3  A group dream of Grandfather wearing the conductor’s face: 380 Positive vertical and complex transference 14.4  Disillusionment: Negative vertical transference 383 14.5  Good sisters, bad sisters and good sisters again: Changing horizontal transference 384

Vignettes xvii

14.6  Dreaming together about the conductor wearing her apron and withholding delicious soup 15.1  Postman Pat: Stepping in and out of each other’s pictures 15.2  Was it nice when you kissed the conductor in your dream? 15.3  Other people’s babies 15.4  So you want us to eat potatoes? No, we’re coming home! 16.1  The angel in the torture chamber: Individual psychotherapy 16.2  The angel in the family 16.3  A band of angels in a group of refugees 16.4  Jacob’s Ladder in the group 17.1  Where is the conductor’s baton? 17.2  On making a home amongst strangers 18.1  The patients are the ones who get better and go away

386 404 406 410 412 425 428 431 434 441 452 465

Tables

0.1  Elementary principles in group-analytic theory 13 1.1  The important lessons distilled from personal experience: Gans 32 1.2  Basic principles in group-analytic psychotherapy 39 1.3  Categories of need amongst people attending intensive groups 43 1.4   Definition and classification of conductors’ interventions: Roberts 50 2.1  Tripartite division of psychoanalytic interactions: Holmes 62 2.2  Qualities of dependency in groups: von Fraunhofer 64 3.1  Current developmental literature in group-analytic psychotherapy: Inclusion criteria – key elements in clinical theory89 3.2  Developmental tasks, critical issues and focus 96 5.1  The human experience of silence: Haddock 146 5.2  Speech and silence in group psychotherapy 146 6.1  Dick’s phases in group process and content 166 6.2  Specific areas of disturbance in eight parameters of life situation166 6.3  Levels of satisfaction/dissatisfaction in eight parameters rated by patient/therapist 167 6.4  Pre- and post-group rating of total series 168 6.5  Block group therapy: Attendance numbers 186 6.6  Block group therapy: Occupational categories 186 6.7  Categories of need amongst people attending twice-weekly groups190 6.8  Basic demographic and clinical data amongst people attending twice-weekly groups 191 6.9  Basic clinical data for people attending twice-weekly groups: Ratings on five-point scale (14 and 15) 191 6.10 Twice-weekly group therapy: Occupational categories 192 6.11 Twice-weekly group therapy: Family situation 192 6.12 Twice-weekly group therapy: Referral source 193 6.13 Twice-weekly groups: Presenting problems 193 6.14 Twice-weekly groups: Diagnosis on presentation 193

Tables xix

  6.15 Twice-weekly groups: Leaving reasons 194   8.1  Visible elements in the dynamic life of a group 233   8.2  Invisible elements and the emergence of a three-dimensional model233   9.1  Basic organising principles for group psychotherapy 236   9.2  Twelve principles and practices of dynamic administration: Behr and Hearst 237   9.3  Principles for group composition 241 10.1a Foulkes’s original list of group-specific factors 249 10.1b Foulkes and Anthony’s revised list of group-specific factors 249 10.2  A new working list of process dynamics in small group psychotherapy251 10.3  Resonance: Simple, complex, descriptive and unconscious 266 10.4  Mirroring in seven forms and ensuing group dynamics 269 11.1  Tyerman’s four questions about non-verbal communication 281 11.2  Working with content: Five therapeutic challenges for the conductor282 12.1  Advice to aspiring group analysts: Seven cautionary points 303 12.2  Phases in the cycle of a group’s development: Conductor’s 313 prevailing identity and responsibilities 12.3  Leadership principles for small and median group therapy 315 12.4  Leadership principles for large groups 316 12.5  Requirements for therapeutic competence in group-analytic psychotherapy317 12.6  The conductor’s interventions in time and place 318 12.7  Summary of therapeutic principles in group-analytic psychotherapy: Leadership, analysis and interpretation 319 12.8  Conductor’s therapeutic role mapped against group’s three 320 dimensions and four domains (refers to Figure ii.1) 13.1  Foulkes’s four levels of communication in group: Original and current formulation 339 13.2  Four ‘regions’ of the group described now as domains: With 341 conductor’s role responsibilities 13.3  Progression of subjects and figurations in ‘The crying group’ 354 13.4  Frequency score of figurations during life of group 357 14.1  The transference situation in psychoanalysis and group analysis – Foulkes and Anthony 366 14.2  Different forms of transference: Simple, complex, vertical horizontal370 14.3  Illustrations of transference and countertransference in the text 376 15.1  Four forms of play in relational life and the authors who describe them 400 16.1  Brown’s three stages of growth and development: Self-development through subjective interaction 423

xx Tables

16.2  The dialectics of self-experiencing: Bollas 17.1  Twelve features of group psychotherapy arising from the principle of translation: Foulkes and Anthony (1957/1984) (Foulkes 1975:55–60) 17.2  Interpretation in groups: The who what and why of Foulkes’s approach. Who does the interpreting, what do they interpret and why do they do it? 17.3  Ten basic tenets for conductor’s interpretation in group-analytic psychotherapy from Group Analytic Psychotherapy: Method and Principles (Foulkes 1975) 17.4  Forms of interpretation to be avoided in group-analytic psychotherapy from Group Analytic Psychotherapy: Method and Principles (Foulkes 1975)

427 446 448 449 450

Figures

  2.1 The three dimensions of psychotherapy   3.1 A pentangle of group development and focal issues   4.1 Forms of speech in the group and corresponding psychologies   7.1 A simple classification of group methods   7.2 The elements of a Tavistock group   7.3 The elements of an Interpersonal group   7.4 The elements of a Group-analytic group   7.5 Tools for systematic comparison of leader activity and focus across models: Rutan, Stone and Shay 7.6a Tools for systematic comparison of leader activity across models response profile A 1–3: therapist’s role 7.6b Tools for systematic comparison of leader activity across models: response profile B 4–9: therapist’s focus in group   ii.1 The conductor’s map – Structure, process and content   8.1 Defining the group-analytic model   9.1 Structural dynamics at work 10.1 Process dynamics in small group psychotherapy 11.1 Six questions about the language of the group 11.2 Content analysis and the modalities of time and place 11.3 Progression of group discourse towards resolution and change 12.1 The three role functions of the conductor 12.2 The conductor as convenor: With their therapeutic and member-role functions embedded 12.3 The conductor as therapist: With their convening and member-role functions embedded 12.4 The conductor as group member: With their convening and therapeutic role functions embedded 13.1 Four levels of a group’s communication described as domains: Current, transference, projective, primordial 13.2 The four domains of a long-term analytic group

61 97 115 201 206 208 210 214 215 216 222 227 245 251 281 295 296 305 307 309 311 343 344

xxii Figures

14.1 Transference and projective levels of experience in a group 14.2 Circular and reciprocal movement between layers or domains of group experience 17.1 Three principles of therapeutic intervention in groups: Location, translation, interpretation

368 369 444

Foreword

The importance of groups as an arena for psychodynamic work and understanding has been established for nearly 100 years – at least since Freud’s comment in his Group Psychology and the Analysis of the Ego that ‘In the individual’s mental life someone else is invariably involved, as a model, as an object, as a helper, as an opponent; and so from the very first individual psychology, in this extended but entirely justifiable sense of the words, is at the same time social psychology as well’ (1921:69). Despite this endorsement from the creator of psychoanalysis, however, it was not until the Second World War that group psychotherapy became a significant force in psychotherapy, and it was not until after that war that group analysis, as an organised body of theory and practice, began to develop. It might be said – or at least I might claim – that whilst group analysis has thrived as a systematic practice that seems to have great power and integrity, it has not advanced so much in terms of theory. The great source book, Foulkes and Anthony’s Group Psychotherapy – the Psycho-Analytic Approach (1957, 1984) remains the premier publication in the field, and despite quite a lot of publishing activity since then, it is arguable that the early promise of the work has still to be realised. This seems unlikely to be because there is no call for group psychotherapy, as so much that is offered in clinical and other institutional settings is group-based work; nor is it because the techniques, procedures and concepts employed in group analysis are somehow obvious or mundane. In fact, they are complex and demanding, and the skills required in actually running (or ‘conducting’) groups are very subtle and stretching. Perhaps it is because group analysts have been under-confident about their ability to compete with their psychoanalytic colleagues in the creation of new concepts; or maybe it is simply that in the busy work of a psychotherapeutic practice that is not rooted in universities, it is very hard to find time to step back, make sense of things and move them on. This is where John Schlapobersky’s new book is of great significance. First, he writes from a position of immense authority in the field, draws expertly on his extensive experience, manifested especially in excellent case material, and holds to an ethical standpoint that will be appreciated by students and practitioners alike. Indeed, this book is best understood as the product of the professional

xxiv Foreword

life’s work of a leading British group analyst, someone who has trained many generations of other group analysts, someone absolutely immersed in the lived reality of group analysis as a practice and also committed to its conceptualisation and to the advancement of the field through careful observation, new theorisation and, where possible, evaluative research. John’s ambition is vast: basically, to write the book that will draw together what can be seen as the inherited wisdom of group analysis since Foulkes’s time; and also to make it accessible, so that group analysis will be preserved and will advance as a profession, and everyone working with groups, from whichever ‘school’ they come and at whatever level of experience, can benefit. This is a big challenge for a writer, especially one who has his hands full with teaching and clinical work, and it has taken quite a while to come to fruition; but here it is, and it arrives as a very major contribution to the field. In From the Couch to the Circle, John writes as someone completely at home with the ideas of group analysis and also with the wider context in which they have meaning. This is the context not only of psychotherapy but of relationships between individuals and in societies as a whole. He has an anthropological cast of mind but also a political and a cultural one, by which I mean simply that he understands the importance of frames and contexts, differences and similarities, connections and disjunctions of all kinds. This both makes him a fine guide to what matters in group work and gives him the ability to describe and evaluate key concepts in a way that is both ‘inside’ them in the sense of understanding how they work and ‘outside’ in that he maintains enough distance to evaluate them. Because of this, the book is a mine of information about group-analytic ideas and how to use them, presented accessibly and yet with the weight of an appreciation of their full complexity behind them. I am sure every student of group psychotherapy will find John’s presentation of the theoretical material compelling and enlightening. But to my mind the absolutely massive strength of the book lies in the way case material is used to drive it forward, with wonderfully engaging and often moving examples and incisive, consistently instructive commentaries on these. These case examples enable John to show his acute clinical sensitivity and also his virtues as a teacher, deploying the concepts he is using to make sense of the clinical material without detracting from its human (and humane) impact and using the clinical material recursively to flesh out the theoretical concepts. This is a terrific way to work through such a comprehensive account of this mode of psychotherapy, bringing the ideas alive and converting what might have become a very long and technical read into something accessible and consistently absorbing. As I read the book, every section drew me in, and I felt I lived alongside John as a kind of co-therapist, or perhaps a co-member of his groups, sharing their experiences and yet also able to stand outside them and reflect on them, as he does so beautifully throughout the text. I also realised that I was benefitting from the work of someone who is not only a fine teacher – as I know from direct experience working alongside him in the Group-analytic training that we ran for many years as an MSc between the Institute of Group Analysis in London and Birkbeck – but who also has a teaching, in the sense of an embodied history of clinical

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and theoretical wisdom in group analysis. He imparts this in many ways: in his contribution to groups of which he is a member, through supervision of clinical work and also of research in group analysis, as witnessed for instance in the many master’s dissertations that he has supervised, several of which are drawn on in the book. But he also imparts it through his manner, in that everything he presents here is positioned in the context of systemic and dynamically relational principles; or, to put things simply, he has an idea about what group relationships mean and what we might learn from them. I see this as a powerfully ‘psychosocial’ element in his work and one that links it closely to the approach that my colleagues and I have taken in building a presence of what we are calling psychosocial studies within the university scene. We should all be grateful for this book. Group analysts need it: if they are new to the work, it will help them understand the history, context and content of groupanalytic ideas and will guide them in how to use these ideas in practice. If they are more experienced, it will deepen their understanding and spark a process of reflection on which ideas have staying power and on how different modes of work can extend or challenge them. For readers from the broader world of psychotherapy, the book makes a very strong case for considering group analysis as a method of choice and also articulates how group theory can feed off, challenge and enrich other types of approach. And for readers who are not primarily psychotherapists but are interested in interpersonal and social relations, this book gives tools of inquiry and self-reflection and hints at what will no doubt be in the second volume – ways in which group analysis in clinical settings can be extended to help us make sense of the complex lives of groups wherever they are found. Stephen Frosh BA, MPhil, PhD Professor of Psychology and Pro Vice-Master, Birkbeck, University of London

Bibliography Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Freud, S. (1921). Group Psychology and the Analysis of the Ego. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XVIII (1920–1922): Beyond the Pleasure Principle, Group Psychology and Other Works, pp. 65–144.

Tribute

‘Astonish me!’ was the challenge from Serge Diaghilev to Jean Cocteau when he commissioned a new ballet from him. Well, I am astonished by John Schlapobersky’s monumental text, a work which is both artistic and scientific. From his 35 years of experience in an extraordinarily wide field of group psychotherapy – in group-analytic therapy groups and training groups; group-analytic workshops; forensic psychotherapy; with victims of torture; and in conference challenges. From all these experiences he has amassed a rich harvest shown by the protocols through which we learn how skilfully he applies group-analytic theory and technique. This is a narrative art. Science is in the tabulations, the careful categorization of diagnoses, of treatment results, of illuminating diagrams. John has the literary ability to present a wide range of theory in a way that both stimulates and maintains interest through novelty and challenge, as in these diagrams and tables. He has written a textbook that will interest and inform readers, both those seeking an introduction to group analysis and mature practitioners who want to revise their own experience and ideas. I have followed the growth of this book over several years, admiring the author’s ambition and the tenacity with which he has reached his goal. Rarely nowadays do we read a single-author text written with the authority that derives from such rich experience as practitioner, as a teacher and as a teacher who enjoys and is able to utilise the work of his students whose writing he quotes from so generously. One of the book’s striking features is the foreground John gives to movement between monologue, dualogue, dialogue and discourse that is so well brought out in the many clinical illustrations. I particularly welcome the close attention that he gives to the Foulkes and Anthony ‘Ur-text’ of group analysis and to the subsequent, separate writings of Foulkes and Anthony that have been such fertile ground for his own development in thought and practice. ‘The Last Word’ is a delightful way of closing his text. The writings of some former patients give the final stamp of authority to his work. Malcolm Pines Founder Member, Institute of Group Analysis, London Formerly Consultant Psychotherapist, St. George’s Hospital; Maudsley Hospital; Tavistock Clinic

Historical Preview

I am very pleased to have been asked to write a Preview for John Schlapobersky’s new handbook that is destined to find its place on both sides of the Atlantic. It will make a valuable contribution to the field of group therapy, and to honour this I will say something here about Group Psychotherapy: The Psychoanalytic Approach that Foulkes and I published in 1957. This allows me to bring forward my own origins in group analysis which American readers might not be familiar with – especially my relationship with Michael Foulkes – and to bring forward American achievements in child and adolescent psychiatry that readers in Europe may not be familiar with.

Resiliency Our original development of resiliency as a field of study with its concepts of vulnerability and protective factors, based on empirical research, led to a new understanding of the relationship between constitution and environment. The emergence of a developmental science has its origins in our early work in St. Louis, Missouri, where I took up a professorial appointment. It also has earlier origins in my relationship with Foulkes, for he was the man whose own resiliency helped me to find mine. In this new book it is heartening to see an emerging focus of two different kinds – on the person and personality of the group analyst and on empirical research in group analysis. They are both critically important for the future. In recognition of our work in St. Louis, the American Academy of Child and Adolescent Psychiatry (AACAP) honoured me with their Lifetime’s Achievement Award in 2009. It has a place of honour in my office and takes the form of a collage with photographs of three mentors, each of whose personal influence was most important in my own development – Anna Freud, Jean Piaget and Erik Erikson. In 2011 the Group Analytic Society, an organisation I helped to found in 1953, honoured me with their Lifetime’s Achievement Award for my contribution to group analysis. It is written in beautiful calligraphy and also has a place of honour in my office.

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My own background: the search for little people ‘The Search for the Little People’ was the title for my acceptance speech on being honoured by the AACAP. The title ‘Little People’ stems from Yeats’s writing about the goblins of Ireland. I fell in love with the term because it conveys my own experience of being ‘a little person’ and I fell in love with little people themselves in all their variety (Yeats 1998). I was born in India and was sent to a boarding school in a Himalayan hill station by my parents at the age of five. Our community of children was a world of little people, and our school looked on to Mt. Kangchenjunga, the third-highest peak in the world. The mountain presided over my childhood and made us aware that we were very, very little people in a vast world. My mother was an operating theatre nurse who decided that I should become a brain surgeon and so, on completing high school, I was dispatched to a medical school in London in the first step of a career that would take me on to work with little people as a psychiatrist. World War II My arrival in London coincided with Hitler’s decision to bomb Britain, and we had to contend with a tornado of missiles every night. One of the tasks of new medical students like myself was to evacuate patients from the open wards at St. Thomas’s Hospital to underground shelters at the end of the day. With some elementary counselling on how to communicate with them I found myself a pusher for sick and frightened children, and this experience set me up – in due course and after further such exposure – to become a child psychiatrist. On qualifying as a doctor through an accelerated training I was seconded to the 9th Essex Battalion as their general medical officer and, by the most extraordinary chance, I was accommodated in a tent with Dr. John Rickman, a British psychoanalyst who had been at the Tavistock Clinic and was very interested in groups. For three weeks we had only one another to talk to, and it was an extraordinary education. He was a kindly man, a Quaker who told me about Freud, psychoanalytic theory and groups and suggested I put my name down to go to Northfield. This took two years to come through, during which I gave lectures to the troops in my battalion on dealing with fear and anxiety and was with them when we crossed the Channel to encounter the German army. I dealt with casualties endlessly before returning to the safer shores of England and to the Northfield posting, the military hospital for shell-shocked soldiers near Birmingham where I met psychiatrists, psychologists and psychoanalysts including Michael Foulkes. I did not know how important he was to become for me, and the most memorable thing I recorded about him then was his skill as a tennis player. He was the fastest man on the court in Birmingham. When the attack on Japan was devised I travelled on a war ship to reach a country devastated by the first atomic explosions. I was appointed Chief Medical Officer for Southeast Asia and was charged with setting up nurseries and kindergartens for

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Japanese adolescents and children who survived the Hiroshima bombing. We used a group approach for the care of these terrified children who, unlike their parents, had escaped that explosion. Later on I saw other children who had to witness Japanese adults now ordered to pull the Hong Kong buses, eight to a bus. My concern for children forced to watch this exercise in humiliation confirmed my decision to focus my life on the psychiatric care of children. When the war ended I was certain of only two things: I wanted to become a psychiatrist-psychoanalyst and I wanted to work with children. At this point life chose to place me on a Foulksian conveyor belt that carried me steadily along as his analysand in a training analysis; as an analyst sharing an office with him; as his student in group dynamics and group psychotherapy; as a co-therapist in an analytically orientated group, as a fellow consultant at the Maudsley Hospital; as a co-author of a book on group therapy from the psychoanalytic point of view; and finally as joint visiting professors at the University of North Carolina (op. cit. 1978:2). The Maudsley Hospital After the war I returned to the UK to take up a training position at the Maudsley Hospital, the main post-graduate centre for psychiatry in Britain. What I gained from my time at the Maudsley equipped me to later take up a position as the world’s first Endowed Professor of Child Psychiatry at Washington Hospital, St.  Louis. As well as the benefits that came to me from the formalities of the training, I also met four extraordinary people. The first was Sir Aubrey Lewis, who was laying the foundations for the Institute of Psychiatry. He interviewed and admitted me to the training and later also sent me to work and study with Jean Piaget in Geneva, for which he raised the funds. The second was Foulkes, Head of the Maudsley’s Department of Psychotherapy where I had a posting. It was on discovering his inspiring presence and understanding there that I chose him as my training analyst for admission to the British Psychoanalytic Society, and I began a long analysis. The third was Anna Freud who had been invited by Aubrey Lewis, despite his own commitment to organic psychiatry, to conduct psychoanalytic seminars for us at the Maudsley. She became a mentor and later invited me to work with her at the Hampstead Nursery. This bond laid the foundations for a working relationship and friendship that was to last to the end of her life. And the fourth was Malcolm Pines, then a junior registrar, who became a life-long friend. He was also in training analysis with Foulkes, and we are now the last of that generation. As a fellow member of the Group Analytic Society he went on with Foulkes and others to found the training institute, the Institute of Group Analysis, London. There are now IGAs in many parts of the world and a co-ordinating, regulatory body, EGATIN. Malcolm has been a tireless influence fostering group analysis through the development of these training resources in a range of different ways.

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S. H. Foulkes When Foulkes invited me to write Group Psychotherapy: The Psychoanalytic Approach with him, I was honoured but uncomfortable because he had been my training analyst. But we settled down to productive writing together. I had been working in his psychotherapy department at the Maudsley Hospital, where I had also been a member of one of his groups, I went on to co-lead groups with him, and we became accustomed to working together. We wrote the different chapters of the book separately and then discussed each of them with one another and became colleagues in this shared task through a friendship that was to last the rest of his life. Although we had confidence in the book we could not have imagined that it would be continuously in print from 1957 for the next 58 years. I find it extraordinary that the second edition published in 1965 and reissued by Karnac in 1984 remains a best-selling text in group psychotherapy to this day. In my Foulkes lecture given in 1978 I gave an account of The first and most enduring group lesson that I learned from Foulkes . . . that although the conductor’s perspective is bifocal (focussed on the group and the individual) his interpretations are invariably directed to the group as a whole. (Anthony 1978:9) And second, His theory of network . . . has had a major impact on my own investigative work. The way in which the patient represents himself to us (and this is so true of the child) is the symptom of a disturbance that involves a whole network of circumstances and people. As Foulkes put it: ‘It is this network of interacting circumstances and persons which is the real operational field for effective and radical therapy’. (Anthony 1978:15) The problem confronting us then is the same one we face today: ‘How to trace the network into all its ramifications therapeutically’ (Anthony 1978:15). These principles guided us in our work at the University of Washington when I arrived in St. Louis in 1958. The Department of Child Psychiatry that I founded had a focus on both treatment and research, and we began to develop a body of findings in close collaboration with others to define resiliency and outline those factors that protected children through adversity and those that made them more vulnerable. Today resiliency studies make up a wide field of investigation with relevant bearing on group therapy. Here I will identify only our originating findings. In studying three generations of families with recurring psychotic illness we found that the children who did well could be identified if, within their first three years of life, they had one good year; if within a

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context of instability or adversity they had one good relationship; and if within their own range of problems and limitations they had one competency they could see as their own. Foulkes was the man whose resiliency helped me to find mine. He lost so much that had been his own in the Holocaust; he came to the UK to live and take up a professional life in an alien language; he established a war-time service that matured to become a way of understanding people and relationships; and he generated a therapy that opened up for us a whole new field of endeavour that was ‘gradually forged . . . through trial and error using the group as a laboratory situation in which his evolving ideas were continuously put to the test of observation, reformulation and revision’ (1978:8). While doing all this he lived through a World War in an adopted country and alien language, through a divorce with his first wife and the untimely death by cancer of his much loved second wife, Kilmeny. On one of my visits to London he told me of a new, developing symptom that was worrying him and which I encouraged him to have investigated immediately as it was a palpable mass. It turned out to be a tumour for which he was being investigated but he died of a heart attack in his own consulting room in the early stages of treatment.

This new book John’s book embraces many of the key concepts in our original book. It amends the thinking and practice to bring it into line with contemporary developments in attachment and relational theory and in neuropsychology. John documents a wide range of innovative applications with groups for refugees, for couples, in private practice, mental health and forensic settings; once-weekly, twice-weekly and block group therapy. He deals with the role and concept of the conductor and the matrix and explores the subject of transference – with a big ‘T’ and with a small ‘t’ – in an original way. And he takes up what we called group-specific factors in the phenomenology of the group and re-describes them here as process dynamics. His accounts will interest all who work with a relational paradigm – group analysts and others. When I first read his manuscript I was at once impressed with the wide range of settings in which he has worked with groups, the breadth of his different applications, the depth of his work and his fluency in describing it. His own distinctive contribution in the field begins with a paper he wrote for the Brown/ Zinkin compilation, The Psyche and the Social World in the 1990s titled The Language of the Group. It is re-issued in this book as Chapter 4. His exploration of human communication through monologue, dialogue and discourse runs through this handbook. It also brings in the writing of others who have followed him into the study of therapeutic language, of silence and of the music of the group. In my Foulkes Lecture I said that: Every now and then in the history of the therapeutic sciences, certain key words suddenly appear and illuminate the intellectual landscape. Two of

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these words that are highly pertinent and have become the basis of metapsychology are process and structure. . . . together they generate content (which) can be described as the stories that patients tell within the individual and group situation or the nonverbal messages they convey. (Anthony 1978:11) I am delighted to see the use to which John has put these terms, structure, process and content, as deeper dimensions of the group. Each of them has been given its own chapter as a resource for therapeutic guidance of new and experienced group therapists. In 1978 I went on to say that: We have a pressing need to develop our own metapsychology and to buttress it with good theory. We further need to look developmentally at the group, observing how its history unfolds and the stages become delineated . . . Foulkes and I spoke of the group historian, the member who kept the archives of the group and reminded us of anniversaries, earlier events, developments and traumata. The group analyst, like the psychoanalyst, must carry the history of his patients inside him and from time to time it may be necessary for him to reconstruct the early group experience of the members – primary family groups, latency groups, early heterosexual groups, homosexual groups, adolescent groups, etc. . . . One speaks of restructuring in psychoanalysis: to what extent can the same term apply to group analysis; do we see restructuring of the individual members as individuals or do we see a restructuring of their group behaviour or of the behaviour of the group? This new book addresses these important questions and relies on detailed descriptions in vignettes that show its author to be a fine storyteller as well as a committed group analyst. As I said in my memorial lecture: Foulkes’ death led me to sense, like Rilke, the ugliness underlying the smiling face of existence. But mourning comes to an end as life goes on, as group institutions and societies grow and the young are always coming along to take their share of the load. The death of the leader is a time for grief, for reconsideration, for re-organization but not for catastrophe. As Freud put it: ‘When once the mourning is over, it will be found that our high opinion of the riches of civilization has lost nothing from our discovery of their fragility. We shall build up again and more lastingly than before’. (Anthony 1978:18; Freud 1915) Michael Foulkes would have given this message to his successors, and I believe he would have been as delighted with this new book as I am. E. James Anthony, MD, FRCPsych Co-author with S. H. Foulkes of Group Psychotherapy: The Psychoanalytic Approach

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Bibliography Anthony, E. J. (1978). The Group-Analytic Circle and Its Ambient Network: 2nd Foulkes Lecture. In Group Analysis 11 (Supplement 1): 1–18. http://gaq.sagepub.com/content/ 11/2/S1.citation. In Pines, M. (ed.). (1983). The Evolution of Group Analysis. London, Routledge. Reissued 2000, London, Jessica Kingsley, pp. 29–53. Anthony, E. J. (2010). In Search of the Little People. Presentation Address Given on Receipt of His Lifetime’s Achievement Award. American Academy of Child and Adolescent Psychiatry. www.aacap.org/aacap/Life_Members/Life_Member_Archives/Inau gural_Life_Members_Wisdom_Clinical_Perspectives.aspx Anthony, E. J. (2011). Address Given on Receipt of His Lifetime’s Achievement Award, 15th Symposium. Group Analytic Society International. Goldsmiths College, University of London. Flapan, D. (1982). The Ongoing Journey of an Extraordinary Man in the Field of Group Psychotherapy – an Interview With E. James Anthony. GROUP 6 (3): 49–58. http://link. springer.com/article/10.1007/BF01459280#page-1 Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Freud, S. (1915). On Transience. In (2005) Freud’s Requiem. New York, Riverhead Books. Schlapobersky, J. (1994; 2000). The Language of the Group: Monologue, Dialogue and Discourse in Group Analysis. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. London, Routledge, pp. 211–231. Yeats, W. B. (1998). Mythologies. London, Harper Collins.

Acknowledgements:  Extracts from the Group-Analytic Circle and Its Ambient Network: 2nd Foulkes Lecture first published in Group Analysis 11 (Supplement 1): 1–18. http://gaq.sagepub.com/content/11/2/S1.citation. Reprinted by permission of Sage. Reissued in Pines (1983), The Evolution of Group Analysis. London, Routledge. Reissued 2000, London, Jessica Kingsley, pp. 29–33.

Acknowledgements

Personal acknowledgements The participation of my partner Claudia Arlo in the drafting of this book has been a constant source of renewal, like water for a long-distance runner. This book is a tribute to her and an expression of my deep gratitude. My family have shown immense kindness during these years of investment, and I thank them for their understanding. My daughter Hannah accompanied me to the publisher with the submission of my first manuscript – Selected Papers of Robin Skynner – when she was a teenager. She is now a mother and writer in the field herself, and I thank her for her continuing good faith and patience, which I hope have been vindicated here. If a book can be said to have grandparents the honour goes with my thanks to Phyllis Cohen and Walter Goldstein. Malcolm Pines has been gracious with his consent for the re-issue here of material we drafted together for other papers. I am grateful to him for much more than publishing consent. He was my first teacher in psychotherapy at the Maudsley Hospital in 1976 and has been an enduring source of guidance and friendship. This book has benefited from his influence throughout and his Tribute to it is deeply appreciated. James Anthony befriended this project from afar, and we met in the course of recent years to draft his Historical Preview. We could not have foreseen that it would be one of the last things he was to write. My gratitude is in the dedication of this book to his memory. My thanks also go to his widow Virginia and his daughter Sonia, who saw us through the drafting process. My other friends who, as authors, inspired me and offered valuable guidance include Robi Friedman, who played an active and vital part supporting me textually and personally. Stephen Frosh took an interest in the book that draws from the psychosocial perspective that he pioneered at Birkbeck College, which he extended to help shape our training at the IGA. He was this book’s first advocate, has remained its loyal friend and his Foreword is deeply appreciated. Liesel Hearst was one of my first supervisors and has remained a constant source of assurance in the book’s development. Peter Marshall will be pleased we can walk again in the West Country and perhaps even sail between the writing of his books and mine; Norman Rosenthal’s gift of adversity has been a profound one; Erol Yesilyurt befriended this project and supported it down the years, and I trust its

Acknowledgements xxxv

completion will be an invitation to his own writing projects; Rabbi Jonathan Wittenberg has been a spiritual guide, mentor and friend who has seen me through the years. His books are helping to create a new literature; and Morris Nitsun encouraged me down the years, taught me by example, gave me confidence in Routledge and inspired us all with his authorship.

Working acknowledgements I have been fortunate with my publishers who recognised the need for a book like this, showed confidence in its design, and provided invaluable support. My thanks go to Kate Hawes and Kirsten Buchanan at Routledge for their editorial excellence, and to Sheri Sipka and the staff at Apex CoVantage for their excellence in copyediting and typesetting the manuscript. I  have had the benefit of guidance from a panel of readers including Gwen Adshead, James Anthony, Robi Friedman, Stephen Frosh, Dominick Grundy, Liesel Hearst, Sylvia Hutchinson, David Kennard, Molyn Leszcz, Thomas Mies and Malcolm Pines. This book’s most recent contributors are its two literary secretaries, Louise Crane and Diane Parker. The former has responsibility for the collation of vignettes and the preparation of tables and figures and the latter for the collation of textual permissions and bibliography. The quality of their work is reflected throughout and speaks for itself – I am very grateful. Commitment of this kind began much earlier with the contribution of June Ansell, formerly administrative director of the Group Analytic Practice. She helped me collect and collate practice records for my twice-weekly groups described in Chapter 6, and I wish to honour her dedication to the work down the years. I have had collegiate benefits at the Group Analytic Practice in the past and currently at the Bloomsbury Psychotherapy Practice. I extend thanks to my colleagues there and also to those at the Institute of Group Analysis in London with whom I have worked for more than three decades. The work of committees responsible for professional training can be invisible, but their merits speak through the contribution our graduates later make in the field. Their work is reflected in these pages, and I wish to honour in particular the teaching contributions of Diane Kinder, Sue Einhorn, (the late) Sheila Ernst, Sylvia Hutchinson, Frances Griffiths and Amelie Noack; and the current London Courses Committee comprising Stephen Arcari, Anne Bocock, Maria Papanastassiou, Sheila Ritchie, Linde Wotton and Jale Cilasun, our large group conductor. Peter Wilson and Sarah Tucker are now responsible for the development of a national training in the UK, and this book is offered as a resource to support the wider prospects of this new phase. I have learnt much from a long association with those in other countries and wish to honour friends and colleagues that include members of the following: the Group Analytic Society International; the European Group Analytic Training Institutes Network and the current Chair of its Committee, Zoe Voyatzaki; the American Group Psychotherapy Association, in particular Angela Stephens, Director of Professional Development and the panel responsible for our Trans-Atlantic

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Dialogues including Phyllis Cohen, Howard Kibel, Molyn Leszcz and Robi Friedman; the Eastern Group Psychotherapy Society (New York) including Claudia Arlo, Dominick Grundy, Ronnie Levine and Jan Vadell; members of the Israeli Institute of Group Analysis and Israeli Group Psychotherapy Society who have participated in my clinical seminars over the years including Anca Detroi, Ofra Feinman, Robi Friedman, Bracha Hadar, Hava Kadosh, Marit Milstein Joffe, Tamar Einat Lachman, Uri Levin, Gila Ofer, Bruce Oppenheimer, Ido Peleg, Pnina Rapaport and Suzi Shoshani.

Further acknowledgements I have enjoyed the support and understanding of a number of people who have played a key part in supporting me with this book, including two psychoanalysts seen at different times. It would not have been written without your support and guidance – my thanks go to all of you.

Introduction

All real living is meeting . . .

(Martin Buber 1958; 2000:26)

A branch severed from an adjoining branch necessarily becomes severed from the whole tree. A man, likewise . . . divided from any of his fellows has thereby fallen away from the whole community . . . His feelings of hatred or aversion bring about his own estrangement from his neighbour and he does not see that . . . he has cut himself off from the whole framework of society . . . It is in our power . . . to grow back and become one with our neighbour again, so playing our part once more in the integration of the whole . . . (Marcus Aurelius 2004:142)

This handbook of group therapy is a guide to the group-analytic model – the prevailing form of group therapy in Europe. It is based on my own engagement as a practitioner and draws on the words and experience of people in groups as they face psychotherapy’s key challenges – understanding and change. The book is written with three different readerships in mind. First it provides a manual of practice for therapists’ use that includes detailed descriptions of groups at work; accounts of therapists’ experience and the issues they face in themselves and their groups; tables, diagrams and up-to-date literature. The book is illustrated with vignettes drawn from groups of different kinds, each of which is followed with a commentary that discusses dynamics and interventions. Second it is intended for those seeking psychotherapy, whether to resolve personal problems or to find new sources of meaning in their lives. The vignettes will give the interested general reader direct access to groups at work. And third it is intended for policy makers in mental health, students of different models of psychotherapy and the psychosocial field. The comparative discussion running through the text about methods and models of practice will be of interest to the wider mental health and psychotherapy fields. The other principally psychodynamic models of group therapy – the Tavistock, Interpersonal, Psychodynamic, Modern Analytic and Systemic models – are brought into a comparative discussion with the Group-analytic one and drawn upon to create an integrated and coherent approach.

2  Introduction

It is organised in three sections. Section I lays down the foundations. Chapter 1 is focussed on the aims and vocabulary of psychotherapy; Chapter 2 sets out the relational, reflective and reparative dimensions of group psychotherapy; Chapter 3 explores the developmental experience of the group; Chapter 4 is on the language of the group – monologue, dialogue and discourse; Chapter 5 addresses speech and silence in the group; Chapter 6 defines terms in the frequency, duration and composition of groups in the current field by describing ten representative clinical studies in UK practice; and Chapter 7 concludes the section with a systematic comparison between the group-analytic and the other main models of group psychotherapy. Section II explores the basics of the group-analytic approach through three primary concepts in clinical theory – structure, process and content – which are used to frame a wide-ranging enquiry across the field. First, Chapter 8 provides an integrated review of the three primary concepts, each of which is then studied separately; Chapter 9 focuses on structure; Chapter 10 is about process; Chapter 11 is about content. The section is concluded with Chapter 12 devoted to the conductor, who is considered in their three different roles – as a person in the group, as the group’s convenor and as its therapist. These first two sections of the book are intended to be of use for all who call on the group-analytic model for guidance in providing either supportive or dynamic psychotherapy and for those who use groups in teaching, consultancy or organisational work. They will be useful to those providing groups for children, adolescents and the elderly, those working in community support and those providing therapy for people affected by severe physical or mental illness and trauma. Section III goes beyond the basics to explore the dynamics of change in group-analytic psychotherapy. Chapter 13 focuses on a group’s four domains of meaning – current, transference, projective and primordial/archaic; Chapter 14 singles out the transference domain for special attention and reviews the use made of transference and countertransference throughout the book as basic therapeutic principles along with projection, identification and projective identification; Chapter 15 explores longing and belonging and the dialectic between them in groups through studies of holding, containment and play; Chapter 16 considers the language of suffering and its symbolic meaning, the voice of the symbol and the relationship between metaphors in group psychotherapy and their ‘products’ – metamorphosis; Chapter 17 looks at principles of therapeutic method that lie at the heart of the group-analytic model – the integrated use of location, translation and interpretation; and the conclusion, Chapter 18, reviews the scope of the book; the evidence base for practicing the model; opens a discussion on training, supervision and the ethics of good practice and on the methodology behind the use of vignettes in which former group members have ‘the last word’.

Heuristic learning It is hard to do justice to group therapy in writing. Whether a group session is active or quiet, there is just so much happening. The conductor has to be mindful at many different levels and contend with so many people at once. Anyone who

Introduction 3

has been moved by a chorus of voices, inspired by a team at work, embraced by the unforgettable emotions of a family’s life – for better or for worse – will know that you cannot reduce a dance to its footsteps. There is something extraordinary about shared experience that seems to stand beyond reason and explanation. The vignettes are written to convey this and, carrying much of the book’s weight, they run through the text like a spine. They are followed by commentaries to engage with the reader in looking for reason and explanation in the unfolding events of therapeutic process. Sometimes they can find neither and stand at the threshold of what I call portal moments – moments that open the door between the unspoken and unspeakable – in silent respect of the extraordinary. As a book about human experience this is not written with a view to simply ‘technical’ understanding. The only way to gain sufficient understanding of group psychotherapy to practice is – like all heuristic methods – through apprenticeship. The best way to learn about the subject of this book is not by reading it but by joining a group conducted by a sound group analyst. If, however, there is no group available, then the book is intended to serve this and other purposes. Much of its narrative and all its illustrations are based on what people say and do in group therapy. It draws on my own experience – first of being in therapy, then of training and then practising for 35 years. I have worked with people in different walks of life and settings amongst whom I have learnt a great deal, and I continue to do so. For much of this time I have been a teacher in training institutes, at conferences and meetings. Many of the chapters contain material prepared for teaching, so I am indebted to my students over the years for teaching me how to teach them. I am even more indebted to those who have been in therapy with me from whom I have learnt much of what I need to know to do the job. Going to work as a group analyst is a privilege every day – it is sometimes humbling, sometimes inspiring, sometimes challenging and frustrating, but it is always of compelling and touching interest. Heuristic approaches are experience-based techniques for learning, discovery and problem solving that rely on our natural human affinities to talk and work together in groups. They can equip people to enrich and speed up the process of self-development by learning to use their own ‘rules of thumb’.1 In groups people gain confidence to call on their own educated guesswork as to what it might be that is hurting or wrong in their own lives and those around them. This can improve self-esteem and, by enhancing intuitive judgment, people can learn to use their own and fellow group members’ common sense to deal constructively with the troublesome and sometimes darker dimensions of life’s problems and turn adversity into a teacher. There is ‘strength in numbers’, as Nitsun describes (Nitsun 2001), which can be called on to better equip a group of people to face the unspoken and sometimes unspeakable issues that bring its members into therapy, as Chapters 4 and 5 illustrate. The atmosphere of ‘self-help’ is cultivated in a well-composed group comprised of people brought together according to ‘the principles of similarity and difference’ described in Chapter 9. When people’s natural relational sense is guided by a therapist whose resources can lead them into the next two dimensions of the work – the reflective and reparative

4  Introduction

dimensions – then all three dimensions can work together to achieve the sometimes profound qualities of resolution, recovery and change described in Chapter 2. The conception of the group as a forum that can turn people’s experience of adversity into new sources of knowledge sees hope as a new emergent and the key to its transformative process (Hopper 2001; Yalom and Leszcz 2005; Rosenthal 2013; Wainstein 2013; Levine 2014). Wainstein explores Intimacy in the group as a process and, using the myth of Pandora’s Box, offers seven conceptual topics of trust, being known, white noise, authority, conflict, reciprocity and hope that need to be worked through in order to be able to relate intimately . . . We sit with white noise and mess in an effort to integrate splitting and conflict. By tolerating the unfairness and pain of reality together there is potential for mutually reciprocal and loving relationships. (Wainstein, 2013:63)

Defining group psychotherapy Group-analytic psychotherapy provides a powerful psychotherapy with beneficial results in a wide range of applications. When members of a troubled population are brought together, common sense would lead us to see their troubles multiplied. To greet a lonely, depressed person with the encouraging news that you have a group of such people just waiting for them to come along is to invite ridicule. A troubled child who feels they don’t fit or belong will not be encouraged by an invitation to join a group of others just like themselves. Groucho Marx’s famous saying – that he wouldn’t want to belong to any club that would have a person like him as a member – stands above the door of every consulting room in which group therapy is practised (Marx 1994:321). Most of us when troubled would expect to feel a lot worse amongst others with similar problems. A hospital psychiatric ward is not an encouraging place to go when in despair or depressed. In a prison setting we know that criminals often reinforce each other’s worst attributes. Insight, outsight and the paradox of the group We also know that therapeutic groups – even for those in prison – can work in just the opposite direction and equip people to bring each other healing and change. This book explores how and why this is possible. The use of group methods in psychotherapy rests on a central paradox. Exposure to one’s own problems as they are experienced in the lives of others facing you can bring about change of an unforeseen and unexpected kind with far-reaching consequences. A therapy group fosters intimate conversation providing both insight and outsight2 and, when led by a reliable therapist, can relieve pain, undo isolation, resolve distress, provide healing and make for deep-seated changes in the inner life and personal relations of most of us.

Introduction 5

Vignette 0.1  About Heaven and Hell

In The Theory and Practice of Group Psychotherapy, Yalom and Leszcz recount an old Hassidic tale about a rabbi who had a conversation with the Lord about Heaven and Hell. He was led on a visit to both and found in Hell that its occupants suffered starvation in the presence of delicious food. The only utensils were spoons too long to reach their mouths and the food was too hot to be handled. The place was characterised by the tormented gestures of hungry people struggling with food they could not get into their mouths. On visiting Heaven he found the same hot food in large vats and the same long spoons but the ‘saved’ looked nourished and satisfied. He was informed that the difference ‘. . . Is simple but requires a certain skill. People . . . here have learned to feed each other’. (Yalom and Leszcz 2005:13)

This parable reverses Sartre’s famous dictum that ‘L’enfer, c’est les autres’ (‘Hell is other people: Sartre 2000:223.) The reversal holds good in a story from real experience in the Holocaust.

Vignette 0.2  Survival and reciprocity

In a television documentary, a mother and daughter, both of whom had gone on to lead rewarding lives, described some 40 years on how they once struggled against starvation in a concentration camp in the closing days of World War II. They had a little food but could not agree on who should eat it. Mother wanted the daughter to survive and the daughter wanted it for the mother. Eventually they agreed they would feed each other. They did so with their crude utensil mouthful by mouthful and so they both survived. When the camp was later liberated they saw other inmates preparing to murder their former guards and brought this to the attention of the liberating soldiers, who interceded. The soldiers asked them, after all they had endured, how could they still care? They replied that it was because they cared that they had survived. It was not only the food that sustained them but their mutual care – the reciprocity of their bond – and the light this shed on the value of human life. (Weisner and Zeleny 1979; Bodenstab 2004)

6  Introduction

Resonance and reciprocity In putting relational resources like these to work group analysis relies on a paradox that is part of the human condition. Healing and resolution can be found for suffering in the very association of those who are hurting. Groups can be equipped to work as therapeutic agents by setting a process in motion that cultivates resonance and reciprocity in which ‘Giving help (becomes) the very process by which one might receive help, and therefore develop towards health . . . a unique and radical component of group analysis’ (von Fraunhofer 2008:288). The intimate fellowship created by the regular meetings of a small group provides a forum for growth and change which, when led by a reliable therapist in a contained setting, can stimulate development and provoke reflexive questioning – self-examination – with radical, reparative and far-reaching consequences in the lives of most. This text celebrates these paradoxes and their applications. A woman whose childhood was blighted by injury and abuse said, on leaving a group, that she discovered here that it was never too late to have a happy childhood. She later went on to raise a family of her own and develop a career. Part of her story is described in Vignettes 5.2, 5.3 and 5.4. One of the most telling definitions of group therapy comes from a survivors’ group conducted in a centre for refugees.

Vignette 0.3  Sipology with soap and bubbles

Mustafa was an Iranian Shi’ite and, though fluent enough in English to be eloquent, had endearing quirks of miscommunication due to his Farsi diction. He first joined us with florid post-traumatic symptoms and fractured relations with his family, some of whom were with him in London and others in hiding at home. After two years of group therapy we were reviewing our time together in the closing sessions when he came forward with the following: ‘This sipology group’, he said, ‘Is like a band of brothers (the film [Band of Brothers] was being screened at the time on television) but it’s not for war. We come together each week like a band of brothers who go to the laundrette and you therapists climb in the machine with us after you put in the soap powder and turn on the switch so we go round and round with you in soap and bubbles for 90 minutes. We come out each week cleaned by the sipology of talking and listening so we can go home safely, love our families and give thanks to God’.3

From a mouthful of air – the spirit of sipology, soap and bubbles There are many such stories that testify to the working benefits of group therapy across the spectrum of need and experience. In a poem to his beloved, Yeats

Introduction 7

answered the question of how he formed his poetry. ‘From a mouthful of air’, he said. ‘Weigh this song with the great and their pride/I made it out of a mouthful of air’ (Yeats 1990: 85). The spirit of this discovery introduces this book. A band of brothers or sisters can invoke the spirit of sipology, soap and bubbles in a mouthful of air to garner happiness from their own lost and blighted histories. Humour can also bring the more serious into relief, and the book’s single, most urgent question is its focus on the conductor’s primary job – to equip people to ‘play’ safely with human experience and do so across its widest range of emotions. The sense of play is not to reduce experience to its toys but to see in the play of words, and in the play of feelings that may have no words, a chance to capture anew amongst others, the gifts of people’s own experience. Rosenthal (2013) demonstrates that even adversity has its gifts. Groups can help us find these gifts through process that is relational, reflective and reparative. An ‘invitation to the dance’ can be taken from the Beatles song of 1969, ‘Come Together’, an invitation to come together when we might otherwise fall apart. Therapy groups are comprised not only of those who consciously need one another but also of those who, fearing injury at others’ proximity, can find safe forms of intimacy often for the first time.

Evaluating group therapy – metapsychology versus practice Levity does not call into question the need for evidence that can be tried and tested by numbers. Today more urgently than ever we need to make informed use of valid and reliable evidence to support the benefits of our work. The custodians of psychological services are now cost keepers as well as clinicians. Many invaluable therapeutic resources, including group programmes, have been dissolved for want of an evidence base and no transparent benefits or structured results. When those responsible for psychotherapy programmes based on other models – whose work involves structured forms of programmatic therapy – insist that group analysis is a model without a theory and a practice without a method, many group-analytic colleagues have found themselves needlessly silenced. But a response that insists on the claims of a radical new method introduced during World War II and expounded in texts written between 1948 and 1975 is hardly a reply. Unfortunately, many current publications in group analysis stand shy of urgent clinical questions about working practice. Much of the contemporary literature in group analysis favours metapsychology and theory at the expense of key practical questions that our trainees face at the workplace. There are many welcome exceptions to this profile that will be documented in this book. Recent writing with and without clinical focus Clinically focussed writing Writing with a strong clinical focus includes the distinctive contributions that the group-analytic approach has made to forensic psychotherapy described

8  Introduction

on page 15. Publications by other group analysts who have made vital contributions include de Zulueta and Mark (2000), Friedman (2004, 2008, 2011, 2013), Gordon (2005, 2009), Kennard, Roberts and Winter (1993), Lorentzen (2014), Molnos (1986), Nitsun (1996, 2006, 2015), Pines (1998, 2015), Urlić (2004) and many of the dissertations written by students during the course of their training including those at the Institute of Group Analysis, London, cited throughout the book. Barnes, Ernst and Hyde have a good introduction to therapeutic group work based on the group-analytic model that is in standard use (Barnes, Ernst and Hyde 1999), and there are important contributions to clinical practice by group analysts and others in both Schermer and Pines’s edited collection Ring of Fire (1994), which is of enduring importance, and in Kleinberg’s recently edited collection The Wiley Blackwell Handbook of Group Psychotherapy (2011). The only current, comprehensive studies of clinical practice in group-analytic psychotherapy are available in Croatian (Klain 2008), Norwegian (Karterud 1999) and Portuguese (Cortesão 1971, 2008). Writing without a clinical focus Theory is of critical importance to the way in which we practice, and some of the recent publications in English include studies of Foulkes himself by Pines (1983), Bledin (2003, 2004), Dalal (2000, 2014), Lavie (2005) and Nitzgen (2008); of culture in groups and groups of different cultures by Weinberg (2003); of gender by Burman (2011a, 2011b); of complexity theory by Stacey (2001, 2003); and of metapsychology by Ormay (2012) and Weegman (2014) and of political and violent disruptions in civil society (Mojović 2015). Pines’s writing has done more to shape group analysis than any one else since Foulkes (Pines 1998, 2015). Chapter 1 traces a distinctive line of theoretical development that builds on the study of context and communication in language and musicality that provides a key focus for this book and includes several of the writers already cited in this introduction and includes Thomas (2002); von Fraunhofer (2008), Brooks (2009), Wotton (2011, 2013), Verebes-Weiss (2011), Levens (2011), Rayfield (2013), Tyerman (2012), Wainstein (2013) and Peleg (2012). The German contribution, particularly in the writing of Mies (2012, 2013) and Schultz-Venrath and Kütemeyer (1984, 2011), is taking up lost links to the origins of group-analytic theory in the pioneering work of Buber, Cassirer, Goldstein, Mannheim and Elias which will have bearing on how the discipline matures in current theory and practice. Does group therapy help its clients? The dominant line of metapsychology in group analysis has the unfortunate consequence that we conduct our work as if the evidence base for its benefits in the

Introduction 9

wider field is not yet secured on any set of convincing terms. This is simply not the case. As early as 1970 Yalom assembled an evidence base pointing to the incontrovertible benefits of group therapy in a passage that has been replicated in every subsequent edition of The Theory and Practice of Group Psychotherapy. It is set out more fully in Chapter 2 on page 64: Does group therapy help clients? Indeed it does. A persuasive body of outcome research has demonstrated unequivocally that group therapy is a highly effective form of psychotherapy . . . (with the) power to provide meaningful benefits. (Yalom and Leszcz 2005:1) There are strange constraints at work in our profession which mean that students learn of Yalom’s 11 therapeutic factors and can recount them immediately, but few know the research-based, empirical questions that these questions were intended to clarify, posed from the very first edition of his book onwards. These constraints in our institutions and professional culture obscure what is already in hand, deprive us of our own landmarks and leave us working across a divided field. It did not begin like this. Foulkes’s widow Elizabeth describes how: One of (Foulkes) lasting regrets . . . was the difficulty of obtaining funds for major research in psychotherapy. He and his colleagues spent time and effort on designing workable large-scale research projects (but) without success. (Foulkes 1990:17) NIHCE and evidence-based practice in the UK, Europe and the United States Foulkes’s closest associate who settled in the United States was Grotjahn, who also put questions of empirical evaluation at the centre of his own concerns (Grotjahn 1983). Group therapy in North American practice has developed a robust and sound evidence base. Despite Foulkes’s own early interest and – perhaps – because his most numerate follower, Anthony, left the UK for the United States, those working in the Foulksian tradition in the UK have a strange disinclination to count. Chapter 6 will demonstrate these puzzling consequences. As a result group therapy in the UK has no status in the clinical guidelines of the National Institute for Health and Clinical Excellence (NIHCE) as an evidence-based practice. The implications are as avoidable as they are lamentable. Our field is diminished when those with competency in research methods spend so little time turning these numbers into an audit that could be properly evaluated.

10  Introduction

Evidence-based practice in the United States In the decades following Yalom’s first edition, the evidence base has been strengthened. There are currently well-developed programmes for audit and evaluation in North America, Germany and Scandinavia. The website of the American Group Psychotherapy Association gives a comprehensive picture of seven discrete areas in which group therapy has an evidence base for effectiveness: www.agpa.org/ home/practice-resources/evidence-based-group-practice. This is considered in Chapter 1, and some of it is documented in Chapters 6 and 18. We look forward to a time when work in the UK can be strengthened on similar terms. Lorentzen’s recent work (2014), studied in Chapters  3 and 6, is of vital importance but we continue to behave as if the only practitioners with a valid and reliable evidence base are those working with other models. Whilst wise practitioners often behave as if we cannot count, those with the research skills to provide the necessary quantitative and qualitative evaluation overlook the needs of their clinical colleagues. The divide remains puzzling and close collaboration across it is urgently needed. From Dick to Lorentzen: 10 clinical studies in Chapter 6 Chapter 6 documents ten relevant studies, eight of which are devoted to groups in a range of public services where the group-analytic model delivers therapy to a wide population. Its two concluding studies review my own private practice to give an audit of block and twice-weekly groups over a long period of time. This book relies on vignettes drawn from these groups, so the book as a whole illustrates these two concluding studies. The first of these studies of groups in public service is Dick’s 10-year study of outpatient analytic group psychotherapy in the NHS, which goes back to 1975. She evaluated the work of 11 therapy groups providing each of 93 people with up to two years of outpatient group psychotherapy. Some 40 years later Lorentzen’s studies in Norway’s public health service cover the same ground to integrate clinical and research expertise and to evaluate the significance of treatment duration in closed groups offering once-weekly group therapy for a mixed population of 148 prototypic patients. Six further studies of once-weekly small group therapy with homogeneous populations in different public settings are reviewed in the years between these landmark studies. The audit of my own twice-weekly and block groups in private practice introduces a simple instrument I devised to monitor their process and outcome.

The group-analytic approach: social theory and clinical practice Our faith in groups takes on the relevance of a jury in judicial proceedings and competitions, a parliament in government, a cabinet in authority, a committee in management and a congregation in worship. All the significant rites of

Introduction 11

passage that mark someone’s birth, adulthood, partnership and death bring people together as families and groups to invoke those dimensions of life by which we are related to and through the others who make our lives meaningful. Most people can be helped – through membership of a group established for therapy – to gain a relational context through which life can be renewed, whether we have backgrounds that provided satisfying experience in our families of origin and society or if we have been isolated and injured by circumstances of origin, ill-health or events. Tucker (2004) and Adshead (2009) describe group therapy as a pro-social therapy: Forensic mental health work requires an understanding of not just the antisocial in man, but also the pro-social. Unless we can harness the psychological elements of pro-social behaviour and utilize healthy group processes in the work force, we will not be able to mount mature defences against the anti-group in forensic institutions. (Adshead 2009:88–90) The potency of groups means that if they can help, they can also harm. Groups can bring hurt as well as healing. The two elementary conditions for successful group therapy – on the one hand, membership and composition and on the other, the capabilities of the conductor – both have determining influences on the quality of a group’s work. Chapters 9 and 12 are devoted to each of these topics. But the irony in the humorous definition of a camel – a horse designed by a committee – points to the recognition that collective process can readily bring distortions. There are only small degrees of separation between a group that is constructive and one much more like a gang in its destructiveness. A crowd can express itself with civil accord but can easily become a mob.

Social theory and history Freud’s late work The metapsychology of group therapy – its values, underlying assumptions and philosophy – has its own historical context. Group and family therapy emerged on both sides of the Atlantic at similar points in history around World War II, during and in the aftermath of collective processes that were unsurpassed in their assault on humanity and their attack on life itself. Recognition of a group’s therapeutic potential arose paradoxically at a time when destructive social relations put the whole world in danger. We remain in the shadow of these historical threats. Freud’s own account of Civilization and Its Discontents looks backwards from 1930 but contains a grim foretelling of impending violence. He later noted at the time of the Nazi book burning in Berlin in 1933 that they were only burning his books now and not the person himself. But the ‘optimistic’ conclusion he drew – that this was a sign of society’s progress since the Middle Ages, when they would

12  Introduction

have burnt him – was belied by the fate he would never live to see, awaiting most of his family in the Holocaust (Cohen 2009:xiii). The events of the Holocaust would have found a place in his book. It describes the worst forms of suffering that history recorded until 1930, visited by humans against one another  – and it provides a grounded account of how destructive processes remain a constant feature of our sociability. The source of group analysis: Frankfurt – a centre of enlightenment The foundations of relational understanding The intercollegiate exchange of clinical perspective and theory that flourished in Frankfurt until 1933 was the ‘source’ of group analysis – and the source of a great deal else in the psychosocial field. This intellectual matrix was one of the first targets of Nazi ascendancy and was soon destroyed by arrest, exile and death. Despite this, those named here have had an influence on medicine, social science and psychosocial theory for generations, on terms that cannot be overstated. The profound impact of their contributions has yet to receive an integrated study. One of Foulkes’s mentors was the neurologist Kurt Goldstein, who developed a clinic in the city for brain-injured soldiers during World War I that he directed until 1930, when he moved to Berlin. As well as Foulkes, Fritz Perls, the founder of gestalt therapy, trained with him. The philosopher Ernst Cassirer – both a colleague and a relative of Goldstein – spent time at the clinic, and a two-way channel was opened between philosophy and clinical practice that influenced Foulkes, who was then director of the city’s Psychoanalytic Clinic that in turn shared premises with Horkheimer’s Institute for Social Research. This institute had a formative influence on Adorno, Fromm and many others including Foulkes. Foulkes was also associated with another range of visionary thinkers at the city’s Goethe University. Wertheimer developed gestalt psychology and, under his influence, Kurt Lewin devised the principles of group dynamics that he later developed at the National Training Laboratories in Maine, United States; Mannheim and Elias developed the sociology of knowledge; and earlier still, Martin Buber wrote his I and Thou (1923/2000), a seminal text in theology and philosophy that has had a profound influence on the relational field. Millard’s exploration of its relevance to clinical practice is described in Chapter 1, and elsewhere Maurice Friedman’s study (2002) explores the lines of influence from Buber and the other pioneers named here. Lavie (2005), Nitzgen (2008) and Mies (2012, 2013) consider their impact on Foulkes. From 1933 all those named here were driven into exile. Mann­ heim, Elias and Foulkes settled in London, and Adorno, Cassirer, Fromm, Goldstein, Lewin, Horkheimer and Wertheimer settled in the United States. Those identified can be named because they survived and led productive, though in some cases foreshortened, lives. Their biographers associate the early deaths of Mannheim and Lewin with exile and displacement, and those who perished in the Holocaust were a multitude.

Introduction 13

The psyche and the social world: Foulkes’s locational interest We can take a philosophical interest or we might not, in debates about individual and society and in the paradoxes created by group therapy between the one and the many, the psyche and the social world, the ego and its social identity, the ‘wego’ between the individual and the social unconscious. Some believe these issues have only passing relevance to clinical practice. But questions about whether the organising principles of the psyche belong within the individual mind as Freud sometimes believed or whether the human mind can never be understood individually but only as one amongst others – in the context of our primary and secondary groups – as believed by group and family therapists today will be of profound relevance to how we practice. Exploration of these issues runs through this text, and a reader who is new to them may find that Foulkes’s account of the location of a disturbance at the opening of Chapter 17 makes them immediately relevant. At the conclusion of his foreword, Anthony celebrates Foulkes’s locational interest making its influence clear on his own development of resiliency studies, a subject he helped establish. Today it is a wide field of clinical and social studies, and though its Frankfurt sources are invisible they are vital, as they are in the widespread use of the Foulksian model across 10 clinical applications in the UK described in Chapter 6. The key group-analytic principles described in Table 0.1 have bearing throughout this book and underlie many of the applications described.4 Five key principles in group analysis: from Buber to semiology The concluding principle in Table 0.1 has its origins in the work of Buber and two Russian academicians, Bakhtin and Vygotsky, who, though contemporaries of Table 0.1  Elementary principles in group-analytic theory 1 Our understanding of human relations needs to be relational. When it comes to analysis and therapy, relations ‘between’ take precedence over relations ‘within’. 2 In the configuration of wholes and parts – cities and suburbs, societies and citizens, groups and members – we need a picture of the whole, the gestalt and its form, in order to understand the parts. We can only form a picture of the whole by considering the parts. The psychology of wholes and parts – gestalt psychology – is a challenge of form and feature, of the individual and their context. 3 If we want to help someone grow and change we will do so much more successfully if they are amongst others. This ‘plurality of interdependence’ calls on the restorative potential inherent in people’s social bonds. 4 Mental processes always imply a real or imagined set of others, even when they look ‘as if’ they belong to one person. 5 Language is one of the first ‘currencies’ of sociability. And so, from a relational standpoint, the unconscious is inherently social and can be explored through the language forms of interpersonal process.

14  Introduction

Buber, had lines of influence separated by World War I and the Russian Revolution. Pines introduced these Russian contributors to English-speaking readers, as he also first brought the work of Mead to the attention of group and psychoanalysis. Mead’s relevance is well described by Burkitt (2008), and Wright puts Mead’s thinking to work in psychotherapy practice in Chapter 15 (Wright 2009). Pines’s own Selected Papers will soon be available which call on these different early contributors and reveal his own decisive influence (Pines 2015). Bakhtin’s first book, long believed lost, Towards a Philosophy of the Act (1993), introduced what he called ‘dialogism’ as a way of approaching relationships. He offers us a model of the psyche in three forms: ‘I-for-myself’, ‘I-for-the-other’, and ‘the-otherfor-me’, out of which he believed personal identity is forged. In a similar vein Buber conceives of a radical difference between the I-Thou and I-It relationships, a difference that is framed by his own language that I have called on for quotations to open Chapters 1 and 2. Millard, in Chapter 1, calls on Buber’s philosophy to describe how group therapy works. Today intersubjective theory and transpersonal psychology rely on these (often invisible) foundations. Vygotsky was one of the first developmental psychologists and made a unique contribution to understanding language acquisition with an account of the zone of proximal development – widely influential in education – that has parallels with Foulkes’s idea of the common zone that runs through this text (Chaiklin 2003; Kozulin, Gindis, Ageyev and Miller 2003). The development of the new field of semiology also draws on these foundations with immediate relevance to group analysis (Kristeva 1995, 2010; Beardsworth 2004). Semiology has been influential in my own construction of psychotherapy’s three dimensions in Chapter 2 and in the three forms of a group’s language in Chapter 4. These ideas are under active and creative development in Germany, where the group-analytic field is enjoying vital innovation amongst writers who combine clinical practice with theory like Mies and his colleagues (Mies 2014).

Group-analytic psychotherapy Early development Foulkes was the only clinician associated with the different Frankfurt circles to take up residence in the UK, where he linked up with the sociologist Norbert Elias. The early development of group analysis arose out of a collaboration between them, which is demonstrated in Foulkes’s first book and in the first edition of his second, written with Anthony, that contains original references to the figurations of group experience (Foulkes 1948; Foulkes and Anthony 1957). The thrust of Foulkes’s contribution was in clinical practice beginning in Exeter and – moving on to Northfield – in the pioneering military hospital near Birmingham. The principle of the therapeutic community was established in adult psychiatry at Northfield and was later developed by Main (2001) and Maxwell Jones (1953, 1968). Their use of large groups was later extended by de Maré (1991) and applied to

Introduction 15

institutions and mental health treatment and training programmes (Kreege 1975; Weinberg and Schneider 2003). These pioneers, together with Anthony, also based at Northfield for a time, as his preview to this book describes, were the founders of the Group Analytic Society described in Chapters 6 and 18. Anthony went on to co-author with Foulkes the single most widely influential text in the group-analytic field in 1957. His preview to this book, one of the last things he was to write, makes clear he was still contributing to the field until his death at 98. Current development As the 20th century came to a close emerging literature focused on The Traumatic Origins of Violence (De Zulueta 2006) sheds new light on the darker areas of The Social Unconscious in trauma studies (Hopper and Weinberg 2010), in the understanding of race and ethnicity (Dalal 2002) and in the study of repetition compulsions that can convulse whole societies or turn individual victims into perpetrators. Volkan has applied this kind of thinking to the wider political arena (Volkan 2001). In the UK, Cox (1978, 1996, 1998), Welldon (1992, 2012), Adshead and Pfafflin (2004), Gordon (2005, 2009) and Woods (Woods and Williams 2014) have applied their own distinctive understanding of attachment-based disorders and group analysis to the practice of forensic psychotherapy. Their work has led to the formation of an International Association of Forensic Psychotherapy, which has been influential on group therapy in clinical practice. Other vital contributors in North America include Gilligan (1997) and the Firestones (L. Firestone 1997; Firestone, Firestone and Catlett 2003; R. Firestone 2011), who have developed a unique synthesis of developmental psychopathology and clinical therapy, especially for the treatment of violence and suicide. The Firestones’ approach – ‘voice therapy’ – holds striking affinities with group analysis, as does Frosh’s applications of psychoanalysis outside the consulting room (Frosh 2010). Inside the consulting room Nitsun’s (1996) conception of the anti-group draws perspectives like these together so that group therapy can help us recognise the destructiveness inherent in all our social bonds. It offers the challenging but heartening recognition that even destructive processes hold prospects for their own transformation if they are honestly and openly addressed in the circles in which we meet. The violence of our current time – with knife crime amongst the young on the peace-time streets of our cities, in terrorist atrocities, mass killings and in the dismemberment of countries in conflict from the former Yugoslavia to Syria and Iraq – calls on all with concerns about the psychosocial field to develop our disciplines to meet the challenges of our own time (Friedman 2010, 2015; Ofer 2015; Schlapobersky 2015). Recent developments and the core of this book This book will illustrate the commitment in our field to applications that range from the mainstream of private psychotherapy practice to populations at risk who

16  Introduction

are specially troubled and marginalised and who are worked with in specialist settings described in this book (Greif and Efros 2010). Today practitioners across the field use groups of every kind to grapple with the demands and contradictions of our time in the troubles of a ruptured world. Small group psychotherapy – what Foulkes called therapeutic group analysis – is making a vital contribution, enriched by other applications in educational, consultative and organisational group analysis. This book is about that core. It is at the heart of the cycle of creativity that inspires our work with groups that has seen the field diversify to promote growth and serve need in all social classes and life situations. The applications include groups for psychiatric patients in some of Europe’s most dense conurbations and remote places whose lives have been transformed, asylum seekers and refugees, forensic patients in secure settings, private practice, work in government, corporations and training and in medical colleges and university departments of psychology. In contrast to this range of successful applications, the group-analytic approach in Europe has not kept pace with other models in North America and continental Europe in providing group services for children, the elderly and the medically ill, with a few notable exceptions. When this text was written there was little to draw from in current English literature in these areas, so it serves to highlight gaps in the field as well as to identify strengths.

From Foulkes the person to Foulksian practice The group-analytic ‘turn’ Foulkes’s own writing leaves questions of therapeutic method – of how to practice – strangely incomplete. A reading of his first book describing the Northfield experience shows him at work cultivating accord, gaining access to the most troubled areas of people’s lives and seeing to their resolution. Nitzgen draws our attention to its originality and radical import (Nitzgen 2008), and in Chapter 14 I have named this the period of his group-analytic turn. However, with the notable exception of the text written with Anthony his books are hard to commend to modern readers. Had he written them in German as some of his most notable peers like Goldstein and Fromm wrote theirs, we might have more access to what he set out to convey, for his contribution stands beside theirs in originality. Had he done so, however, group analysis in the UK may not have flourished in the way that it has. A personal and oral tradition For those of us who are not S. H. Foulkes – everyone else in fact – how do we get results in this model without direct access to the man? Many of our pioneers benefitted profoundly from their personal relationships with him as patient, supervisee and colleague, and some lived through these stages and went on to pioneering work in their own right. But how do we take a personal and oral tradition

Introduction 17

forward when Foulkes’s own writing is so far short of what is needed to impart his model once the last of those pioneers who knew Foulkes personally is no longer with us? Nitsun (1996), Dalal (2000), Levens (2011) and others have addressed some of the deficiencies and ensuing problems in his writing that are discussed in Chapters 14 and 17. Weegmann suggests this incompleteness is one of the strengths that keeps the approach human and safe from reductive or manualised terms (Weegmann 2011). This important point leaves open for question how we get results in the Foulksian approach if we are not Foulkes himself. Falling back on ourselves: Socrates and psychotherapy We have the writing of his successors to guide us and must then fall back on ourselves, as both Skynner and Weegmann, in their own writing cited in what follows, encourage us to do. Skynner suggests this was the undeclared intention in all that Foulkes was about – getting people to fall back on themselves. With this as my purpose I have approached Foulkes and Anthony’s available literature and, with the generous support of my own teachers like Pines and Hearst, I have drawn this book up to embody what their writing points us towards in its best practice. In a prescient observation that speaks to us across the decades Skynner said, All great men have their weaknesses, and (Foulkes) was no exception. He prided himself on his ability for conceptualisation which was not one of his strong points, not only in my opinion but according to the reaction of every audience of which I was a member, or in which I chaired his presentation. I can say that now he is not here, and I think it should be said, if only for the sake of the future of his own work. (Skynner 1983/1987:235) The accounts of those who knew and loved him describe a paradoxical charisma. Pines and Hearst describe how he appeared unassuming, relying on his personality to draw people towards him with a Socratic way of posing questions and assuming that those he was amongst would find the answers with him. As the Northfield story testifies this got results that others could not achieve. He was much loved in the field, engendered confidence amongst colleagues and patients and combined this unassuming manner with self-assurance and openness to self-scrutiny that many found disarming. He engendered trust and goodwill, creating what Anthony called ‘an ambient network’ of which we have a vivid picture in his preview to this book. In his Foulkes’s Lecture Skynner describes how the [c]entral principle in Foulkes’s ideas and methods which attracted me to seek contact with him (meant that) . . . he seemed to have this open, curious, questioning attitude, whereby he was always stepping back to examine the ground that he himself had just been standing on. By engaging in this constant

18  Introduction

search for truth himself, in a light, amusing and enjoyable way, he seemed to arouse in others, quite automatically, the same lively, high-spirited, searching attitude. And it was good fun, like a game. You were expected to catch the ball and throw it back, or throw it on. In teaching he expected to learn and made you teach him what was wrong with what he had said. Thus a stimulating process of mutual learning would occur, a shared search for new knowledge in which all could join, all could contribute and all could receive, including him. This simple principle was the most important thing he had taught me . . . And I saw that this, in essence, is the basis of the process we call group analysis. (Skynner 1984/1989:193) From the Maudsley Hospital to a world-wide influence Between 1950 and 1963 Foulkes was responsible for the group psychotherapy service at the Maudsley Hospital, the main post-graduate centre for mental health training in the UK associated with the Institute of Psychiatry. Junior psychiatrists were largely responsible for delivering the service under his supervision. Anna Freud, his close colleague, offered parallel supervision for individual psychotherapy, and there was a premium on gaining entry to these programmes. Many passed through them in their professional development, going on to later train in group and psychoanalysis including Anthony, Clark, Jackson, Fordham, Pines, Wolff and Skynner, who later described Foulkes’s presence as follows: His effect on those who came to work with him was already a legend and remains a mystery . . . Everyone who worked with Foulkes remains as puzzled about the nature of what they received from him as they are certain that they got it and that it proved of exceptional value in their lives. It was certainly not conveyed by intellectual, conceptual means. Even his speech often appeared confused, rambling on from parenthesis . . . so that one lost him long before the end of a sentence . . . but he was good humoured, full of fun and you enjoyed talking to him partly because he made you feel that he enjoyed talking to you. Above all, he had a marvellous sense of curiosity, a constantly lively spirit of enquiry he invited others to share. He believed that the group always knew more, could find out more, than any individual if its creative power could be harnessed. And he assumed the best way for the leader to facilitate this creative potential of the group was to throw any question open, to listen attentively to all participants, and to assume that all views might contribute to a solution . . . in this spirit he would lead, and throw his ideas into the ring like the rest. He generated an excitement, an eagerness to learn, where all members discovered that each really had something to contribute. (Skynner: Bethlem and Maudsley Gazette 1982: 14–16)

Introduction 19

This picture is both inspiring and endearing. In a lecture given some years earlier Skynner recounted how ‘I was attracted to what Foulkes was rather than to his ideas alone’ (Skynner 1983/1987:235) and describes ‘the profound change which often occurred in anyone who had personal contact with him even for a short time’ (1983/1989:235). But he went on to note that, for the same reasons, ‘his writings have not given him the degree of recognition he deserves’ (1983/1989:236), though he was ‘a living actualisation of the integration we are speaking about. And of course the ability to be, and to do, is the aim of therapy, to which the theories and techniques are only incidental’ (Skynner 1983/1987:236). Chapter 17 documents Foulkes’s emphasis on a ‘prescribed’ use of interpretation within a closely defined series of caveats. Reinforced by the writing of Pines and others who have extended the model, they can be found like a hallmark in all who have had a Foulksian training. However, much of the work in training our students takes place through clinical supervision of their practice and their personal assimilation of the model through their own group-analytic therapy. The textual transmission of method and precept has relied on a limited literature in which Foulkes’s own writing does not commend itself. It both intrigues and frustrates our students, as it has done for generations. Skynner points this out in what follows, and it may help us understand why the model has not ‘travelled’ to North America, for example, in the way Bion’s writing has. But Chapter 6 will also show how Foulkes’s terms and definitions are in standard use across the field worldwide. They will be found in all the models of group therapy. He established the terminology of our field at large with ‘open’, ‘closed’, ‘time-limited’, ‘slow-open’, ‘mixed’ and ‘homogeneous’ groups and ‘combined’ and ‘conjoint’ therapies. Skynner made another, critically important set of points addressed to these issues. He described: The enormous burden on our students, who . . . tend to feel their lack of clarity about group functioning, and about the way to intervene therapeutically, is due to some deficiency in themselves. Often it is not. It is due to the fact that, in addition to not having a clear and comprehensive theory to teach them, we are behaving as if we have . . . We have all somehow believed that an adequate theory of group psychotherapy existed, even if we ourselves had never quite been able to grasp it clearly. There is no point in going shopping if one thinks the larder is full, and we have therefore had no motivation to look at the whole matter afresh and try to remedy the deficiency. (Skynner 1983/1987:233–234)

On using this book – guidance for the reader The vignettes can be read independently of the chapters they illustrate and, with their commentaries, they provide the reader with a direct understanding of what happens in groups. Anyone new to the field and unfamiliar with its literature would likely find Chapter 5 on speech and silence in psychotherapy an accessible

20  Introduction

beginning. Clinicians and other practitioners new to the group-analytic model would likely find Chapter 12 on the conductor a good place to begin. In Section I the opening chapters will be of interest to a wide range of practitioners in psychotherapy and to students in the psychosocial field. They document a developmental progression first in the psychotherapy process, then in a group’s life, then in its language and in the interplay between speech and silence; and they provide definitions and terms of use for the main applications, comparing the group-analytic with other widely used models. They can be read sequentially or for their specific focus. Section II provides a systematic exposition of the basics in the group-analytic model leading to the person and role of the conductor. Together they offer a progressive narrative and will be of interest to group analysts and other therapists training to run groups. In Section III the chapters go beyond the basics to address the dynamics of change and look at the more complex and challenging issues faced by conductors. A group has a makeup like a hologram whose four domains are comprised of its current and transferential dynamics and its projective and primordial dynamics. They can allow a progressive interplay between longing and belonging if the conductor’s ‘orchestration’ can keep these domains open to one another. If these dynamics are wisely addressed by the conductor’s use of location, translation and interpretation as therapeutic principles, then a group’s work can advance through monologue to dialogue and discourse and develop from relational through reflective to reparative experience. These chapters will be of interest to experienced group analysts and therapists and to those who teach psychotherapy or who have any comparative interest in the different therapeutic models. The concluding chapter surveys the book as a whole and reviews some of the key professional topics. It is intended to make the book relevant to policy makers in mental health and those concerned with NHS practice and management. The conclusion has in its closing pages a section titled ‘The Last Word’, which is given to group members from the past who, on being asked for their consent to the publication of vignettes in which they might recognise themselves, have come forward unprompted to furnish comments about their past experience. They vary in their retrospective span, with some going back one or two and others more than 20 years. Group psychotherapy is a vital, diverse and developing field with large attendance at conferences and meetings, a rich and growing literature and a sizeable student enrolment in courses and training programmes in many countries, despite the stringencies of our time. From the Couch to the Circle will appeal to all those interested in groups and therapy, discourse and communication theory, the emerging relational paradigm of psychoanalysis, those working in psychodrama and those working systemically in family therapy. It has been written during my period of tenure as a Research Fellow in the Department of Psychosocial Studies at Birkbeck College, University of London, where the department’s parameters of study have helped set a context for its scope. Grateful acknowledgements are made to Professor Stephen Frosh for the department’s hospitality.

Introduction 21

Notes 1 The phrase ‘rule of thumb’ has ancient origins and is in common use in many languages and language families. It denotes a principle with broad application that is not intended to be strictly accurate or reliable for every situation but one which is easily learned and applied for making determinations. 2 ‘Outsight’ is one of the terms in group analysis that readers may be unfamiliar with. Although barely defined, it is relied on in our field as the group equivalent of insight in psychoanalysis and this book seeks to define its use. It is called on throughout as a key to the dynamics of change in groups. It is described in the Introduction on page 4 and defined in Chapter 2 page 61; illustrated in Vignettes 8.1, 8.2, 9.1, and 10.2; related to mirroring in Chapter 10 page 255 and Vignette 10.2; and to longing and belonging in Vignette 15.2. 3 I acknowledge the valuable contribution made to the work described here by my colleague Paul Burns, who conducted the Men’s Survivors Group with me as co-therapist for more than two years, first at the Medical Foundation for Victims of Torture and then at the Traumatic Stress Clinic, University College Hospital, London. There are further such groups described in Chapter 10, Study 6, and in Vignettes 10.8, 16.1 and 16.3. This work stands as a tribute to the late Helen Bamber, founder of several foundations devoted to work with refugees and asylum seekers, to whose memory this book is dedicated. She was my original co-therapist in the first group we established with this population in 1986. 4 I am indebted to Thomas Mies for his guidance in the drafting of this account of Frankfurt as the source of group analysis and in the construction of Table 0.2.

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22  Introduction Brooks, F. (2009). The Othering of Silence In Groups. MSc Dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Buber, M. (1958; reissued 2000). I and Thou. Trans. Ronald Gregor Smith. New York, Scribner Classics, Simon and Schuster. Burkitt, I. (2008). Social Selves: Theories of Self and Society. London, Sage. Burman, E. (2011a). Psychology, Women and Political Practice in Britain. In A. Rutherford, R. Capdevila, V. Undurti and I. Palmary (Eds.), Handbook of International Feminisms. Perspectives in Psychology, Women, Culture and Rights. New York, Springer, pp. 219–246. Burman, E. (2011b). Taking Women’s Voices, or the Psychological Politics of Feminisation. In N. Bozatsis and T. Dragona (Eds.), The Discursive Turn in Social Psychology. Athens, Metaxio, pp. 259–290. Cassirer, E. (1955; 1965). The Philosophy of Symbolic Forms. New Haven, Yale University Press. Chaiklin, S. (2003). The Zone of Proximal Development in Vygotsky’s Analysis of Learning and Instruction. In A. Kozulin, B. Gindis, V. Ageyev and S. Miller (Eds.), Vygotsky’s Educational Theory and Practice in Cultural Context. Cambridge, Cambridge University Press, pp. 39–64. Cohen, D. (2009). The Escape of Sigmund Freud. London, JR Books. Cordess, C., and Cox, M. (1996). Forensic Psychotherapy: Crime, Psychodynamics and the Offender Patient. London, Jessica Kingsley. Cortesão, E. L. (1971). On Interpretation in Group Analysis: Keynote Paper, First European Symposium in Group Analysis, Estoril, Porgugal 1971. Group Analysis 4: 39–53. Cortesão, E. L. (2008). Grupanálise, teoria e técnica. Lisboa, Sociedade Portuguesa de Grupanálise. Cox, M. (1978; reissued 1995). Structuring the Therapeutic Process: Compromise with Chaos – the Therapist’s Response to the Individual and the Group. London, Jessica Kingsley. Cox, M. (1998). Remorse and Reparation. London, Jessica Kingsley. Dalal, F. (2000). Taking the Group Seriously: Towards a Post-Foulksian Group-Analytic Theory. London, Jessica Kingsley. Dalal, F. (2002). Race, Colour and the Processes of Racialization: New Perspectives from Group Analysis, Psychoanalysis and Sociology. London, Routledge. Dalal, F. (2014). A  Rumination on Intimacy and Its Defences in the Consulting Room: A Response to Elizabeth Rohr’s 38th Foulkes Lecture. Group Analysis, December 2014 (47): 392–407. De Maré, P. (1991). Koinonia: From Hate through Dialogue to Culture in the Large Group. London, Karnac. De Zulueta, F. (2006). From Pain to Violence: The Traumatic Roots of Destructiveness 2nd edition. Cambridge, Wiley-Blackwell. De Zulueta, F., and Mark, P.  (2000). Attachment and Contained Splitting: A  Combined Approach of Group and Individual Therapy to the Treatment of Patients Suffering from Borderline Personality Disorder. Group Analysis, December 33 (4): 486–500. Dick, B. M. (1975; reissued 1983). A Ten-year Study of Out-patient Analytic Group Therapy. British Journal of Psychiatry 127 (4): 365–375. Reissued in Pines, M. (ed.). (1983). The Evolution of Group Analysis. London, Routledge. Erikson, E. (1968; 1995). Identity Youth and Crisis. Austin Riggs Monograph 7. New York, Norton.

Introduction 23 Firestone, L. (2011). Understanding and Assessing Violence. Webinar at: www.psychalive. org/2011/09/psychalive-ce-webinar-series/ Firestone, R. W. (1997). Suicide and the Inner Voice: Risk Assessment, Treatment, and Case Management. Thousand Oaks, CA, Sage. Firestone, R., Firestone, L., and Catlett, J. (2003). The Wisdom of Psychotherapy: Creating a Life of Meaning and Compassion. Washington, DC, American Psychological Association. Foulkes, S. H. (1948; reissued 1983). Introduction to Group-Analytic Psychotherapy. London, Karnac Classics. Foulkes, S. H. (1990). Selected Papers: Psychoanalysis and Group Analysis (ed. Elizabeth Foulkes). London, Karnac. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Freud, S. (1930). Civilization and Its Discontents. SE21, London, Hogarth Press. Friedman, M. S. (2002). Martin Buber: The Life of Dialogue. London and New York, Routledge. Friedman, R. (2004). Dream-telling as a Request for Containment: Reconsidering the Group-Analytic Approach to Work with Dreams. Group Analysis 37 (4): 508–524. Friedman, R. (2006). Thoughts about Therapy in Wartime – Why Is the Group Still Coming? Contexts, November. Friedman, R. (2008). Dreamtelling as a Request for Containment: Three Uses of Dreams in Groups. International Journal of Group Psychotherapy 53 (3): 327–344. Friedman, R. (2010). The Group and the Individual in Conflict and War. Group Analysis 43 (3): 281–300. Friedman, R. (2011). Dreams and Dreamtelling: A Group Approach. In J. Kleinberg (Ed.), Wiley Blackwell Handbook of Group Psychotherapy. Chichester, Wiley, pp. 479–497. Friedman, R. (2013). Individual or Group Therapy? Indications for Optimal Therapy. Group Analysis 46 (2): 164–170. Friedman, R. (2014). Group Analysis Today – Developments in Intersubjectivity. Group Analysis 47 (3): 194–200. Friedman, R. (2015). Enemies, Love Story: Reconciliation in the Presence of Foes. In G. Ofer (Ed.), Bridge Over Troubled Waters: Conflict and Reconciliation In Groups And Society. London, Karnac. Fromm, E. (1941; reissued 2001). Escape from Freedom (Fear of Freedom). New York, Farrar and Reinhardt; reissued London, Routledge Classics. Frosh, S. (2010). Psychoanalysis Outside the Clinic: Interventions in Psychosocial Studies. London, Palgrave MacMillan. Gilligan, J. (1997; reissued 2000). Violence: Reflections on a National Epidemic. London, Jessica Kingsley. Goldstein, K. (1939; 1995). The Organism: A Holistic Approach to Biology Derived from Pathological Data in Man. New York, Zone Books. Gordon, J. et  al. (2005). X-treme Group Analysis: On the Countertransference Edge in Inpatient Work with Forensic Patients. Group Analysis 38 (3): 409–426. Gordon, J., and Kirtchuk, G. (Eds.). (2009). Psychic Assaults and Frightened Clinicians: Countertransference in Forensic Settings. Forensic Psychotherapy. Greif, G. L., and Efros, H. L. (2010). Group Work with Populations at Risk. Oxford, Oxford University Press. Grotjahn, M. (1993). The Art and Technique of Analytic Group Therapy. Northvale, New Jersey, Jason Aaronson Inc.

24  Introduction Grotjahn, M. et  al. (1983). Handbook of Group Therapy. New York, Van Nostrand Reinhold & Co. Hopper, E. (2001). On the Nature of Hope in Psychoanalysis and Group Analysis. British Journal of Psychotherapy 18 (2): 205–226. Hopper E., and Weinberg, C. (Eds.). (2010). The Social Unconscious in Persons, Groups and Societies. London, Routledge. Jones, M. (1953). The Therapeutic Community: A New Treatment Method in Psychiatry. New York, Basic Books. Jones, M. (1968). Beyond the Therapeutic Community: Social Learning and Social Psychiatry. New Haven, CT, Yale University Press. Karterud, S. (1999). Gruppeanalyse og psykodynamisk gruppepsykoterapi. Oslo, Pax Forlag. Kennard, D., Roberts, J., and Winter, D. (1993). A Workbook of Group-Analytic Interventions. London, Routledge. Klain, E. (2008). Grupna analiza - analitička grupna psihoterapija. Zagreb, Medicinska naklada. Kleinberg, J. (Ed.). (2011). The Wiley Blackwell Handbook of Group Psychotherapy. Chichester, Wiley. Kozulin, A., Gindis, B., Ageyev, V., and Miller, S. (Eds.). (2003). Vygotsky’s Educational Theory and Practice in Cultural Context. Cambridge, Cambridge University Press. Kreege, L. (Ed.). (1975). The Large Group. London, Karnac. Kreege, L. (1992). Envy Pre-emption in Small and Large Groups. 16th S. H. Foulkes Lecture. Group Analysis 1992 (25): 391. Kristeva, J. (1995). New Maladies of the Soul. New York, Columbia University Press. Kristeva J. (2010). Hatred and Forgiveness. New York, Columbia University Press. Lavie, J. (2005). The Lost Roots of the Theory of Group Analysis: ‘Taking Inter-relational Individuals Seriously’! Group Analysis 38 (4): 519–535. Levens, M. (2011). Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation. MSc dissertation. Institute of Group Analysis, London/ Birkbeck College, University of London. Levine, R. (2014). Progressing While Regressing in Relationships. In R. Grossmark and F. Wright (Eds.), The One And The Many: Relational Approaches In Group Psychotherapy. New York, Routledge. Lewin, K. (1977). Resolving Social Conflicts (1948) and Field Theory in Social Science (1951): Joint Edition 1977. Washington, DC, American Psychological Association. Lorentzen, S. (2014). Group Analytic Psychotherapy: Working with Affective, Anxiety and Personality Disorders. London, Routledge. Main, T. (2001). The Ailment and Other Psychoanalytic Essays. Ed. J. Johns. London, Routledge Classics. Marx, G. (1994; reissued 2002). Groucho and Me: The Autobiography of Groucho Marx. New York, Da Capo Press. McWilliams, N. (1999). Psychoanalytic Case Formulation. New York, The Guilford Press. Mies, T. (2012). Die Gruppenanalyse im interdisziplinären Dialog. Anmerkungen zur Gesschichte und Aktualität des Matrixbegriffs. Gruppenanalyse 22: 4–25. Mies, T. (2013). Die Symboltheorie von Norbert Elias – Ein Paradigma für die Theorie der Gruppenanalyse? Psychosozial 36 (131): 63–84. Mies, T. (2014). Dialog und Vielstimmigkeit: Martin Buber und Michail Bachtin. Teil 1. Gruppenpsychotherapie und Gruppendynamik 50: 30–70.

Introduction 25 Mojović, M. (2015). The Matrix Disrupted. Challenges and Changes. Group Analysis 48 (4): 540–556. Molnos, A. (1986). Anger That Destroys and Anger That Heals: Handling Hostility in Group Analysis and in Dynamic Brief Psychotherapy. Group Analysis 1986: 207–221. Nitsun, M. (1996). The Anti-Group: Destructive Forces in the Group and Their Creative Potential. London, Routledge. Nitsun, M. (2001). Strength in Numbers. The Guardian. Republished (2011) Fitzrovia Group Analytic Practice website: www.fitzgap.com/strength_in_numbers html Nitsun, M. (2006). The Group as an Object of Desire: Exploring Sexuality in Group Psychotherapy. London, Routledge. Nitsun, M. (2015). Beyond the Anti-group: Survival and Transformation. London, Routledge. Nitzgen, D. (2008). The Group Analytic Movement Sixty Years On: Revisiting Foulkes’ Introduction to Group Analytic Psychotherapy. Group Analysis 41 (4): 325–346. Ofer, G. (2015). Forgiving and Not Forgiving in Group Analysis: The Importance of Witnessing in the Process of Forgiveness. In G. Ofer (Ed.), Bridge Over Troubled Waters: Conflict and Reconciliation In Groups And Society. London, Karnac. Ormay, T. (2012). The Social Nature of Persons: One Person Is No Person. London, Karnac. Peleg, I. (2012). Oppression, Freedom, and Recognition in an Analytic Therapy Group: Group and Therapist Interactions from Relational and Group Analytic Perspectives. International Journal of Group Psychotherapy 62 (3): 436–458. Pines, M. (1983). The contribution of S.H. Foulkes to group therapy. In M. Pines (Ed.), The Evolution of Group Analysis. London, Routledge. Reissued 2000. London, Jessica Kingsley Press, pp. 265–285. Pines, M. (1998). Circular Reflections: Selected Papers on Group Analysis and Psycho­ analysis. London, Jessica Kingsley Press. Pines, M. (2015). Collected Papers. London, Routledge. Rayfield, E. (2013). Weathering, Shifting Perspectives and the Space in Between. What Happens in Groups to Change Our Experiences of Each Other and Ourselves? MSc Dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Rosenthal, N. E. (2013). The Gift of Adversity: The Unexpected Benefits of Life’s Difficulties, Setbacks, and Imperfections. New York, Tarcher Penguin. Sartre, J. P. (2000). Huis Clos and Other Plays. London, Penguin. Schlapobersky, J. (1986; reissued 1990). Editor’s introduction and author’s biography. In Explorations with Families: Group Analysis and Family Therapy: Selected Clinical Papers of Robin Skynner. London, Routledge, pp. xvii–xxviii. Schlapobersky, J. (1994, 2000). The Language of the Group: Monologue, Dialogue and Discourse in Group Analysis. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. London, Routledge. Reissued Jessica Kingsley Press, pp. 211–231. Schlapobersky, J. (2015). Group Analysis on War and Peace. In G. Ofer (Ed.), Bridge Over Troubled Waters: Conflict and Reconciliation in Groups and Society. London, Karnac. Schlapobersky, J., and Pines, M. (2009). Group Methods in Adult Psychiatry. In M. Gelder et al. (Eds.), New Oxford Textbook of Psychiatry. Oxford, Oxford University Press, pp. 1350–1368. Schneider, S., and Weinberg, H. (2003). The Large Group Revisited. London, Jessica Kings-­ ley Press. Schultz-Venrath, U. (2011). Das Gehirn in der Gruppe oder die Gruppe im Gehirn – Zur Neurobiologie des Mentalisierens in Gruppenpsychotherapien. Gruppenpsychother Gruppendynamik 47: 111–140.

26  Introduction Schultz-Venrath, U., and Kütemeyer, M. (1984). Kurt Goldstein (1878–1965): Begründer einer psychosomatischen Neurologie? In C. Pross and R. Winau (Hrsg.), Nicht mißhandeln. Das Krankenhaus Moabit. 1920–1933 ein Zentrum jüdischer Ärzte in Berlin. 1933–1945 Verfolgung Widerstand Zerstörung. Berlin: Edition Hentrich, pp. 133–139. Skynner, A.C.R. (1982). Reflections. The Bethlem and Maudsley Gazette 30 (2): 14–16. Skynner, A.C.R. (1983; 1987). Group Analysis and Family Therapy. In M. Pines (Ed.), The Evolution of Group Analysis. London, Routledge. Reissued in J. Schlapobersky (Ed.). (1986; 1990). Explorations With Families: Group Analysis and Family Therapy. London, Routledge, pp. 231–235. Skynner, A.C.R. (1984; 1989). Institutes and How to Survive Them: 8th S. H. Foulkes Lecture. Group Analysis 15, 11/2. Reissued in J. Schlapobersky (Ed.). (1989). Institutes and How to Survive Them: Mental Health Training and Consultation – Selected Papers of Robin Skynner. London, Methuen. Reissued Routledge 1993, pp. 189–211. Stacey, R. (2001). Complexity and the Group Matrix. Group Analysis 34: 221–239. Stacey, R. (2003). Complexity and Group Processes: A Radically Social Understanding of Individuals. London, Routledge. Thomas, A. (2002). Kind of Blue: The Role of the Group in Developing an Unconscious Communication Into a Musical Icon. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Tucker, S. (2004). From Group Norms To The ‘Group Super-Ego’: The Therapeutic Efficacy of The Ethical and Political In Foulkes. MSc Dissertation Birkbeck College. University of London/Institute of Group Analysis, London. Tyerman, S. (2012). Watching the Body in the Group. Theory Paper for Qualification. Institute of Group Analysis, London. Urlić, I. (2004). Trauma and Reparation, Mourning and Forgiveness: The Healing Potential of the Group. Group Analysis 37 (4): 453–471. Verebes-Weiss, J. (2011). Capacity to Be in a Group: Small Group Psychotherapy in a Forensic Therapeutic Community for People with Dangerous and Severe Personality Disorder. Theory Paper for Qualification. Institute of Group Analysis, London. Volkan, V. (2001). Transgenerational Transmissions and Chosen Trauma: An Aspect of Large Group Identity. Group Analysis 34: 79–97. Von Fraunhofer, N. (2008). What’s in It for Me? The Development from Immature to Mature Dependence in Groups. Group Analysis 41 (3): 278–290. Wainstein, S. (2013). An Exploration of Intimacy in Group Analytic Psychotherapy. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Weegman, M. (2011). Working Intersubjectively: What Does It Mean for Theory and Therapy? In E. Hopper and H. Weinberg (Eds.), The Social Unconscious in Persons, Groups and Societies. Vol. 1: Mainley Theory. London, Karnac, pp. 133–154. Weegman, M. (2014). The World within the Group: Developing Theory for Group Analysis. London, Karnac. Weinberg, H. (2003). The Culture of the Group and Groups from Different Cultures. Group Analysis 36 (2): 255–267. Weinberg, H., and Schneider, S. (2003). The Large Group Re-Visited: The Herd, Primal Horde, Crowds and Masses. London, Jessica Kingsley. Weisner, R., and Zeleny, J. (1979). Holocaust Testimony (HVT-34). Holocaust Survivors Film Project Fortunoff Video Archive for Holocaust Testimonies, T-34, T-220, T-972. Yale University Library.

Introduction 27 Welldon, E. (1992). Mother, Madonna Whore: The Idealization and Denigration of Motherhood. London, Karnac. Welldon, E. (2012). Playing with Dynamite: A Personal Approach to the Psychoanalytic Understanding of Perversions, Violence, and Criminality. Karnac, London. Woods, J., and Williams, A. (2014). Forensic Group Psychotherapy: The Portman Clinic Approach. Karnac, London. Wotton, L. (2011). Expecting the Unexpected: A Source of Change in Analytic Groups. Group Analysis 44 (3): 315–327. Wotton, L. (2012). Between the Notes: A Musical Understanding of Change in Group Analysis. Group Analysis 46 (1): 48–60. Wright, K. (2009). Mirroring and Attunement: Self-Realizations in Psychoanalysis and Art. London and New York, Routledge. Yalom, I., and Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy (5th ed.). New York, Basic Books. Yeats, W. B. (1990). He thinks of those who have Spoken Evil of his Beloved. In The Poems, London, Everyman, J.M. Dent & Sons, p. 85.

Acknowledgements: Extract from Marcus Aurelius (2004), Meditations, Book 11:8 reproduced with permission from Penguin. Extracts from Skynner (1984; 1989). Institutes and How To Survive Them: 8th S. H. Foulkes Lecture. Group Analysis, 15/11/2. Reissued in Institutes and How To Survive Them: Mental Health Training and Consultation – Selected Papers of Robin Skynner, J. Schlapobersky (ed.); Skynner (1983), Group Analysis and Family Therapy in Schlapobersky, J. (ed.), Explorations With Families: Group Analysis and Family Therapy, Skynner (1985). Robin Skynner’s (1982) Reflections. Bethlem and Maudsley Gazette 30 (2), reproduced with permission from the Institute of Family Therapy; extract from Yalom and Leszcz (2005), The Theory and Practice of Group Psychotherapy, reproduced with permission from Molyn Leszcz.

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Section I

Foundations

Section overview The seven chapters in this section lay the groundwork for the book. They are written for the interested general reader as well as for trainees new to the field and require no prior training or technical knowledge. Chapter 1 calls on a series of vignettes to introduce the vocabulary of psychotherapy and the language, silence and music of groups at work. It discusses the aims of psychotherapy, the first principles for therapeutic practice and the fundamentals of technique. The scope of the book is based on this chapter and is unpacked through the sections that follow, guided by a special interest in the role of the spoken word, the nature of experience that may have no words, the place of words that function as gestures and the ‘syntax’ of non-verbal communication. It begins with the first principles of the early pioneers, including Freud, and goes on to the pioneers of group analysis, including Foulkes, Anthony and Pines, and then provides an empirical review of categories of need amongst those attending group therapy today. Chapter 2 introduces three elementary dimensions to therapeutic experience – relational, reflective and corrective dimensions – that can arise separately or together, each of which builds on the one that goes before. The conductor faces a developmental challenge to help the group turn relational into reflective experience and then reflective into reparative experience. Chapter 3 introduces a general theory of group development described as journey literature that is based on past and current writing. It summarizes the basic reciprocity between personal and group development to explore how the development stages of a person’s journey through a group or of a group’s journey over time are shaped by its formative purposes, membership, conductor and milieu. It considers the conductor’s responsibilities for dealing with group-based impasse, regression and resistance at key stages of development. Chapter 4 explores free-floating discussion – Foulkes’s first therapeutic principle – and introduces the three primary speech forms that arise in a group, monologue, dialogue and discourse, which contribute to its semantic field. These

30  I Foundations

language forms are located in a group’s field of meaning and are mapped against a corresponding progression from one-person to two-person and three-person psychologies that are located in a group’s relational field. The developmental challenge faced by the conductor involves helping a group turn monologue into dialogue and dialogue into discourse. Chapter 5 explores speech and silence in group psychotherapy. It works from the real to the constructed and the representational, using Winnicott’s ideas to address the unspoken and the unspeakable. The non-verbal dimension of group life arises in the silences before, between and after words and in the ‘music’ of the group. Non-verbal communication can give access to profound areas of psychic life that are otherwise deeply hidden and that can emerge during silences in groups that speak more eloquently than words to those who can hear. Chapter 6 explores basic definitions and the originating literature for different kinds of applications that the group-analytic model lends itself to in terms of duration, frequency, setting and form and points to the far-reaching influence of Foulkes’s original terms and ideas. Chapter 7 explores methods, models and applications in group psychotherapy using the three-dimensional model of structure, process and content, as well as a diagram from Stone, Shay and Scott Rutan’s book to demarcate comparative differences between the six psychodynamic models discussed: Tavistock, GroupAnalytic, Interpersonal, Psychodynamic, Modern Analytic and Systemic.

Chapter 1

Aims and vocabulary of psychotherapy

I feel so rich in knowledge and confident in skills in relation to my stranger-group work, even though I still find myself so hopelessly inadequate when I try to formulate it . . . The theory and practice required for really effective stranger-group therapy . . . is most complex of all. The problems and possibilities involved in this kind of therapy are very much greater than in the others . . . Stranger group psychotherapy has potentially far more power and possibility than the forms we have considered already and it is not surprising, therefore, that we should find it a far more difficult continent to conquer. (Robin Skynner 1983/1987:231, 235) Human communication rests on our innate musicality . . . human intention and emotion are immediately shareable with others through gestures of the body and voice. The very idea of intersubjectivity depends on the human capacity to develop a sense of intersubjective time within which to construct joint meaning . . . only by aligning ourselves alongside another – through being in time and in tune . . . might we be able to make sense of what Mead calls the conversation of gesture and response. The social nature of . . . experience is, in essence, musical. Linde Wotton (2012:49) We are one another’s weather . . .

Emma Rayfield (2013)

In the group-analytic approach the person responsible for the group is called the conductor. The first thing he or she will do is bring people together on the basis of their related needs and common capacity to contribute to a shared resource – the group – from which its members can each derive benefits. Second, the conductor calls this ‘community’ into the room where the group as a whole becomes the therapeutic agent. And third, the conductor does nothing for people in the context of the group that they can do for themselves and one another. A  group that is well constructed and well led will release naturally occurring sources of renewal and resilience amongst its members that can

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bring profound benefits. This book is addressed to the ‘how to’ of making it work; the ‘why’ in why it works; the ‘for whom’ in whom it works for; and the ‘by whom’ about those who do the work. It explores the language, silence and music of groups to engage with words and with non-verbal and pre-verbal communication. It puts group therapy in the context of an oral tradition that involves storytelling so early stages of development, including regressed and hidden forms of infantile states, can be worked with productively in adult, child and adolescent populations long thought unreachable in psychotherapy (Nitsun 1988; Usandivaras 1989). Embarking on a new book at this stage I feel something like Skynner did writing about group analysis in 1976 when he said in the passage quoted, ‘I still find myself so hopelessly inadequate when I try to formulate’ what makes group psychotherapy work. The foundation texts were addressed to a subject as complex in the days of our pioneers as it is in ours. Whilst they worked at the time with little to go by in terms of a field of literature and precedent, we have the immense advantages of their pioneering work to hand. However, until quite recently group-analytic psychotherapy remained a more advanced practice than its understanding could describe. Today there is a developing literature that the second and third of the quotations at the opening of this chapter point towards. This book brings such work forward by studying the model of practice. It faces the additional challenge of working against the customary divisions between ‘theory’ and ‘practice’. This is a study of clinical theory at work in the group room or, alternatively, of group-analytic practice informed by theory. The recounting of stories is centre-stage in the journey from the couch to the circle. Some of these stories are tabled in the List of Vignettes. My paper The Language of the Group addressed Foulkes’s ideas about free-floating discussion. It was published in 1995 and is included here as Chapter 4. There were other early contributions to this focus including Wojciechowska (1993), and since then the field has been opened to the study of language in our groups. As well as the forms of speech first introduced – monologue, dialogue and discourse – there have been wider enquiries that many have taken forward. In group analysis they include

Table 1.1  The important lessons distilled from personal experience: Gans* 1 The important lessons distilled from personal experience become part of one’s therapeutic core. 2 Inflexible adherence to important principles learned in training can limit one’s therapeutic effectiveness. 3 It is important to oppose and, as a result, to neutralize the tendency . . . to focus on what is wrong with our patients and ourselves at the expense of recognizing our patients and our own strengths and successes. * Table 1.1 is adapted from page xvii of: Gans, J. (2010) Difficult Topics In Group Psychotherapy: My Journey From Shame To Courage. Karnac, London. Grateful acknowledgements are made to the author and publisher.

1  Aims and vocabulary of psychotherapy  33

von Fraunhofer (2008), Brooks (2009), Wotton (2011, 2012), Verebes-Weiss (2011), Levens (2011), Rayfield (2013), Tyerman (2012), Wainstein (2013) and Peleg (2012), and only some of these papers have been published. Further lines of enquiry and development in the language of group-analytic psychotherapy have been opened through Chapter 4 of Dalal’s Taking the Group Seriously (2000), through Nitsun’s three original texts (Nitsun 1996, 2006, 2015) and Weegmann’s many creative publications (Weegmann 2001 to 2015). Behind us are the pioneering publications of Pines, who helped establish the group-analytic field and whose collected papers will soon be available (Pines 2015); and beyond us are wider enquiries into field theory, language and metaphor in psychotherapy that include original contributions by Bollas (1987, 1990) and Wright (2009) and those by Montana Katz and her colleagues (2013) in an edited collection that includes Modell’s perspectives – drawing on Winnicott – that have bearing on what happens in groups (Modell 2013).

Illustrating monologue, dialogue and discourse: Three vignettes and commentaries The scope of this book is introduced by a preliminary series of vignettes that illustrate its focus on language. This is followed later by a study of the language of the group in Chapter 4 and the management of speech and silence in Chapter 5. The following vignettes move from the personal life of the therapist outside the consulting room to therapeutic practice inside it to make the work accessible to the general reader. Monologue and dialogue Vignette 1.1  The seer’s eye in the mirror Outside the consulting room: someone close to me in a state of grief was going through the psychic dissolution that it can involve and was coming out the other side. She told me that as she began to recover she looked in the mirror and saw herself again. ‘I saw that I was there again’, she said – and the relief was tangible and palpable as we talked. As the seer’s eye captures itself anew in a glance, restoration of the lost sense of self, seen silently in a mirror, gives impetus to renewal. It can happen silently through the monologue of self-engagement in the privacy of the self. The recovery brought on can release natural powers of resilience, especially as it becomes part of a shared dialogue with someone else. Our discussions about her bereavement brought forward my own past sorrow and, in the course of our conversations, shared descriptions of my own grief and recovery were taken back to hers. The dialogue between us re-shaped the privacy of her monologue.

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Commentary This kind of restoration is much older than depth psychology. Intimate conversations generating movement from monologue to dialogue and back again are at the heart of all the other dynamics in psychotherapy and – in one way or another – they condition them all. Society has been governed by processes of this kind for as long as we have been able to speak, sing, cry and celebrate. Self-disclosure of the kind described here is outside a psychotherapist’s practice, but in the group-analytic model the person of the therapist is a crucial resource. Foulkes described the group-analytic model as ‘a form of psychotherapy by the group, of the group, including its conductor’ (Foulkes, 1975:3). The phrase ‘including the conductor’ refers to the conductor’s own subjectivity that we call on continuously. But whilst the conductor needs to be able to call on their subjectivity they need to do so without reporting on it to the group. The novelist Gorky advises that ‘To make soup the cook doesn’t need to get into the pot’ (Gorky 1953:446). This book is focussed by the challenges posed for the conductor in the dilemma of being present – accessible and available – without being transparent. They are explored through the text. The group-analytic model will be enriched in dealing with these fundamental issues by developing literature elsewhere. Gans’s Difficult Topics in Group Psychotherapy (2010), written in the psychodynamic model of North American practice, puts the person of the therapist at the forefront of his study. The three guiding sets of ideas that organise his text provide this book with sound points of departure:

Dialogue and discourse Vignette 1.2  Empathic mirroring1 In the consulting room in a therapy group for individuals: a man talks about a recent weekend visit by his two children who now live with his former wife, their mother. He is devoted to them but quite at a loss as a single father, especially in the light of his former wife’s critical hostility. What was specially challenging is that his daughter, now 12, had her first period whilst she was with him. He saw to her physical requirements, took good care of her emotionally and he now wants to share the experience with us. People in the group listen attentively, and one of the women is so absorbed that she is silenced, though she cannot take her eyes off him. When prompted to speak by the conductor she shares associations that take her back to the fact that when she began to

1  Aims and vocabulary of psychotherapy  35

menstruate, it marked the point when her own father stopped molesting her. She talks with shame about his abuse of herself and her older sister. None of this is new, but her account is now marked by something different in the mirror reaction between herself and the man facing her. She says to the group, his daughter really trusts him – how extraordinary! We listen in pain and the man begins to weep. When I ask him about his tears he tells the group – whilst looking at her – just how unbearable he finds the picture of her violated childhood. She responds to his tears with her own. The relief she then expresses in words is about finding in him a man who is moral and accountable, who has feeling for someone other than himself. He is unlike her father and, in the course of the group, we see that by finding in him a man whose strength is not annulled by vulnerability, she gains access to her own long-lost sense of trust. We later see that she helps give him access to his own sense of goodness that was lost after a breakup with his partner. This goodness is what he now offers her in the group.

Commentary All seven of us become witnesses to a reparative dialogue between these two based on empathic mirroring, which turns into discourse round the circle as people resonate to the sense of both injury and resolution with other stories of their own. These detailed, interpersonal exchanges progress from reflection to reparation through the dimensions of psychotherapy set out in Chapter 2. The progression rests on the climate of the group and the qualities of its matrix that are discussed below and again in Chapter 9. Its process dynamics are discussed in Chapter 10. Associative depth in the content of its language is studied in Chapter 11; the person and resources of its conductor are studied in Chapter 12; the group’s different levels or domains that allow the same subject to be dealt with in profoundly different ways are considered in Chapter 13; transference is singled out from amongst these and is studied in Chapter 14; the move from longing to belonging – we can see how people in this vignette ‘belong’ together in the moment – is studied in Chapter 15; the way in which the emerging issue of a child’s sexuality is kept safe or not in the care of her father, which, becoming the central metaphor for a sense of safety in the group, is the subject of Chapter 16; the disturbance generated by the move between out-group to in-group and again to out-group material is the substance of Chapter 17 that deals with location.

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Monologue, dialogue and discourse Vignette 1.3  Why are we talking about sausages? In a therapy group for couples in trouble: a woman’s anxieties about her overweight husband consuming yet another round of sausages are expressed in a lengthy monologue. She describes his recent assault on the refrigerator and the fry-up he made for himself in the middle of the night. She cuts a diminutive figure in the group and – by comparison – he is enormous. However, by the time her monologue is concluded she has grown to outsize him and become a large figure of reproach whilst he shrinks beside her in embarrassment. Without much need for intervention from the two therapists this leads to an exchange involving all ten members – four couples and the therapist couple – about just how dangerous sausages can be. After all, his wife continues to insist, his blood pressure is already much too high. Through this discourse some of the other men blame their female partners for their weight problems and this leads to indignant protest from the women, some of who say that what men put in their mouths is their own responsibility. My co-therapist and I have been silent for much of the group but at a point judged finely for its timing, she turns towards me across the group and asks with a smile, ‘John, why do you think we’re talking about sausages?’ Through the ensuing laughter the group’s ‘humourist’, a man who is often entertaining, says ‘Why not sausages? And why not bananas too!’ There is more laughter and the group continues playing with sexual symbols, punctuated with suggestive humour and excitement as people compare sausages with bananas but never go closer than this to any phallic reference. The question is not answered directly and we laugh and play together. In the emerging cohesion this engenders, members’ discourse focuses on what underlies it in the shared unconscious of the invisible group. People come to agree, when asked at several points, that what we are really talking about is cholesterol. One man says it’s an identified poison. Some of the men complain that it is their partners they are being poisoned by – every time they’re fed sausages – which leads back to vigorous opposition from the women. With further therapeutic intervention we conclude with a tentative new understanding of the poisonous projections by which people confound each other. We return to this new quality of understanding in the sessions that follow. During the next few weeks anxious monologue about weight and health, oppositional dialogue between men and women and then free-floating discussion, take us to the heart of self-harm and the collusions around it. With this new found understanding the group progresses

1  Aims and vocabulary of psychotherapy  37

from cohesion to coherence (Pines 1998:211–223) in which the mirror is the group itself, as it reflects back to each painful truths about the damage people do to themselves and the way their partners are either enlisted to collude or forced to protest. My co-therapist and I – the conductors – are in the group and outside it at the same time.2

Commentary Working from monologue through dialogue to discourse – and back again – each of these depictions captures an essential language form. The communicating movement between them is part of what it means to be human as the group progresses from the relational to the reflective dimensions of psychotherapy. These dimensions call for close attention of a focussed kind on the part of the therapist to help them act in the service of the next dimension – reparation – that allows growth and change by making good. The progression from one language form to the next also brings people back to earlier speech forms as discourse leads back to dialogue and then to monologue but now on new and different terms as the group grows through a spiral of emotional development. Most of Yalom and Leszcz’s therapeutic principles can be seen at work in these vignettes, including the instillation of hope.

Basic principles in group-analytic psychotherapy This book sets out to show these dynamics at work. Terms like ‘monologue’, ‘dialogue’ and ‘discourse’ have been used above in ways that are self-explanatory. Other more ‘technical’ terms – ‘empathic mirroring’, ‘resonance’, ‘reparation’, ‘cohesion’ and ‘coherence’ – are also introduced, and their meaning will become clearer in the course of the book. Another term that will recur is ‘figuration’, introduced to the field by Foulkes through his early association with Elias. It describes a thematic subject in the life of a group, in combination with the dynamics – the personal, interpersonal and transpersonal dynamics – that give rise to it. In the interests of clarity I have used the term through this book without introducing its relative, the term ‘configuration’. This book engages with its subject  – group-analytic psychotherapy – first by making the work transparent and second by giving special attention to the place and responsibility of the conductor. The ‘conductor’ is a term, described in Chapter 12, that includes the roles of convenor, therapist and group member. Each of the conductor’s three roles has the other two embedded within it to equip them to live through the flux of feeling and exchange

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in the reciprocities, discords and concordant experience of a group’s members. Their resources are critical in turning the group into a directed enquiry that, with the well-being of its members at its core, can progress from work in the relational to the reflective and then reparative dimensions. Metaphor, music and the re-making of meaning Free-floating discussion is the group-analytic equivalent of free association. Its expressions and relations are undirected and spontaneous like improvisation in music or drama. During group therapy we both shape and follow narratives and enactments to capture the point at which something new is created. Change can be understood through the metaphors the process gives rise to – illustrated in the vignettes – where they work like moments of novelty in music or theatre.3 Metaphors arise from the primordial or archaic domain of a group’s life that is often hidden, ‘out of reach’ and unavailable; but it is sometimes dramatically visible. They can enter the room through dreams, wordplay or a transferential encounter that can bind a group’s members in the common zone of shared experience to illuminate moments of significance and help turn longing into belonging. ‘The common zone’ is a term used frequently through the text. Foulkes defined it in his third book (1964:111–112; 214), and in this book its significance is explored in Chapter  4. It is further discussed in Foulkes’s first book (1948:133–146), in his text with Foulkes and Anthony (1957; 1984:243–250) and in his last book (1975:107–117). Foulkes referred to moments of novelty – including shared laughter or acute distress – that go beyond set and familiar experience as the condenser, which is studied in Chapter 10. It is part of the spontaneous life of a group, cannot be planned for or predicted, happens when it does and can foster change in patterns that may have been counter-productive on intractable terms. Cox encouraged the conductor to respond to moments of impasse in therapy that he called narrative failure with mutative metaphors (Cox and Thielgaard 1987, 1994). Words used as improvisers, like variations in musical rhythm, tone or key, can bring people to startling new positions (Wotton 2012). The scope of these dynamics is studied in detail in the five chapters of Section III, but we start at the beginning with some elementary group-analytic principles set out in Table 1.2. Beyond the therapeutic principles described by Yalom and Leszcz, there are twelve drawn from the group-analytic model. These basic principles in group-analytic psychotherapy are set out in Table 1.2, and they summarise the scope of the book. In Tables 8.1 and 8.2 that open Section II, they are extended. We can apply the first principle of Table 1.2 to the groups described in Vignette 1.2 and 1.3 that, like all groups, are under constant development. The progression they live through carries and is carried by the development of its members. Growth, like other forms of change, works in both directions. What the group can do for the individual is bound up with what the individual does, in and for the group. The term journey literature in Chapter 3 identifies writing of this kind about group and personal development. The second principle in the table identifies the three dimensions of a group – structure,

Table 1.2  Basic principles in group-analytic psychotherapy 1

Any one joining a group goes on a journey. In journey literature – writing on group and personal development – we find that what the group can do for the individual is bound up with what the individual does, in and for the group. Growth and change work in both directions (Schlapobersky 2015).

2

The three basic dimensions of a group are its structure, process and content (Foulkes and Anthony 1957).

3

The conductor leads the group in three ways. The conductor is a member of the group and is also its convenor and therapist. The convening role involves dynamic administration (use of structural principles), and the member role allows the active use of countertransference, so equipping the conductor to work from outside and inside the group at the same time (Behr and Hearst 2005).

4

In their therapeutic role, the conductor’s methodology is guided by the considered use of time, depth and mutuality (Cox 1976).

5

Process dynamics (group-specific factors) include resonance, reciprocity, mirroring, valency, condensation and amplification that can generate insight and outsight (Foulkes and Anthony 1957/1965; de Maré 1972 Pines 1998; Schlapobersky 2015).

6

The language of the group – its content – moves through free-floating discussion between monologue, dialogue and discourse generating different kinds of exchange (Schlapobersky 1995). There is also a ‘meta-language’ of speech, silence and the non-verbal that generates attunement and alignment (Wotton 2012). The conductor works by accepting monologue and helping to turn it into dialogue, and by accepting dialogue and helping to turn it into discourse.

7

The group is an arena for the bearing of witness generated by process dynamics (Foulkes 1964; Barwick 2004; von Fraunhofer 2004; Nitsun 2006; Kleinot 2011; Berger 2014; Berman 2014; Ofer 2015).

8

In a group’s common zone communication includes all (Foulkes 1964). The group’s domains of meaning grow out of it. These emerging domains – the current, transference, projective and primordial – are like holograms so you can look through one and in the others discover new and different facets of yourself and the people around you (Foulkes and Anthony 1957/1965; Schlapobersky 2015).

9

Through people’s exchange, the group becomes an auxiliary ego (group-as-a-whole) for each member (Neeld 1995). A new normative context is created in this auxiliary ego (Tucker 2004) that fosters ego training in action enacted through play (Foulkes 1964; Brown 1995).

10 Play arises in the relational field fostering affect and engendering cohesion. It arises in the semantic field – the field of meaning – to engender coherence. Cohesion and coherence involve subjective interaction (Brown 1995; Pines 1998). 11 Subjective interaction matures to become intersubjective validation (Brown 1995). 12 Intersubjective validation progresses through three dimensions in group therapy. It begins with the relational dimension and evolves into the reflective dimension out of which the reparative dimension emerges. The conductor works to help the group turn relational moments into reflective ones and reflective moments into reparative ones (Schlapobersky 2015).

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process and content – that Foulkes and Antony introduced to the field (1957). It provides the focus for all of Section II. The third principle is about the conductor who is described in Chapter 12 as a person in the group, as its therapist and as its convenor who is responsible for dynamic administration, which is described by Behr and Hearst (2005). The fourth principle gives a methodology for the conductor’s therapeutic role, which Cox describes in terms of time, depth and mutuality (1976). The fifth principle identifies the dynamics of process that are evident in Vignettes 1.2 and 1.3, as we see them governed by resonance. Chapter 10 gives an account of Foulkes and Anthony’s original description of group-specific factors – including resonance – and it argues for a new term describing them now as process dynamics. The sixth principle describes the language of the group – its content – as it moves through free-floating discussion between monologue, dialogue and discourse. Words and language are a special focus for the work of the group in Vignette 1.3. In the seventh principle the group works as an arena for the bearing of witness, an evident feature of Vignettes 1.2 and 1.3. This is explored in Chapter 2 where it builds on the work of a number of key contributors, including Barwick (2004), Berger (2014), Berman (2014), Kleinot (2011), Nitsun (2006: 194–204) and Ofer (2014). The eighth principle identifies a group’s common zone first described by Foulkes (1964) and studied in Chapter 4. It includes all its members who relate through different domains of communication – current, transference, projective and primordial – first described by Foulkes and Anthony (1957) and explored in Chapter 13. Transference and its associated concepts – countertransference, projection and identification – are studied in Chapter 14, where Foulkes and Anthony’s early table, reproduced in this book with permission as Table 14.1, is described as the Rosetta Stone on which group analysis and classical psychoanalysis can be read against one another. The ninth principle describes how groups work as an auxiliary ego for each of their members, which is clearly demonstrated in Vignettes 1.2 and 1.3. This is a recurrent interest through the book and in Chapter 17 page 455 Tucker shows how a group’s emerging auxiliary ego helps amend its normative context. Vignette 2.4 and its commentary provide detail of the conductor’s special responsibility for fostering the ‘micro-processes’ through which this takes place (Neeld 1999; Tucker 2004). The tenth principle focuses on play as a key driver in the life of a group – most evident in Vignette 1.3  – fostering affect in a group’s relational field, engendering cohesion and cultivating meaning in its semantic field, engendering coherence. Pines introduced us to the differences between cohesion and coherence (1998), and Chapter 4, the oldest chapter in this book and the first to be published in 1995, differentiates between the relational and semantic fields of a group. Chapters 15 and 16 explore play, word play metaphors and metamorphosis, and they focus on how subjective interaction matures to become intersubjective validation in principle eleven of this table (Brown 1995; Pines 1998). In principle twelve intersubjective validation is described progressing through three dimensions of therapy – relational, reflective and reparative. Chapter  2 describes how the conductor works to help a group turn relational moments into reflective ones and reflective moments into reparative ones.

1  Aims and vocabulary of psychotherapy  41

The person in the group and the group in the person The work of a therapeutic group is closer to the terms of ‘normal’ human intercourse than many other forms of therapy. Intimate conversations that make a group therapeutic replicate the kind of exchange that happens between people at a dinner table, in a meeting or round the hearth. Group therapy ‘borrows’ from these normative groups, but behind the seeming simplicity of its conversation something more complex is going on. The group’s attention needs to be shifted from what is troublesome in the world – reported on in people’s homes or offices  – to what is troublesome about the world within the room and the person in the group. It is here that resolutions may be found as the group progresses through its spiral of growth and development, revealing the hidden but active group at work inside each person in the room. The troubled members of a group are found internally ‘occupied’, and therapy bears fruit as the troubled group that each member has within is played out amongst the others. The group’s resources – its narrative, drama and analysis – move the experience from the telling of stories to interactions of the moment, and then to reflection and reparation. In a group people talk to each other in the presence of the conductor whose role as convenor, therapist and group member helps foster trust in the setting; establishes conditions for intimacy; cultivates reciprocity and exchange; makes themselves available for transferential projections; calls on countertransference to locate focal issues; attends to the developmental dynamics of the moment; and uses principles of location, translation and interpretation to help generate a new understanding of the issues located at the source of a group’s disturbance. It can thus be moved forwards to help make metaphors mutative so novelty can be harvested in the interests of growth and change. These challenges are the focus for Chapters 13 to 17.

Freud on love and work Language is emblematic, a kind of badge for its user. One of the best-known such emblems begins with Freud, who is reported to have said that mental health can be found in someone’s capacities to both love and work. This captures in a single statement the original goal of his talking cure (Jafee 2014) that aimed to make possible a person’s enjoyment of loving relationships on the one hand and on the other a generative disposition through which to express themselves through work, child bearing or creativity. References to the phrase ‘love and work’ in Freud’s writing are occasional. For example, he describes how ‘the communal life of human beings had, therefore, a two-fold foundation: the compulsion to work, which was created by external necessity, and the power of love’ (Freud 1930, S.E. 21:101). Google has many entries for the phrase that today give authority to a wide range of contrasting schemata for psychological well-being. Although this

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emblem now has so many different uses, it does provide a fitting phrase of departure for the journey from the couch to the circle. There are other such phrases to guide us. Auden’s epitaph in poetry, In Memory of Sigmund Freud, honours his passing in 1939 by saying that ‘To us he is no more a person now but a whole climate of opinion under whom we conduct our different lives’ (Auden 1940/1986). Climates change, but even in psychotherapy’s current concerns with behaviour and cognition, audit and evaluation, the motives that Auden attributes to Freud are of lasting relevance. Auden saw in Freud’s vision a hope that psychoanalysis could equip us to live on satisfying terms with our sexuality; find freedom from childhood’s injuries and make terms with the childhood that lives on in every adult. That it could help us to make terms with what he called ‘the nervous and the nights’; accept that ‘to be free is often to be lonely’ and accept the loneliness with a rational voice and without illusions. The post-modern era carries with it a special caution about grand systems and claims that go beyond the possible, so we are wary of global answers to life’s most challenging questions some of which  – like Freud’s  – are cast in secular terms and others in religious ones. If it is too much to expect of psychotherapy that it could help a person find both love and work, using each of these terms as a figure of speech for much more than the word itself, it may be more realistic to claim for psychotherapy that it can help a person free themselves from the opposites of these fundamental states of mind. Psychotherapy can offer freedom from hatred and paralysis. Hatred, directed against self or other, has many attendant, related emotions like shame, malice, envy and contempt.4 Paralysis also has many similarly troubled relations that include impotence, passivity, subservience, self-loathing and dejection.

An empirical approach: Categories of need in group psychotherapy Categories of need identified in a clinical population in London A more empirical approach to definitions for the aims of group psychotherapy comes from studying groups and the needs they cater for. I have reviewed my own records over a period of years and using the clinical principles set out by McWilliams (1999), I  have related people’s presenting problems and needs to the evaluations made by myself and the referring clinicians. The range of both presented and evaluated needs are organised into seven basic categories in Table 1.3. This table gives the top line of a more comprehensive audit of the work that is presented later in Table 6.7, Chapter 6, pages 189–90, where it is fully discussed. It pictures the aims of group psychotherapy in categories of need found amongst people attending intensive groups in private practice. The categories in the table have been compiled empirically by systematic study of the case records and notes of some 40 people who passed through my two twice-weekly groups

1  Aims and vocabulary of psychotherapy  43 Table 1.3  Categories of need amongst people attending intensive groups* 1. H igh 2. C harac- 3. C hronic 4. S erious 5. S elected 6. T raining 7. P ersonal relaborderof mental developdependter prob- and mal­ tional line health ment ency lems adaptive problems profesneed reactions problems sionals to traumatic life events * Table 1.3 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Table 6.3.6.9, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1365. This table is an abbreviated form of Table 6.7 below. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my co-author Malcolm Pines for his consent to its re-use here.

over a period of some 16 years. None of these categories are mutually exclusive, and individuals can come into groups to meet more than one set of needs under these headings. Table 6.8 gives the basic demographic and clinical data for these group members, and Table 6.9 gives the results of measures used to evaluate the process and outcome of their group therapy experience, based on a simple, self-devised instrument. Practice guidelines of the American Group Psychotherapy Association Those seeking evidence for the effectiveness of group psychotherapy need look no further than the website of the American Group Psychotherapy Association: www.agpa.org/home/practice-resources/evidence-based-group-practice. It documents proven effectiveness in seven discrete areas of application: Addictions and substance abuse; Cancer; HIV/Aids; Character disorders; Depression and grief; Eating disorders; Youth violence. References to the work under development there will be made throughout the book.

Indications and contra-indications for group psychotherapy A group’s membership will determine its outcome, and the issue of composition is a critically important subject – it is the conductor’s first and most enduring contribution to the group. This is discussed in Chapter 9, where principles of similarity and difference are introduced as a guide. Indications for and against group therapy are not addressed in detail elsewhere in this book because they relate so closely to the population catered for and the setting in which a group is offered. The 10 studies in Chapter 6 give the model’s broad range of applications, many of which have their own selection criteria. It is hoped that in the future we can review the selection criteria for each of these applications on a comparative basis. What can be offered now are some general principles.

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Mixed groups, outpatient psychotherapy and psychiatry For mixed groups and in outpatient psychiatry and psychotherapy, Pines and I recommended that the criteria for selection should be exclusive rather than inclusive, as most people seeking psychotherapy can be accommodated in a group, providing a suitable one is available (Schlapobersky and Pines 2009:1362). Since making these recommendations Friedman has published an enquiry into the indications for optimal therapy in which he raises the following questions: ‘What is the disorder that needs to be treated? What is the optimal therapeutic space and when should a specific optimal space be recommended?’ (Friedman 2013:165). He seeks ‘clearer indications for different spaces of treatment (individual, groups, couples and family therapy) . . . to help define the unique contribution of small and median groups’ (op. cit.:164) and takes us on an enquiry that spans the journey described in the introduction. He moves from an isolated symptom or presenting problem to one that has locational significance and looks for categories of disorder that have relational meaning. Basing his work on that of Agazarian’s classification of dysfunction he suggests – on a preliminary basis – that there are four kinds of relational disorder involving deficiency, rejection, a troubled relationship with the self and exclusion. He argues that ‘for many reasons, relation disorders, characterized by dysfunctional patterns, need to be treated where they were created’ (op. cit.:168) and for all except the first of these patterns, he puts groups forward as the therapy of choice. The selection process should take into account both the needs of the individual and the composition of the group, and a service should ideally provide a range of groups in which people can be placed according to both their needs and characteristics and those of the particular group. Selection criteria aim to optimise the ‘fit’ between the needs and resources of the individual and those of the group. Checklists like those below can only be a rough guide, as there are so many exceptions. The list of exclusion criteria Pines and I assembled, based on the literature available at the time, led us to suggest caution about offering group therapy if four or more of the following factors were present on the assessment of a candidate. Exclusion criteria Acute crisis; prior history of broken attendance in therapy; major problems of self-disclosure; major problems with reality testing, i.e. paranoid projections or psychosis; pathological narcissism; difficulties with intimacy generalised into personal distrust; defences that rely excessively on denial and disassociation; emotional unavailability; tendency to be verbally subdued or withdrawn; tendency to be hostile and aggressive, verbally or otherwise. Inclusion criteria If four or more of the following factors were present on assessment, then group psychotherapy could be offered with confidence: Motivation to address personal issues or to resolve problems; a willingness to try and participate; some experience of successful relationships in childhood or

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the present; some interest in exploring and understanding the self; some capacity to talk, listen and relate; some interest in others; some sense that being amongst others could be helpful; some ability to sympathise or empathise with others’ needs and problems; and some indication of future reliability in attendance. Homogeneous groups and special needs With homogeneous groups and special populations the range of potential candidates is much wider. Hearst, for example, describes a population of severely deprived mothers drawn entirely from those on the exclusion list (1998). The same is true for all the homogeneous populations described in Chapter 6, where 10 clinical studies give a representative picture of current group-analytic practice in the UK. Six of these 10 studies describe work carried out with populations comprised entirely of people previously thought untreatable in dynamic psychotherapy. Studies 3, 4 and 5 describe the model used in forensic work in different settings; 6 and 7 describe the model used in work with survivors of massive trauma; and Study 8 describes the model used in work with the physically ill.

Preparation for group therapy Preparing people for group therapy with several individual sessions or an extended programme of individual work offered as preparation for entry provides both parties – patient and therapist – with a basis for judgement about therapeutic prospects. This will also give the individual joining the group one relationship of good acquaintance before entry that can form the basis of a therapeutic alliance. When Pines and I made these recommendations (2009) the empirical work on which they were based in Salvendy’s studies about selection and preparation of patients for groups was inconclusive (Salvendy 1993). Since then there have been a number of studies confirming the merit of careful individual preparation, and the best guidance to their recommendations is in Leszcz and Kobos (2008). Their findings can be applied to all the practice guidelines under discussion here.

Foulkes and Anthony: Individual, group and community Foulkes and Anthony introduced the first edition of their book as an account of how ‘patients and students join a common quest for the solution of mental and emotional problems’. They describe group therapy as A new method of psychological treatment of nervous and mental disorders, which may well prove to be the most important advance . . . since the advent of psychoanalysis . . . a practicable approach to the key problem of our time: the strained relationship between the individual and the community. (Foulkes and Anthony 1957:1, 9)5

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These words are an emblem for the emerging relational paradigm in psychotherapy. The history of the paradigm can be traced from here to the elaboration of clinical theory in the recent work of Mitchell writing on relational psychoanalysis (Greenberg and Mitchell 1983; Mitchell 1988), Gilligan (2000), the Firestones, who provide ‘a fully realized and comprehensive theory on neurosis and human development’ (2003), Billow in the United States (2010) and Holmes in the UK, who has turned his understanding of attachment theory into an intersubjective psychotherapy (2010) followed by Harwood, Stone and Pines’s recent publication (2012). Not all of these authors would see themselves as group analysts, but they have broken new ground that lends itself to the theorising of a group therapist and is incorporated in the writing that follows.

Vision and clinical method: The timeless and the timed Group psychotherapy creates an arena in which the unconscious can come to life in the circle of exchange revealing many hidden features kept ‘safely’ out of consciousness by the guises and disguises of daily life. Interactions, stories, metaphors and idiomatic language emerge that are unique to each group and the conductor – by cultivating first cohesion and then coherence – a progression introduced to the field by Pines (1998:211–233) can help the group achieve qualities of understanding through the resources of its fellowship to equip people to face troubled emotions at source as they repeat themselves in the circle. The most basic tool of psychoanalysis is a person’s readiness to talk in the session as freely as possible about whatever comes to mind – this is free association. Questions of method as to what the analyst does with free association have gone through development in different phases during the evolution of psychoanalysis and its derivative therapies. Group-analytic psychotherapy is one of these. It is informed by a radical break, as the work is now done by a small group of people rather than the couple comprised of patient and analyst. Free association in the group – described by Foulkes as free-floating discussion – creates a wider relational matrix for the interplay of psychotherapy’s reflective and reparative dimensions. Chapter 2 will explore how these dimensions can be brought into play in a synchronous way. A mixed or homogeneous group meets on a regular basis with the therapist responsible for selection. Participants will have chosen to participate and will be expected to justify their continuing presence in the group by reliable attendance. There are many variations in the principles of selection, organisation, frequency and patterning of meetings, but the common principles in all the many different applications are set out in the pages below. The ‘Timeless’ Once a group is assembled no instructions are given to its members beyond the therapist’s encouragement that they talk as freely as possible about whatever

1  Aims and vocabulary of psychotherapy  47

comes to mind. What ensues – free-floating discussion – is the group equivalent of free association. Therapy is born out of ordinary language in the free exchange of its members. It occupies the cultural domain of all shared, conversational experience in which people struggle with meaning – in congregational life, in the confessional, in theatre, narrative or poetry – and it calls on principles through which The depths of the mind are reached and touched by simpler words that speak in images and metaphors . . . a universal, timeless language, pre-dating contemporary ideas . . . that touches the heart, the ancient seat of the emotions; (and) that speaks to the soul. (Pines, Preface to Cox and Thielgaard 1987:xxiv) There are accounts that go back to the genesis of storytelling of people who have found points of renewal in the lower depths and have risen to live in ordinary society or to flee from it, speaking of the uncomfortable truths of their experience. Theirs is an occasional and exceptional story. We find biblical illustrations in Joseph’s prophetic dreams in prison and Jonah’s experience in the belly of a whale. Sophocles’s Oedipus, Victor Hugo’s Les Misérables and Gorky’s Lower Depths are three of the many in the literary world. The ‘Timed’ We utilise a set of clinical principles that govern the setting, the therapist, the therapeutic method, the group matrix and its language to take what is occasional and exceptional and turn it into a programme that can open the world of ordinary society to many who would otherwise live and die on its margins. To do so we move from the timeless to the timed, from universal cultural experience to an exacting methodology summarised by Cox as the structured use of time, depth and mutuality (Cox 1978/1995). The method begins with Freud, who Made it possible for therapists and patients to engage in . . . forms of transformational dialogue that had never existed before. He showed therapists how to do things with words to help revise radically their patients’ hitherto fixed, unconsciously directed constructions of both subjective experience and action in the world . . . Freud’s clinical dialogue alters in crucial ways the analysand’s consciously narrated presentation of the self and its history among people by destabilizing, deconstructing, and de-familiarizing it. (Schaffer 1992:156)

From the couch to the circle These transformative principles are given a group context in which, instead of being put to work by one therapist in an exchange with one patient, they are exercised by the group as a whole. They operate through any one of three different forms of

48  I Foundations

speech arising in the matrix of every group. First they are addressed to the monologue of the group’s individual members, along the lines Schaffer describes above. Second, they become part of a dialogue between individuals in the group or between sub-groups representing polarized aspects of the group’s life. We begin to see some exchange between these opposites. Third, in the most advanced form they become part of a group’s discourse in which each member is a contributing participant. Here there is no single or exclusive narrative line and the group’s exploration is open, diffuse and undirected, a chain reaction of associated experiences that can include words, images, feelings, laughter or tears. To understand a group working in this way we would have to consider the texture of the discourse rather than the text of its narrative. We would need to pay attention to context as well as content, ground as well as figure and group atmosphere as well as the dynamics of the individual. There is a steady progression that begins with monologue in the individual’s first encounter with themselves that often emerges in ‘the language of the symptom (which) although already a form of communication, is autistic. It mumbles to itself secretly, hoping to be overheard’ (Foulkes and Anthony 1957; 1984:259–260). It moves to dialogue in the discovery of the other and then to discourse as each individual’s multiple inner objects are externalised and encountered in the group. The group-analytic approach is distinguished from other group methods in that neither of the two earlier speech forms is disregarded. On the contrary, both monologue and dialogue are encompassed by and integral to group-analytic experience. Free-floating discussion allows a pattern of exchange to move freely between these different speech forms, and Through this movement – from monologue through dialogue to discourse and back again – the group-analytic method comes into its own, creating an arena in which the dialectic between the psyche and the social world helps to refashion both. (Schlapobersky 1994:61 and Chapter 3 page 113) In the chapters that follow the book illustrates a progression from constructive experience in the relational dimension to deconstructive experience in the reflective dimension and finally reconstructive experience in the reparative dimension. Each of these dimensions introduces the possibility of change at a different and more fundamental level. The conductor helps turn relational into reflective and reflective into reparative experience. In order to do so they need to be able to frame interventions to communicate about the location of a group’s primary preoccupations and disturbances and help with the translation of these preoccupations from the unconscious language of symptoms and behaviour into shared and openly understood processes. This allows the progression from relational to reflective and then reparative experience. The conductor needs to be able to lead the group in the location of its own disturbance rather than getting the group to address the conductor’s own questions about its development. The work of the group is in the translation of disturbance

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into the ordinary language of shared experience and – as the need arises – the interpretation of irrational and counter-productive dynamics that hinder growth and recovery. In a well-functioning therapy group all three modes of activity operate – constructive, deconstructive and reconstructive – and the group moves between them as it does between the different patterns of speech. Monologue is most usually a defensive stand, and discourse is usually therapeutically productive. So if the conductor’s guiding intentions are to help turn monologue into dialogue and dialogue into discourse, this allows progression from the relational to the reflective and reparative dimensions. Progress takes a spiral form with the conductor’s active though often silent participation, introducing the principles of location, translation and interpretation. When the struggle with meaning – the timeless – is given a bounded and well-structured clinical framework, language can work to generate mutative metaphors that, coming in a moment, can last a lifetime. At such moments, as Cox and Thielgaard describe, ‘A sense of mystery, astonishment, and uniqueness . . . transcends any descriptive technicalities’ (1987:17). These portal moments can arise through monologue, dialogue or discourse in which therapeutic transformation is close to its more timeless cultural forms. Monologue is like a soliloquy, dialogue in the resolution of opposites is like Plato’s dialogue and discourse is like the work of an ancient Greek chorus.

Therapeutic technique or operational principles Kennard, Roberts and Winter’s Workbook of Group-Analytic Interventions (1993) remains one of the few publications addressed directly to clinical practice and has been translated into a number of languages. The scope of my own book is a response to it. What is a ‘group-analytic intervention’? Attempts at portraying ‘standardised’ responses to complex situations run the risk of reading like a cookbook or Victorian manual on the art of conversation. The challenges facing group analysts – and facing those of us who try to portray our work – are daunting. We put our colleagues in a double bind when we encourage those new to the work to ‘just be yourself’ in the situation. But if you encourage a mental health professional to sit quietly in a room full of troubled people, to stay close to them, tolerate the conflicts they have with themselves, with one another and with you and to say something only occasionally, that might be wise, sensible and facilitating, whilst ‘just being yourself’, the injunction has about it a sense of the impossible. I used to think that a workbook was not the way to do it, as our bearing and deportment in a group are so personal. Foulkes’s own guidance – described in detail in Chapter 17 – was that conductors should encourage a group’s spontaneity. The only authentic way to do this is by our own spontaneity, and Foulkes says very little about this. How can one do any of this with a manual in your hands? Kennard, Roberts and Winter classify eight main forms of conductor intervention and give a ‘typology’ for them, set out in Table 1.4. They identify ‘the element of the group addressed by the intervention’ that includes one or more individuals, the group

50  I Foundations Table 1.4  Definition and classification of conductors’ interventions: Roberts* Intervention

Description and Dynamic Purposes

1

Maintenance of structure

All activity that defines limits which may include place, time, membership, task or rules. Can be applied to group, member or therapist.

2

Open facilitation

Open interventions aimed at bringing the group forward, unrelated to dynamic formulations or hypotheses.

3

Guided facilitation Promoting comments that reveal the therapist’s hypothesis or background understanding.

4

Interpretation

Verbal interventions that put words to feelings or meaning that is latent in the contributions of individual members or the group as a whole. ‘Translation’ is often used to describe this.

5

No immediate response

Much of the therapist’s interventive repertoire consists of silent participation in the group.

6

Action

All physical activity the therapist might undertake like leaving his chair to open a window or touching a member of the group.

7

Modelling

All the therapist’s behaviours carried out with the implicit intention that they be adopted and become part of the repertoire of the group or its members. This may include mastery of stressful events or modelling an analytic, enquiring and compassionate attitude.

8

Self-disclosure

Any statement by the therapist about the content of his internal world, thoughts or feelings or the external world which does not fit into any of the above categories.

* Table 1.4 is reproduced from Kennard, Roberts and Winter’s Workbook of Group-Analytic Interventions (1993). Grateful acknowledgements are made to the authors and publisher.

as a whole, parts of the group or the conductor themselves (Kennard, Roberts and Winter 1993:18). They construct eight scenarios describing group situations drawn from clinical practice that present ‘possible turning or pivotal points in the life of a group’, and they invite the reader to consider their own intervention and to then ‘study the interventions made by a number of experienced therapists, together with a commentary on these interventions from the authors of the book’ (Kennard, Roberts and Winter 1993:24). The book has been an essential text in my own development, and I have seen it put to fine use by practitioners and teachers including Lorentzen. This book builds on their foundations, and I have called on it in my construction of the vignettes and commentaries that follow. Their classification of interventions in Table 1.4 is given here in the same edited form used by Lorentzen in Chapter 6 of this book. It shapes the chapter divisions

1  Aims and vocabulary of psychotherapy  51

of this book6 in which readers will see that maintenance interventions belong in Chapter 9 on structure, and guided facilitation belongs in Chapter 10 on process, interpretation belongs in Section III Chapters 13 to 17; no immediate response belongs in Chapter 5 on silence; and action, self-disclosure and modelling belong in Chapter 12 on the conductor. Lorentzen’s work in which he systematises therapist interventions to study them for purposes of comparison and research relies on the Workbook and is referenced here in Chapter 3 and then examined in Chapter 6.

The group as a vehicle – not the destination A group is a therapeutic vehicle but is not the therapy itself. A car is the vehicle for a journey, and here confusion between the vehicle and its journey is unlikely. We most usually get in a car to go somewhere. Why do we find it hard to differentiate the group from the therapy it makes possible? Whilst a car is a mechanical object and a group is a human, dynamic entity, they are both vehicles. In a car the journey travels through space over time, and in a group the journey travels through intersubjective processes involving growth and recovery. One key to understanding this confusion is the fact that a person in the car is being conveyed by an external agency and usually has a destination in mind. A group on the other hand is a self-created vehicle, the product of many selves and their engagement with one another. Not even the conductor of a group can be compared with the driver of a car who knows exactly where they are going. Amongst the other factors that set group methods apart from individual psychotherapy is the fact that here you gain not only by what you get but also by what you give to the experience of others. In group therapy you are conveyed by the vehicle you help create. Foulkes and Anthony put it like this: Group psychotherapy uses the group and its power for therapeutic purposes . . . but does not treat the group for the group’s sake, to improve its working efficiency, in the way  .  .  .  a team might be treated. The group is treated for the sake of its individual members, and for no other reason. All psychotherapy is, in the last resort, treatment of the individual. (Foulkes and Anthony 1957; 1984:32–33) The group works as the ‘agent’ of therapy by setting a process in motion that cultivates reciprocity in which ‘giving help (becomes) the very process by which one might receive help, and therefore develop towards health’ (von Fraunhofer 2008:288). In order to remedy the confusion between the medium or matrix of therapy – the group – and the benefits of the journey that it makes possible, I have taken the three dimensions of a group described in Section II – its structure, process and content – and have distinguished this from the other, more fundamental dimensions of therapy in the journey itself described in Chapter  2. All the psychodynamic schools of psychotherapy, whatever their methods – individual,

52  I Foundations

family, couple or group – share a three-dimensional frame that begins with relational experience, progresses to reflective and moves on to reparative experience. The relational, reflective and reparative dimensions of therapy are taken here to encompass all psychotherapy has to offer. This book is a working study of how these dimensions can be cultivated in a group. The matrix: The group as a weather system or TARDIS Anthony tells us that Foulkes regarded the matrix as his most important contribution (Anthony 1978). Readers will find the term ‘matrix’ used infrequently in this book because, for those coming to group-analysis from outside, the term can have an alien quality and mystify the obvious. It has been studied by Pines with an original contribution about the German philosopher Dilthey in whose tradition Foulkes was trained (Pines 2015). Roberts put it to early clinical use (Roberts 1982) and his paper led to a rich exchange including contributions by Guys, Ahlin and others (Guys 1983; Ahlin 1985). Stacy has extended our understanding through his use of complexity theory (Stacy 2003), and Wotton has built on this using an account of musicality (Wotton 2012). The term has been around a long time and remains the most cited in group-analytic literature. Of the many definitions available I find Weegmann’s the most useful. He defines the matrix as [a] hypothetical web of communication and relationship [in which Foulkes] distinguished the ‘dynamic matrix’ observed in the active life of the therapy group and the ‘foundation matrix’ of shared meanings, cultural images, and other aspects of human life and emotionality. (Weegmann 2014:168) In Chapter 4 I introduce another distinction to our understanding of the matrix, building on terms introduced by Pines and differentiating between the relational matrix, the group’s affective world characterised by cohesion, and the semantic matrix, the group’s world of meaning which is characterised by coherence. But why do we need a notion of the matrix at all? Well, if readers consider the books you have read about group therapy and review the illustrative material on their covers, you may have in mind a circle of chairs or a photograph of people sitting in a circle or semi-circle. Illustrations like these are on the websites of many group-therapy organisations. I  find them uninviting and inauspicious. How can one give a convincing, pictorial account of the shared internal world? Hearst and Behr open an illuminating debate about the matrix that explores whether it is a process or a structure (Behr and Hearst 2005:270). Rayfield’s recent contribution describes it as something like the weather. In ‘the shared tasks of elemental reconstruction’, she says, The group as a whole comprised of individuals (is) subject to the forces of group process driven by intersubjectivity, through which we are modelled,

1  Aims and vocabulary of psychotherapy  53

carved, exposed and imprinted on over time, like the process of weathering. This has the effect of changing our experience and ultimately ourselves and our groups. In this picture of the group we are one another’s weather and each individual is affected by and influences others. (Rayfield 2013:5) Her contribution has bearing on the idea of a group’s climate first introduced to the field by Johnson and colleagues (2005). We can also view the group as a structure and Doctor Who, the science fiction story on British television, can help us do so with its vehicle, the TARDIS, which serves as a metaphor for the group. Its name comes from the acronym for time and relative dimensions in space. Something unexpected happened in its original design so it is much bigger on the inside than it is on the outside – that is a common attribute of the groups we conduct. The TARDIS looks like a blue police box on a street corner, but inside it a different world awaits you – an extraordinary array of space, structure and technology that can travel through time and space.7 In our equivalent, this police box is the circle of chairs on the outside cover of a book. Once inside the group we discover a capacious ordering of shared experience with a matrix that can be described in two different ways. One account distinguishes its foundation and dynamic properties, the other its relational and semantic fields, and together they generate the three dimensions of psychotherapy. The group itself has three dimensions, structure process and content; there are different ways of charting its development and at least five phases of group life. Its four domains of meaning – the current, transference, projective and primordial – can be understood as holograms so that you can look through one and see the others. Its three different language forms – monologue, dialogue and discourse – can include everybody. Its pilot is called the conductor, and it has a rare capacity to travel through time and space. This vehicle is not comprised of anything mysterious or science fictional. It is a fabric woven from the lives of people’s shared experience in which their problems can heal each other (Friedman 2010). This can happen through processes as familiar as the weather and it can take its members a long way. I hope readers will appreciate these journeys.

Notes 1 The story in this vignette is revisited in Vignette 4.2 in order to consider dynamics from different sides of the same reflective mirror. 2 I am indebted to my co-therapist Gill Nathan for the work we did together conducting couples’ groups for some 12 years, first in the Department of Psychiatry at the London Hospital and then in private practice. 3 I am indebted for these constructions to my colleagues Marit Joffe Millstein, Ido Peleg and Linde Wotton, fellow contributors to the Symposium of the Group Analytic Society International Symposium, Lisbon 2014. Our workshop was titled The Four Ms in Group-Analytic Psychotherapy: Metaphor, Music and the Re-Making of Meaning. 4 Many of this book’s vignettes address these problems as they arise in group-analytic psychotherapy. Different chapters bring their vignettes to bear on different areas of difficulty. The writing of others that gives focus to some of these issues include

54  I Foundations Pines (1986/1988), Hearst (1998), Graham (2003), Scott (2004), Clews (2011), Verebes-Weiss (2011), Tyerman (2012), Wainstein (2012), Hayes (2014), Brown (2015), Czech (2015) and Sharp (2015). 5 The two editions of this book, the 1957 edition and the second 1965 edition, both published by Penguin, differ from each other in significant ways. The recent Karnac edition (1984) reissues the book in its 1965 form. All references to this book will be identified as being from the first or second edition. 6 The table given here matches the one described by Lorentzen in order to be consistent with his writing. It is a simplification of the original one set out as Table 1.4 on page 19 of the original workbook by Kennard and colleagues (1993), to which readers are commended. 7 I am indebted to Libby Wittenberg for her guidance on how the TARDIS was originally constructed.

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1  Aims and vocabulary of psychotherapy  55 London, Jessica Kingsley, pp. 80–98. Reissued in J. Maratos (Ed.). (2006). Resonance and Reciprocity: Selected Papers by Dennis Brown. London, Routledge, pp. 107–123. Brown, D. (2000; reissued 2006). Self Development Through Subjective Interaction: A Fresh Look at Ego Training in Action. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. London, Jessica Kingsley, pp. 107–123. Republished in Maratos, J., ed. (2006). Resonance and Reciprocity: Collected Papers of Denis Brown. London, Routledge. Brown, S. (2015). Relatedness and Belonging: Altering Identity In The Analytic Group. Dissertation for the Qualifying Course, Institute of Group Analysis, London. Clews, M. (2011). The Dynamics of Absence – Re-Embodied Shame in Group Analysis. MSc Dissertation. Institute of Group Analysis, London/Birkbeck College, University of London. Cox, M. (1978; reissued 1995). Structuring the Therapeutic Process: Compromise with Chaos  – the Therapist’s Response to the Individual and the Group. London, Jessica Kingsley. Cox, M., and Thielgaard, A. (1987). Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley. Cox, M., and Thielgaard, A. (1994). Shakespeare as Prompter: The Amending Imagination and the Therapeutic Process. London, Jessica Kingsley. Czech, D. (2015). The Group and its Discontents: Contempt. Dissertation for the Qualifying Course. Institute of Group Analysis, London. Dalal, F. (2000). Taking the Group Seriously: Towards a Post-Foulksian Group-Analytic Theory. London, Jessica Kingsley. Firestone, R., Firestone, L., and Catlett, J. (2003). The Wisdom of Psychotherapy: Creating a Life of Meaning and Compassion. Washington, DC, American Psychological Association. Foulkes, S. H. (1964; reissued 1986). Therapeutic Group Analysis. London, Karnac. Foulkes, S. H. (1975; reissued 1986). Group Analytic Psychotherapy: Method and Principles. London, Karnac. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Freud, S. (1930). Civilization and Its Discontents. S.E. 21. London, Hogarth Press. Friedman, R. (2010). The Group and the Individual in Conflict and in War. Group Analysis 43 (3): 281–300. Friedman, R. (2013). Individual or Group Therapy? Indications for Optimal Therapy. Group Analysis 46, 164–170. Gans, J. (2010). Difficult Topics in Group Psychotherapy: My Journey From Shame to Courage. London, Karnac. Gilligan, J. (1997; reissued 2000). Violence: Reflections on a National Epidemic. London, Jessica Kingsley. Gorky, M. (1953). Autobiography of Maxim Gorky: My Childhood: In the World: My Universities. London, Elek Books. Graham, R. (2003). Mind the Gap: A Group-Analytic Perspective on Envy. MSc Dissertation. Institute of Group Analysis, London/Birkbeck College, University of London. Greenberg, J., and Mitchell, S. (1983). Object Relations in Psychoanalytic Theory. Cambridge, MA, Harvard University Press. Guys, J. (1983). Foulkes’ Concept of the Matrix. Group Analysis 15: 111. Harwood, I., Stone, W., and Pines, M. eds. (2012). Self-Experiences in Group Revisited: Affective Attachments, Intersubjective Regulations and Human Understanding. New York and London, Taylor & Francis.

56  I Foundations Hayes, C. (2004). The Language of the Symptom and The Velveteen Rabbit. MSc Dissertation. Institute of Group Analysis, London/Birkbeck College, University of London. Hearst, L. (1998). The Restoration of the Impaired Self in Psychoanalytic Treatment. In N. Slovinska-Holy (Ed.), Borderline and Narcissistic Patients in Treatment. New York, International University Press, pp. 123–142. Holmes, J. (2010). Explorations in Security: Towards an Attachment Informed Psychoanalytic Psychotherapy. Karnac, London. Jaffe, L. (2014). How Talking Cures: Revealing Freud’s Contributions to All Psychotherapies. Lanham, Littlefield. Johnson, J. E., Burlingame, G. M., Olsen, J. A., Davies, D. R., and Gleave, R. L. (2005). Group Climate, Cohesion, Alliance, and Empathy in Group Psychotherapy: Multi-Level Structural-Equation Models. Journal of Counselling Psychology 52 (3): 310–321. Kennard, D. Roberts, J., and Winter, D., et  al. (1993; reissued 2001). A Workbook of Group-Analytic Interventions. London, Jessica Kingsley. Kleinot, P.  (2011). Transgenerational Trauma and Forgiveness: Looking at the Israeli–Palestinian Families Forum through a Group Analytic Lens. Group Analysis 44 (1): 97–111. Leszcz, M., and Kobos, J. C. (2008). Evidence-Based Group Psychotherapy: Using AGPA’s Practice Guidelines to Enhance Clinical Effectiveness. Journal of Clinical Psychology 64 (11): 1238–1260. Levens, M. (2011). Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation. MSc dissertation. Institute of Group Analysis, London/ Birkbeck College, University of London. Mitchell, S. (1988). Relational Concepts in Psychoanalysis. Cambridge, MA, Harvard University Press. Modell, A. (2011; 2013). Metaphor, Meaning and the Mind. In S. Montana Katz (Ed.), Metaphors and Fields: Common Ground, Common Language and the Future of Psychoanalysis. London, Routledge, pp. 59–66. Montana Katz, S. (Ed.). (2013). Metaphors and Fields: Common Ground, Common Language and the Future of Psychoanalysis. London, Routledge. Neeld, R. (1999). The Group as Auxiliary Ego. Theory Paper for Qualification. Institute of Group Analysis, London. Nitsun, M. (1988). Early Development: Linking the Individual and the Group. Group Analysis 22: 249. Nitsun, M. (1996). The Anti-Group: Destructive Forces in the Group and Their Creative Potential. London, Routledge. Nitsun, M. (1998). The Organizational Mirror: A Group-Analytic Approach to Organizational Consultancy. Group Analysis 31 (3): 245–267. Nitsun, M. (2006). The Group as an Object of Desire: Exploring Sexuality in Group Psychotherapy. London, Routledge. Nitsun, M. (2015). Beyond the Anti-group: Survival and Transformation. London, Routledge. Ofer, G. (2015). Forgiving and Not Forgiving in Group Analysis:  The Importance of Witnessing in the Process of Forgiveness. In G. Ofer (Ed.), Bridge Over Troubled Waters: Conflict and Reconciliation in Groups and Society. London, Karnac. In press. Peleg, I. (2012). Oppression, Freedom, and Recognition in an Analytic Therapy Group: Group and Therapist Interactions from Relational and Group Analytic Perspectives. International Journal of Group Psychotherapy 62 (3): 436–458.

1  Aims and vocabulary of psychotherapy  57 Pines, M. (1986; 1988). Coherency and Disruption in the Sense of Self. British Journal of Psychotherapy 2, 3: 180–185. Reprinted in M. Pines (1988). Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London, Jessica Kingsley, pp. 211–223. Pines, M. (1987; 1998). Introduction. In M. Cox and A. Thielgaard, Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Tavistock. Reissued, Jessica Kingsley, pp. xxiii–xv. Pines, M. (1998). Circular Reflections: Selected Papers on Group Analysis and Psycho­ analysis. London, Jessica Kingsley. Pines, M. (2015). Collected Papers. London, Routledge. Rayfield, E. (2013). Weathering, Shifting Perspectives and the Space in Between. MSc ­dissertation Birkbeck College University of London/Institute of Group Analysis, London. Roberts, J. (1982). On Thinking About the Matrix. Group Analysis 15 (2): 111–126. Salvendy, J. T. (1993). Selection and Preparation of Patients and Organization of the Group. In H. I. Kaplan and B. J. Sadock (Eds.), Comprehensive Group Psychotherapy (3rd. ed.). Baltimore, MD, Williams and Wilkins, pp. 72–84. Schaffer, R. (1992). Retelling a Life: Narration and Dialogue in Psychoanalysis. New York, Basic Books. Schlapobersky, J. (1994; 2000). The Language of the Group: Monologue, Dialogue and Discourse in Group Analysis. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. London, Routledge. Reissued Jessica Kingsley Press, pp. 211–231. Schlapobersky, J., and Pines, M. (2009). Group Methods in Adult Psychiatry. In M. Gelder et al. (Eds.) New Oxford Textbook of Psychiatry. Oxford: Oxford University Press, pp. 1350–1368. Scott, S. (2004) Uncovering Shame in Groups. MSc Dissertation. Institute of Group Analysis, London/Birkbeck College, University of London. Sharp, M. (2015) A Call to Arms: Envy and Gender in the Small Group-Analytic Group. Dissertation for the Qualifying Course, Institute of Group Analysis, London. Skynner, A.C.R. (1983; 1987). Group Analysis and Family Therapy. In J. Schlapobersky (Ed.), Explorations With Families: Group Analysis and Family Therapy. London, Routledge, pp. 231–235. Stacy, R. (2003). Complexity and Group Processes. Abingdon, Routledge. Tucker, S. (2004). From Group Norms To The ‘Group Super-Ego’: The Therapeutic Efficacy of The Ethical and Political In Foulkes. MSc Dissertation. Institute of Group Analysis, London/Birkbeck College, University of London. Tyerman, S. (2012). Watching the Body in the Group. Theory Paper for Qualification. Institute of Group Analysis, London. Usandivaras, R. (1989). Therapeutic Use of Regression in Group Analysis. Group Analysis 22 (2): 171–175. Verebes-Weiss, J. (2011). Capacity To Be in a Group: Small Group Psychotherapy in a Forensic Therapeutic Community for People with Dangerous and Severe Personality Disorder. Theory Paper for Qualification. Institute of Group Analysis, London. Von Fraunhofer, N. (2008). What’s in It for Me? The Development from Immature to Mature Dependence in Groups. Group Analysis 41 (3): 278–290. Wainstein, S. (2013). An Exploration of Intimacy in Group Analytic Psychotherapy. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London.

58  I Foundations Weegman, M. (2001). Working Intersubjectively: What Does It Mean for Theory and Therapy? Group Analysis 34: 515–530. Reissued in E. Hopper and H. Weinberg (Eds.), The Social Unconscious in Persons, Groups and Societies. Vol. 1: Mainly Theory. London, Karnac, pp. 133–154. Weegman, M. (2014). The World Within the Group: Developing Theory for Group Analysis. London, Karnac. Weegman, M. (2015). Social Unconsciousness: Verb, Movement and Field of Identity. In E. Hopper and H. Weinberg (Eds.), The Social Unconscious in Persons, Groups and Societies: Vol. 2. London, Karnac. Wojciechowska, E. (1993). The Group as Transformational Object: Fusion, Transition, Transformation. Theory Paper, Institute of Group Analysis, London. Wotton, L. (2011). Expecting the Unexpected: A Source of Change in Analytic Groups. Group Analysis 44 (3): 315–327. Wotton, L. (2012). Between the Notes: A  Musical Understanding of Change in Group Analysis. Group Analysis 46 (1): 48–60. Wright, K. (2009). Mirroring and Attunement: Self-Realizations in Psychoanalysis and Art. London and New York, Routledge.

Acknowledgements:  Extract from Wotton (2012), Between the Notes: A Musical Understanding of Change in Group Analysis. Group Analysis 46 (1): 48–60, reproduced with permission from Linde Wotton; Table 1.1, extracted from Gans (2010), Difficult Topics in Group Psychotherapy: My Journey From Shame to Courage. London, Karnac, reproduced with permission from Jerome Gans; Table 1.2 reproduced with permission from Malcolm Pines and Oxford University Press; Table 1.3 reproduced with permission from David Kennard and Jeff Roberts and Jessica Kingsley Publishers; extract from Pines (1987), Introduction to M. Cox and A. Thielgaard, Mutative Metaphors in Psychotherapy: The Aeolian Mode reproduced with permission from Malcolm Pines; extracts from Foulkes and Anthony (1957, 1965, 1984), Group Psychotherapy: The Psychoanalytic Approach, reproduced with permission from E. J. Anthony; extract from Skynner (1983), Group Analysis and Family Therapy. In J. Schlapobersky (ed.), Explorations With Families: Group Analysis and Family Therapy, reproduced with permission from the Institute of Family Therapy. Extract from Rayfield (2013), Weathering, Shifting Perspectives and the Space in Between. MSc Dissertation, Birkbeck College University of London/Institute of Group Analysis, London, reproduced with permission from Emma Rayfield.

Chapter 2

Psychotherapy’s three dimensions Relational, reflective, reparative

Rhythm, melody and harmony may move at different speeds . . . Music accepts comments from one voice to another at all times and tolerates subversive accompaniments as a necessary antipode to leading voices. Conflict, denial and commitment coexist at all times in music. (Daniel Barenboim 2009:14, 15, 20)  . . . The ‘I’ of man is also twofold. For the ‘I’ of the primary word ‘I-Thou’ is a different ‘I’ from that of the primary word ‘I-It’. Primary words do not signify things, but they intimate relations . . .  The ‘Thou’ meets me. But I step into direct relation with it. Hence the relation means being chosen and choosing, suffering and action in one . . .  The primary word ‘I-Thou’ can be spoken only with the whole being . . .  I become ‘I’ through my relation to the ‘Thou’; as I become ‘I’, I say ‘Thou’. (Martin Buber 1958; 2000:19, 26)

Psychotherapy offers someone a therapeutic relationship to help them develop a reflective understanding of themselves and others through which reparation can promote healing, growth and change.1 This simple description of aims gives the three primary dimensions of psychotherapy that guide the practice described here. Group-analytic psychotherapy is integrative and brings psychodynamics together with the social. The relational, reflective and reparative dimensions give ‘the three Rs’ of the model and provide a conceptual framework – a kind of tripod – that supports the text. The title of this chapter builds on the work of Billow, whose book describes three different Rs and to whom grateful acknowledgements are made (2010)2 and on the work of those in the field from a number of models who are working to understand and develop the new relational paradigm in psychotherapy and whose work is cited in this chapter.3 The distinctions between these dimensions can be used to help organise the complexity of what happens in therapy groups to optimise their dynamics. The dimensions are often different ways of looking at the same basic experience but,

60  I Foundations

if we differentiate them as ‘dimensions’, the features of each become clearer. Therapeutic experience in a group often has its emphasis in one of these dimensions but even when all three are present in the moment, use of these dimensions allows us to deconstruct the moment and understand its components. The group-analytic literature has many implicit references to questions of therapeutic direction. Behr and Hearst describe how ‘analytic groups (are) protected by careful attention to the composition, setting and boundaries of the group, and by the conductor’s awareness of what constitutes a therapeutic direction’ (Behr and Hearst 2005:150). They describe ‘The art of group analysis’ in the conductor’s capacity to find balance between two risks – those of not setting therapeutic direction on the one hand, allowing counter-therapeutic process to run its course; and on the other of making gratuitous interventions that pre-empt a therapeutic process that may already be in full flow. (Behr and Hearst 2005:106) The conductor faces the challenge of setting a therapeutic course to allow a group to develop reflective moments out of relational ones and reparative moments out of the reflective. The book provides direction for this therapeutic course through a series of constructions. I will first illustrate different therapeutic moments that arise in each of the three dimensions. The relational dimension is the first and most fundamental. It generates those relational moments in which bonds and conflicts arise in a group through attachment and friction. They make the substrate of a group’s experience and provide a foundation for both the other dimensions. At the next level – and arising out of a group’s relational work – is the reflective dimension generating reflective moments that can be defined in either of two ways. The first involves self-consciousness, a sense of critical enquiry implied by the word ‘reflective’, and the second involves the discovery of symbolic meaning. Arising out of the relational and reflective dimensions is a group’s reparative dimension when reparative moments can arise in highly charged cathartic experience or in quiet moments of deep resolution. They can be understood in many different ways, and I will focus here on two. The first involves concern and remorse including the development of guilt and the capacity to make restitution to both self and other (Klein and Riviere 1964). The second involves the corrective recapitulation of primary family experience (Alexander and French 1946: 79; Yalom and Leszcz 2005). Figure  2.1 conveys how this three-dimensional model can be made to work for those who want to understand therapeutic experience but may have no direct experience. It starts with the relational dimension at the top. The outside set of arrows describes how therapy begins with the relational and progresses through the reflective to the reparative dimension. Therapeutic experience is always circular, and a therapy that becomes reparative is further enriched in its relational significance. The inside set of arrows shows how these three dimensions are always in dynamic relation to one another.

2  Psychotherapy’s three dimensions  61 Relaonal

Reparave

Reflecve

Figure 2.1  The three dimensions of psychotherapy

Change may be introduced during any of these moments, but the depth of engagement is a progressive one. Each dimension builds on the one that goes before and, as they progress, they lead to insight, outsight, reality testing and self-discovery that can take the business of change to deeper levels. Outsight is a term first introduced to the field by de Maré (de Maré 1972:159) and then used by Pines (Pines 1982/1998:31) that identifies how that which is seen or recognised outside the self and found in the other gives access to what could not otherwise be apprehended within the self.4 It is a key part of the mirroring process in group therapy and is discussed in Chapter 10. Distinctions between the dimensions introduced in this chapter are notional rather than fundamental and are introduced here to lay the groundwork for understanding. Relational moments become therapeutic when they become reflective; reflective moments are often but not always relational in nature; and reparative moments incorporate one or both of the others. The resources of the group therapist lie in their capacity to turn relational moments into reflective experience and reflective moments into reparative experience. The distinctions introduced in this chapter anticipate those to come in Chapter 4 between a therapy group’s relational and semantic fields and those to come in Chapter 5 between the real, the constructed and the representational in group therapy. This three-dimensional account is designed to be of practical use, as it describes what most group analysts are in any event doing in their groups. It provides a coherent and programmatic way of taking the work forward. Practitioners call on the relational dimension as a source of illumination. It involves changes in members’ relations in the group when they create or discover a bond or a conflict. They call on the reflective dimension to deepen moments of self-examination by

62  I Foundations

exploring symbolic meaning, especially when idiom and metaphor have a purchase on the psyche. And they call on the reparative dimension to enrich a timeless aspect of human experience – that unpleasant truths acknowledged have the power to set people free to lay a new groundwork for action. The action, what we call reparation – the business of ‘making good’ – is rarely available at the originating source of the injury or painful discovery. In group therapy reparation can go out to those others who people the circle. Arlo’s account of how this works, which she describes as paying it forward, is introduced later in this chapter. These dimensions are offered as synchronic features of therapeutic experience because, in any truly therapeutic group, they are all present at the same time.

The tripartite division of psychoanalytic interactions: Holmes These synchronic dimensions also apply to the practice of psychoanalytic psychotherapy with individuals and couples that is outside the scope of this book. The relevance of this model to individual practice can be further explored in Holmes’s ‘tripartite division of psychoanalytic interactions’ that describes ‘the three components of an attachment-informed psychoanalytic psychotherapy’. First there is the therapeutic relationship; then there is meaning making and then change-promotion. Holmes’s writing is focussed on the dynamics of the therapist’s relationship with the individual, but its practical utility and its relevance to group analysis calls for its replication here, which is given in Table 2.1 (Holmes 2010:8). Table 2.1  Tripartite division of psychoanalytic interactions: Holmes* Definition

Governing Dynamic Features

i T herapeutic relationship

              

ii M eaning making in therapy

   Use of free association    Exploration of dreams    Exploration of language   Exploration of therapeutic relationship itself in terms of transference & countertransference   Exploration of client’s developmental history

iii T herapeutic action

Intensity Contingency Security Bonding Self-monitoring and repairing

  Promoting client’s capacity to think about feelings & actions of self & others   Helping client to reintegrate repressed, disowned or projected affects or parts of self   Replacing rigidity & transference-driven repetitions with more creative, fluid & interpersonal narrative

* Table 2.1 is adapted from page 8 of: Holmes, J. (2010) Explorations In Security: Towards An Attachment Informed Psychoanalytic Psychotherapy. Karnac, London. Grateful acknowledgements are made to the author and publisher.

2  Psychotherapy’s three dimensions  63

I am calling on the different, earlier conceptual schemata of group therapy to help design a new one addressed not to the phasic development of group life, which is now well established through the literature and is discussed in Chapter 3. I am calling here on some of the features given by Holmes’s account in Table 2.1, on focal conflict theory (Stock Whitaker) and on Friedman’s three uses of dreams in groups, which are also further described in Chapter  3. The three elemental dimensions in the life of a therapeutic group are necessary features of its therapeutic identity, and they stand as pivotal dimensions on which every therapy group rests. They need a graduated and sensible deployment that is afforded first by the conductor’s varying qualities of investment in the process as it develops. A therapy group cannot begin successfully with the reflective and reparative dimensions as an active part of its makeup. The first and early stages of a therapy group will inevitably involve the relational dimension standing for and working by itself. The reflective and reparative dimensions can grow out of the group if it is well led and well composed. This idea of these three active and concurrently present dimensions is offered as a grounded way of organising Yalom and Leszcz’s therapeutic factors and making a developmental hierarchy for their list. Von Fraunhofer’s qualities of dependency and Millard’s three key agencies in groups This idea of three dimensions looks back to Bion, Schutz, Bennis and Shepherd and Durkin, all of whom are discussed in Chapter 3. It also looks forward to the kind of schemata that have been introduced to the field by authors like Millard and von Fraunhofer that await further development. Millard writes of the three key agencies in therapeutic groups as belonging, intimacy and agency (Millard 2002); von Fraunhofer describes an individual’s relationships in the group emerging in a state of fusion, progressing through joining to reach belonging. Millard anticipates the further development of the existential ideas included amongst Yalom and Leszcz’s ‘therapeutic’ factors and explored in the further development of their existential psychotherapy (Yalom 1980). She calls on a range of concepts from the work of Buber, in particular his concept of the I-Thou relationship, which, because it is intersubjective, allows the emergence of both intimacy and agency, and the significantly different concept of the I-It relationship that is instrumental. If a therapist makes a construction about one or several people or an interpretation in which the others are objectified, this turns the communication into something instrumental with counter-therapeutic consequences. The relevance of this perspective to the framing of group interventions runs through this text and is given close attention in Chapters 12 to 17. Von Fraunhofer uses Fairbairn’s concepts to construct her own three-phase development model for the progress of an individual in a group, from regression or immature dependence through a phase of experimentation to a state of mature dependence involving a capacity for mutual exchange. The phases she describes, of fusion, joining and belonging, are original terms of real utility in our

64  I Foundations Table 2.2  Qualities of dependency in groups: von Fraunhofer* Quality of dependence

Immature Dependence

Transitional phase/Partial independence

Mature dependence/ Interdependent

Attitude towards exchange

Non-reciprocal

Incremental experimentation with exchange

Capacity for mutual exchange

Quality of relationship to the group

Fusion (Narcissistic/ Self-denying)

Joining

Belonging

Quality of communication

Monologue

Emergent dialogue

Discourse

* Table 2.2 is reproduced from von Fraunhofer, N. (2008) ‘What’s in it For Me?’ The Development from Immature to Mature Dependence in Groups in Group Analysis, vol. 41, 3: pp. 278–290, with the kind permission of the author and Sage Publications.

understanding of group development that can be constructively mapped against the relational, reflective and reparative dimensions using Table 2.2 and is further discussed in Chapters 8 and 11 (von Fraunhofer 2008:288). Yalom’s therapeutic factors Yalom’s 11 therapeutic factors were formulated to answer key questions he posed in 1970, and they have shaped the field since then. I am returning here not so much to the answers – the 11 factors – but to Yalom’s originating questions. Does group therapy help clients? Indeed it does. A persuasive body of outcome research has demonstrated unequivocally that group therapy is a highly effective form of psychotherapy and that it is at least equal to individual psychotherapy in its power to provide meaningful benefits. How does group therapy help clients? . . . If we can answer (this question) with some measure of precision and certainty, we will have at our disposal a central organising principle with which to approach the most vexing and controversial problems of psychotherapy. Once identified, the crucial aspects of the process of change will constitute a rational basis for the therapists . . . to shape the group experience to maximise its potency . . .    .  .  . Therapeutic change is an enormously complex process that occurs through an intricate interplay of human experiences, which I will refer to as ‘therapeutic factors’. (Yalom and Leszcz 2005:1) The reasons for returning to his questions arise from a dawning recognition as I struggled with this text that a degree of controversy in the field and many of

2  Psychotherapy’s three dimensions  65

its divisions arise from a curious confusion between the group and its attributes on the one hand and, on the other hand, the therapy that the group can provide. Structure, process and content are attributes that belong to the group itself. They describe the vehicle but not the journey or its destination. Yalom’s original answers to the questions he posed – formulation of his 11 therapeutic factors – are not set aside here. His ‘natural lines of cleavage’ have stood the test of time, and our field is shaped by their demarcations. The three dimensions introduced in this chapter can help us, 40 years on, with the reorganisation and reappraisal of these factors. Bloch and Crouch, writing from within the interpersonal model, made an especially valuable contribution to the understanding of therapeutic factors in group psychotherapy (Bloch and Crouch 1985). If we can now devise a clinical and conceptual framework through which to reappraise these factors, then perhaps we can begin to see how the interpersonal and the different psychodynamic models can be integrated. The relational dimension includes 7 of Yalom’s 11 therapeutic factors – universality, imparting information, altruism, socialising techniques, imitative behaviour, interpersonal learning and group cohesiveness. The reflective dimension includes instillation of hope and catharsis, and existential factors belong somewhere between the reflective and reparative dimension. The reparative dimension fully embraces the corrective recapitulation of the primary family group. As Yalom and Leszcz stress, boundaries between these factors are blurred, and elements of these factors belong to all three of the dimensions introduced here. Once this three-dimensional frame can be understood, accepted and integrated with the other three dimensions of structure, process and content set out in Section II, then we might hope for a degree of integration.

Definitions of the three dimensions The relational dimension This dimension frames the group’s interpersonal relations. Relational moments – involving changes in members’ intersubjective relations – arise when the creation or discovery of attachment or conflict becomes a positive bond or a source of trouble that can become illuminating. When relational moments arise they capture a shift in the attachment base of a group’s relational matrix and begin to shape the dynamics for change between people. The emerging bonds and conflicts at such moments are those that make change possible in both the dimensions that follow. The reflective dimension This dimension arises when people can investigate the terms of their engagement and find meaning in the enquiry. It belongs to what Winnicott called the intermediate world (Winnicott 1953:230). Reflective moments in a group can be understood in either of two ways. First, they are moments of self-examination and

66  I Foundations

involve reflexive questioning – the process of becoming conscious or self-aware. And second, they include the discovery of symbolic meaning and the way in which idiom and metaphor have a purchase on the psyche at such moments especially. Reflective moments belong to the representational world in which we can hear the voice of the symbol (Grotjahn 1971) and are close to what we seek in art, music and literature. The holy and the sacramental belong to this domain, as do fetish, obsessional ritual and many other aspects of addictive behaviour that have a symbolic form. Its features are symbolic and metaphorical rather than relational. Bollas described the aesthetic imperative in these moments (Bollas 1987), and Cox added psychotherapy’s mutative metaphors to this dimension (Cox and Theilgaard 1987). The reflective dimension relies on metaphor to take us from one world into another. The movement takes place via symbol systems that are often generated by the group itself. Each group creates its own metaphors that can serve as vehicles for change. They work in the same way that literary or religious symbols do, first to create a common symbolic language, a language of belonging, and then, as they introduce deeper changes, as they become mutative and engage with longing, they can lead on to reparative moments, as Chapter 15 describes. The reparative dimension This dimension incorporates either or both the preceding ones and can be understood in two ways. Reparation arising out of guilt or remorse and leading to concern Reparation first involves the capacity for concern, the experience of guilt, the feeling of remorse and the wish to make good. The Kleinian contribution to psychoanalysis gives the subject a sound literature in individual practice, beginning with Klein’s own writing on Love, Hate and Reparation (Klein and Riviere 1964). The idea that unpleasant truths that are acknowledged may have the power to set you free is central to the psychoanalytic principle that insight can have cathartic benefits. Reparative moments are more than anything else like achieving the depressive position in a relational context so gratitude can grow into generosity. Reparation that turns gratitude into generosity towards others: Corrective recapitulation Second, reparation goes beyond work with individuals or even small groups. As one of our foundation emotions, reparation arises wherever people are trying to make good in the aftermath of injury. It underlies all self-redeeming action and has been widely applied in judicial proceedings and programmes of restorative justice (Sachs 2011). This second aspect of reparation, which extends gratitude to generosity towards others, is illustrated by the story of Jean Valjean, the hero of Hugo’s novel Les Misérables. His transformation from felon to public benefactor begins when he

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is saved from a desperate predicament by the redeeming action of a bishop. His sense of indebtedness informs all his later actions as he harvests his own good fortune and turns it to the benefit of others. The psychoanalyst Alexander called on Hugo’s novel to help him frame the notion of corrective emotional experience that he put at the heart of psychotherapy whilst working in Chicago in the 1940s (Alexander and French 1946). His ideas were drawn into the practice of individual psychotherapy in the UK by Winnicott, who used these ideas to modify the understanding of transference at that time and develop a relational perspective in which the current work of Donnel B. Stern is anticipated (Winnicott 1963:258; Stern 1997, 2010). Yalom put these ideas into the practice of group psychotherapy when he incorporated corrective recapitulation as one of his 11 therapeutic factors (Yalom and Leszcz 2005:27–31). Valjean is the recipient of unforeseen generosity that amends pent-up rage against deep injustice. The amending process begins in his own experience of another’s generosity, to which he reacts with true gratitude. This gratitude is then extended and passed on to others through the course of his successful life as he in turn becomes a generous man. He lives in a constant struggle against his own aggrieved impulses, against the threat of his disguised identity being exposed and in the witness he bears to further grave injustice against others. His life-long devotion to Cosette, an orphaned child who he rescues, adopts and educates, makes for compelling literature and theatre. Arlo’s account of ‘paying love forward’ Arlo provides the promising notion of paying love forward that she extracts from cinema and literary sources to explore other stories arising in group therapy where gratitude is transposed into generosity. In a vivid account of reparation between siblings when one of them has the benefit of group therapy, she describes how the group itself becomes a reparative arena in which ‘you don’t pay love back. You pay it forward’, and this love goes out to the people around you in the group who have helped bring you to a new threshold of development (Arlo 2014:349–351). The lived experience of change in group therapy arises when people struggle with what it means to give and receive generosity; when gratitude gains over grievance; when the struggle takes place in the presence of others who are dealing with themselves in similar ways; when people have to battle against their own or one another’s resistances; when metaphors become mutative, allowing access to the deepest areas of injury and the greatest prospects for restitution; and when the steady process of resolution in all its sometimes painful detail corresponds most closely to what Freud called, ‘working through’ (Freud 1914:147).

Illustrations of the three dimensions The vignettes that follow illustrate the three dimensions and emphasise their differences. Later vignettes will illustrate how the construction works when all three dimensions arise at the same time in a synchronic way.

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The relational dimension Vignette 2.1  My brother, what have they done to you? Some relational moments

A group of eight men sit in a circle with two therapists for the first meeting of what will be a two-year group programme of some 70 sessions. They come from countries in which torture is endemic and have all been profoundly injured. None of them know each other or have any prior association, but they all know one or other of the two therapists. Some are from the Horn of Africa and include a Christian Ethiopian and Muslim Somali. From Black Africa there is a Congolese and a man named Jonas, a Rwandan Tutsi who survived the genocide, both of whom were raised as Christians. The other four include two Iraqis who are Sunni Muslims and two Iranians who are Shi’ite, one of whom is Mustafa. Their religion, nationality and the ethnicity of their origins are given to stress their differences. What they have in common is prior experience of traumatic loss and violence in their countries of origin. They are all refugees. We are meeting in a clinic established to provide such services for this population. All the group’s members have already had extended periods of rehabilitative care followed by preparatory psychotherapy with either one of the two co-therapists. To begin with we struggle through introductions that falter and halt. People refer all their questions to one or other of the therapists, from whom they expect answers. The two therapists are occasional and cordial participants, but we consistently refer back to the group. Then there is silence, followed by limited narrative sequences in people’s fragmented stories of origin and arrival as refugees. We are as enabling as possible, but the edge to people’s anxieties is inhibiting. All new groups begin this way with a form of serial monologue. Thirty minutes into this fractious exchange, governed by seemingly unproductive pauses in which people look frequently to the therapists, one of the men, Mustafa from Iran, asks where the toilet is. He is directed by one of the therapists, and everyone sees him gather his crutches from beneath his chair and limp across the group room to the door. He was already seated when the other members arrived so – until now – only the therapists knew how handicapped he was. We watch his every move in a kind of charged silence that remains unbroken whilst he is out. A few minutes later the door opens and, watched by everyone, he struggles across the room back to his seat and stumbles into his chair perspiring from the effort. Finally he replaces his crutches beneath his chair.

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Jonas from Rwanda has extensive, visible scarring to his face and neck and speaks with a commanding French accent. He looks at Mustafa across the room and, leaning towards him, says, ‘My brother, what did they do to you?’ There is a long pause and then, with the reply, the room fills with relief and a real exchange emerges. Mustafa speaks in broken, faltering English about how soldiers at home broke his back with their rifle butts and boots and how lucky he is to be alive. He goes on to tell us of how his family saved him, how he escaped from Iran with his wife and of the baby they are expecting. This is a truly relational moment that moves us from monologue to dialogue. The dialogue between these two men leads, in turn, to a non-directed and random exchange across the group in the kind of conversational exchange that discourse is comprised of and which informs us that the group is coming to life. It will falter, fall back and confound itself many times over in the coming months of therapy. But in this first relational moment we all became witnesses and, in the act of bearing witness, group therapy begins.

Commentary The question is not only an enquiry but is also a statement of identification and a gift to the group and its therapists. Nothing could have prepared us for this, and it would have been impossible to anticipate or rehearse. Given the right conditions, events of this kind happen all the time in group therapy. They are the portal moments in which ‘A sense of mystery, astonishment, and uniqueness . . . transcends any descriptive technicalities’, described in Chapter 1 by Cox and Theilgaard (1987:17). The moment at which Jonas puts his question to Mustafa could be considered using Tavistock basic assumptions. In the shift introduced by the question, we could see a move from dependency to pairing. But to analyse this move according to simple, basic assumptions is to overlook the richness of the therapeutic encounter. It is better described as a move from monologue to dialogue that helps introduce an intimate conversation. This kind of question is also a communication and an answer to any one of a number of other, unstated, earlier questions: ‘Who are you? How did we all survive? How can we face the extent of human cruelty? What can we do together about the injuries that show on our faces and in our bodies?’

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In the question there is also an answer to yet another unstated question. I will be your brother, he says, will you be mine? In the moment of his question he begins to create brotherhood amongst us. General points can be extracted from this opening that are relevant to all group psychotherapy. These people had lost just about everything – their relatives, health, home and country and their sense of integrity. Though they were preoccupied with their own losses they could – through their compassion for one another – rediscover their dignity. Generosity emerged as a quality they had not lost, and from this discovery each of them would rebuild their world. This ‘band of brothers’, described as a ‘sipology group’ in the introduction, settled down to two years of productive work in the course of which they stabilised their lives in a strange country. They began the mourning process of coming to terms and did so as displaced people in the absence of their customary rituals of mourning and grief work, relying instead on the group itself. And finally, they began to generate together a real sense of future. In Vignette 2.2, a different but related vocabulary is developed in a small group for those recovering from acute mental illness who are meeting in an office near to but outside the psychiatric hospital in which they were once inpatients. They come in now just for the group’s weekly meeting that is described in its early stages and will have the same built-in progression as the one described in Vignette 2.1.

Vignette 2.2  The ‘normals’ in our space capsule

From our first session we looked out at the ‘normal’ world that included the man mowing the lawn across the pathway beyond, at pedestrians crossing the road and at the traffic of human society outside the hospital. This was the view they described as participants decided, through quite a lot of laughter, that the world outside was comprised of aliens whilst we alone lived in a ‘space capsule’ called ‘the Normals’. The laughter took on a quality of almost manic relief when someone started singing, under their breath, ‘We all live in a yellow submarine, yellow submarine, yellow submarine’. In the laughter that followed this was to become a refuge and sanctuary as people slowly rebuilt their lives.

Commentary Moments of this kind are reported by therapists working with all injured or stigmatised groups and will be described amongst those in therapy for life-threatening illness; those in despair about their old age; those in prison coming to terms with their own violence; those in groups for asylum seekers

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and refugees coming to terms with the violence of others; and parents in couples groups coming to terms with the loss of a child. They will be referred to as relational moments when the creation or discovery of a bond is also a source of illumination through which the group itself can become an auxiliary ego.

Relational moments are not only benign or affirmative. Many of the most profound relational moments arising in therapeutic groups involve conflict, hostile opposition or malignant mirroring. Yalom and Leszcz address these moments (2005:138–140, 363–374), and Nitsun’s Anti-Group explores seemingly negative experience illuminating the benefits that arise when they can be investigated (1996). There are many vignettes in this book that document therapeutic work done with conflict and other negative experience, including 4.3, 4.4, 8.2, 10.4, 10.9, 13.2, 14.3, 15.4, 16.3 and 17.2. Relational moments in daily life Vignette 2.3  About mayonnaise on the chin

Standing on a street corner I watch a couple get out of a car that has just been parked. They have obviously been eating something whilst driving. She looks at him across the windscreen and, over the bonnet of the car, says to him, ‘You’ve got some mayonnaise just there’, scratching the point of her chin as she does so. He takes a tissue out of his pocket, applies it accurately and cleans his own chin with one stroke, saying ‘Thank you’ briefly as he does so. He does not need to look at a mirror because he has seen himself in her gesture.

Commentary We are looking here at the detail of the commonplace, the ordinary language that group therapy is built on. In the exchange between these two we are looking at a relational moment. How is this moment related to group therapy? Without these key elements groups are not really therapeutic. But it is the next step in decoding the illustration that shows the commonplace detail of ordinary language to be a relational moment that has import. She located the mess on his chin by the way she pointed towards and touched her own. He then located the mess on his own chin and translated the kindness she showed him, from a gesture she made about herself into a course (Continued)

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(Continued)

of action that was his own clean up operation. They were both relying on a mirroring process by which gestural communication allowed the location of something to be translated into a corrective course of action.

Group therapy is built on gestural communication, mirroring, cleanup operations, location, translation, corrective and reparative action. Mirroring is studied in Chapter 10 and translation and location in Chapter 17. When Jonas asks Mustafa, ‘My brother, what did they do to you?’ he is speaking for the others in the room. And when Mustafa hears this expression of solidarity, so do all the others. In group therapy one voice speaks for many, and what is addressed to one person communicates with everyone else. When he speaks Jonas is also pointing to his own scars and to the scars on the others in the group, and he is standing beside the others and against those who commit such injuries. The ‘cleanup’ operation is the course of the group’s therapeutic work that will follow, and the unstated appeal is for a new ‘brotherhood’ that their recovery will require. He sets about creating this in the act of speech. The depth of his own suffering is manifest in the way he addresses the others. The anger that is yet to come – and whose release is a condition for fully effective therapy – is intimated but unstated. In the months following we will see reactive aggression that cannot find its outlet against the perpetrators and which will be turned sometimes against the self, sometimes against the therapists, sometimes against the inhospitable state even though it has given them asylum, but very rarely against other members of the group. The bond that proves so illuminating for the group is cast across a chasm between two strange men in an alien country. Their origins are separated by the width of Africa, the Sahara and Arabian deserts and by divisions of colour and religion that are charged with mistrust and suspicion. What are the conditions of a group that can help forge an alliance of this kind across such a chasm? Chapters 8 to 12 are devoted to general principles, and Vignettes 10.8, 16.1 and 16.3 describe further work with this population. The reflective dimension Some reflective moments The material in Vignette 2.4 is collected from many months of group therapy to focus on the crucial issue of persecution and self-sabotage – ‘the enemy within’ and ‘the enemy amongst’. People have pulled together through progressive and regressive experience over a long time. There are three women in the group  – Irene, Sonia and Lee Anne, and three men – Mel, Ken and Julius. They joined for different stated reasons, and all have character or psychoneurotic problems of some severity and, in one case, a co-occurring problem of drink dependence.

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Vignette 2.4  The persecutor and the jangling keys

Irene: works in arts promotion on successful terms. She is in her mid 30s and the only men she has been able to find herself are avoidant, detached and unavailable like her father who died many years ago but who stand to good effect interposed between herself and her mother. They are otherwise, she tells us, useless. On losing the last man with whom she separated she fell into a serious depression and nearly went back to find him, as she had already done several times before. Now, however, she is relying on medication, a good psychiatrist and the group. She has a mother like no other, she says, and recounts a recent and dreadful incident. Sonia: comes in late. She is a social work manager with a drink problem who runs the team in her hospital with brisk, brusque precision. She is entertaining and humorous about everyone except her mother, who once tormented her but is now dead and her husband about whom she has nothing good to say. She is charismatic, entertaining and argumentative, especially with her teen-age children, who are in fraught and open rebellion. But she is also distracting and avoidant. She is accompanied on her late entry by the keys for her car and office jangling on a chain which rattles as she comes in. Irene: swears at her ‘Late again, and jangling those fucking keys again! I can’t believe it, Sonia!’ Sonia: apologises, puts the keys away quickly in a grand gesture of compliance and puts on a false face of culpability that would be almost humorous at another time or in another setting. Mel: says to Irene, ‘I know she reminds you of your mother, but why do you have to swear at her? You’re as bad as me!’ He is a businessman with a successful enterprise that is now in trouble. He has been severely depressed, but over the last year and thanks to the group he is rescuing his company. He came into the group under pressure from his wife, who insisted he attend couples’ therapy when, in his irascible state, he started attacking her. They made some progress, but the couple’s therapist found him almost abusive towards his wife and persuaded him to see me about a group. He has now been with us for one and a half years. People ask Mel: ‘So what have you done now?’ He is liked, but others are wary of his virile and volatile energy. He looks at the floor and acknowledges that he used the same ‘f’ words towards his wife. Irene: says, ‘There you go again . . .’ She turns to apologise to Sonia for her own use of the ‘f’ word and then returns to ask Mel what happened when he used it against his wife.

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Mel: tells us about it with his eyes on the floor. Ken: says well, you wouldn’t last a day with me if I were your wife, but at least you didn’t threaten to throw her out of the window. Amongst the painful issues Mel is working on is the legacy from his upbringing ‘on the wrong side of the track’ in which violence was commonplace. He told us that he maintained his business successfully through the slump by going with his brother to visit debtors and threatening to throw them out the window unless they settled. He said it was good for business and bad for the soul, and so he came to the group. There is laughter as Ken reminds us of Mel’s background dramas but: Mel: turns on Ken and says: You’re in no position to talk, given how you intimidated Irene last week. Julius: says: I didn’t think that what Ken said to her was intimidation. Irene asked for attention and got more than she asked for. They are referring to a hot day when Irene came into the group with revealing and suggestive clothing suggesting that something had been happening in her life in the recovery of her sexuality following depression after her breakup. Ken was furious with her for arousing him. Ken: on invitation, tells us more about his frustrated desire for his wife, who will not allow scope for their sexuality despite their otherwise good relationship. He is ashamed about the time he spends on pornography but cannot see that his outburst against Irene was inappropriate. Sonia: the latecomer blasts both men  – Ken and Mel  – one for his aggression against his wife and the other for his aggression in the group against Irene, who must really have wanted him to desire her. Sonia is very unpleasant. Group as a whole: All participate in the ensuing row. Mel and Ken retaliate against Sonia, who escalates the drama. Julius, Lee Anne and Irene try to defuse the aggravation. Therapist: The therapist turns to Sonia and says she is jangling her keys again as a provocation against two of the men in the group who offend her. All that she seems to be saying about them is probably true and accurate, but what she is doing in the group is another one of her emotional Jacuzzis (emotional outbursts that are distracting and absorbing), the same kind of provocation that got her husband, a civil servant with a frustratingly temperate manner, to swear at her at home recently. He says you’re accurate in everything you’ve said to Mel and Ken but you’re jangling your keys in our faces, just like your mother once did to you. It poisons your relationships, just like the alcohol is poisoning you. Your kids tell you at home that your behaviour is intimidating, and you’ve got them in outright rebellion. Can we look at it here?

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Commentary Free-floating discussion ‘is left entirely to the spontaneous mood of the group and its members and the conductor and group accept whatever comes up at each moment of each session’ (Foulkes 1975:56). Free-floating discussion is fully discussed in Chapter 4, and Foulkes’s guidance in its use for the purposes of location, translation and interpretation is explored in Chapter 17 and summarised in Tables 17.1, 17.2 and 17.3. In Vignette 2.4, free-floating discussion leads to Sonia’s infringement of others’ boundaries. Irene is the first to protest against this, and then two of the men come in for a form of bullying that brings the group to impasse. The conductor is responsible for intervening with boundary events of this kind.5 He brings an interpretation forward in line with the account in Foulkes’s guidance that ‘interpretations are called for when there is a blockage in communication . . . concerned with resistances (Foulkes 1975:125, as summarised in Table 17.3). In order to be mutative, ‘interpretations must be based on the available experience of the moment and be as near as possible to the emotional level which seems to be most active’ (Foulkes 1975:123). Sonia is challenged using ‘the fire of the presenting emotion’ (Foulkes 1975:124) as it emerges in the group’s own language. The approach is summarised in Table 17.3.

Vignette 2.4  continued

There is a long silence, and she begins to weep. Sonia: says, ‘I’m just a mess of jangling ectoplasm’, and weeps bitterly. Irene: begins to find compassion for an older woman. She reaches out and says ‘I’m sorry’. Then she tells us that she had thoughts like that in hospital six months ago when it felt like she didn’t have any skin. She was hospitalized for a severe depressive reaction. When it hurts most inside, she says, it feels like it’s hurting on the outside, too. Then she tells us about some strange, recent associations. She recently imagined – on crossing the road – that she could step into the traffic and she would be dead. Later she imagined bringing her mother into a courtroom where she would be the accused and we – the group – would be the judge and jury. Therapist: Invites the group to respond to Irene’s daydreams. People’s associations produce further pictures that allow the conductor to use the group’s language to frame an interpretation. He says to Irene and the group that her daydreams tell us just how trapped she has been feeling as she lives with a mother with whom she has only one of

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Vignette 2.4  continued

two options: to get away by harming herself or to put her mother on trial in our presence. He suggests the group is giving her an increasingly real third option, which is here for everyone else also – that she might at last become herself, on her own terms and in her own right. She is relieved and grateful. Lee Anne: speaking quietly and sitting beside her, says to Sonia, ‘I can imagine you as a little girl, being jangled at by your mother and it was never fair. But now I fear you’ve got John to jangle at you’. Turning to the therapist she says, ‘I think you’re helping Irene and being unfair to Sonia’. Julius: Defends the therapist as he often does, saying that Sonia wouldn’t hear this from any one else, true as it is, and it comes as a relief that John’s said it. He turns to Lee Anne, with whom he is closely identified, and says, you also pay much more attention to him ( John) than you do to the rest of us. But it’s good to hear from you at last. We’ve heard nothing from you for months.

Commentary The jangling keys are called on first by one of the group members and then by the conductor as a figural image that captures nuances of relational meaning. It becomes a symbol of intersubjective relations, capturing a pattern in which aggression breaks up relations with a series of ruptures that cut people off from one another. These are the group’s attacks on linking (Bion 1959). The other images of aggression include throwing someone out a window, attacking someone’s sexuality, a self-image as a ‘mess of jangling ectoplasm’ and a vivid picture of self-harm. The image of the group as judge and jury who will stand with one of its members against her injurious mother tells us that it is working as an auxiliary ego to stand as witness for one of its members, along the lines first set out in Table 1.2. When Sonia weeps over the picture of herself as ‘a mess of jangling ectoplasm’ – her own language and self-perception – both Irene and Lee Anne embrace her emotionally. As these features of reflective experience reach a poignant moment of force and meaning, the reflective dimension progresses to the reparative and, in the sessions to come, the group makes good now that the spokeswoman for the attacks on linking – to which all are parties – is in receipt of compassion. We will return to Mel’s further development in Vignette 3.1. Reparative moments will be further illustrated by another, different group in Vignette 2.5.

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The reparative dimension Reparative moments The illustration that follows in Vignette 2.5 is drawn from a twice-weekly group that has been meeting productively for many years. It has a different population to the one described earlier. In a later group session that takes place some two  years after the events described in the narrative of this vignette, its central figure – Eleanor – is described again in Vignette 15.3.

Vignette 2.5  S eparating a mother and baby: The cries of the cow and her calf

People speak, struggle, stop, and then start talking again. Tonight one of the women is in despair. As Eleanor tells us she has been crying again she begins to weep. She recently said goodbye to the children and staff of the school in which she is teaching. Both her younger brothers have trained, qualified, moved on professionally and married. One of her sisters-in-law is expecting their first child. Eleanor was a parental child and her mother’s ‘partner’ in the upbringing of her younger brothers. She would like to have had a partner and children but is still single in her forties and is now most responsible for the care of the mother who is ageing, infirm and moving into a care home. Their father died in her teen-age years. She did not develop a career when she might have done and is now – later in life – training as a teacher. The bipolar mood disorder that troubled her early adult life recently returned and unsettled her. She is on anti-depressants and a mood stabiliser prescribed by her psychiatrist, who referred her for psychotherapy. For some months she was in individual therapy with me and, as she stabilised, a decision was taken for her to join this group. She was labile for some time and can still have manic ‘highs’ and crushing ‘lows’, as at present, but nine months into group therapy the peaks have almost stopped, and in the group we thought, mistakenly, that the troughs were not so devastating. Her mother was crying at the prospect of losing her home, and she did her best to comfort her and look at the benefits of the care home. But she herself, she tells us, started crying too, and they ended up holding on to each other. Her mother doesn’t know what kind of state Eleanor is in. She keeps it from her and passes it all on to us. She is our most recent arrival and, in the nine months since joining us, she has been struggling to settle. Others are disconcerted by the intensity of her suffering tonight.

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She begins to weep again, bitterly. Someone passes her the tissues, and someone else reminds her of what she told us at the last session when a picture emerged of her mother as a woman who was superficial, unavailable and self-absorbed. People say she seems to be looking for mothering now from someone who hardly ever gave it to her. She remembers the exchange and is asked what she thought about it, but she tells us that it became irrelevant on her way home after last week’s session, and she has not thought of it since. Another woman, Caroline, describes this reply as mild but pure aggression. Eleanor seems to be repudiating the insights she gained from last week’s therapy. Caroline says Eleanor’s tears have more to do with anger than distress. Eleanor turns on her with anger but is soon at a loss, close to disintegration. Caroline tries to clarify what she offered her but is more analytical than empathic. She suggests again that Eleanor is really furious with her mother. She is progressively lost for words. She longs for the comfort she found in the group last week but is withheld tonight. She longs for company at home; she longs for a home. She doesn’t belong anywhere, she tells us, overwhelmed by tears. Someone asks if she feels she belongs amongst us here. Well, she did last time, she says. It felt warm and secure, but those feelings seem to have collapsed now, she says. Mick, a quiet, concrete man, says that he grew up on a farm and in their dairy herd, when it was time to separate the new calves from their mothers so they could milk the mothers, the cries were too terrible  – cries from both the calves and their mothers. Mick says Eleanor’s crying has the same relentless quality. She doesn’t seem able to hear this and continues telling us – in a tearful state – about the complexity of her housing situation. Someone else brings her back to the picture of mothers and babies forcibly separated, and she is startled as she takes it on and the misery abates a little. ‘Yes’, she says, ‘that’s just what it’s like. That’s just what it’s like’. I suggest that what she brings to the group is the despair of being homeless – of life without the security of her mother’s presence. When she is dominated by this mind-set nothing can bring relief, and those she might have been joined and helped by  – like her brothers  – get driven away in turn. In that picture of the mother and calf cut off from each other and calling incessantly she is both the one responsible for the cutoff and the one who suffers most because of it.

Commentary This exchange, dominated by what we come to describe in the group as Eleanor’s unreachable misery, has a vocabulary all of its own. We could call

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it the language of inconsolable desolation. What does it mean? How does it come about? Why does it subside? This is what Foulkes called the symptom that ‘mumbles to itself secretly, hoping to be overheard’ (Foulkes and Anthony 1984:259–260). How does it come to be heard, and how does she then become available for contact? We are in the territory of unrequited longing, the kind of longing that emerges – in her words – from not belonging. These states are further described in Vignette 15.3, where we will return to Eleanor one year further in her therapy.

Vignette 2.5  continued

After the exchange about mother’s milk Caroline softens and notes she has been clumsy with Eleanor’s distress. It is true and reassuring to see her readiness to acknowledge this. She acknowledges that she has enough in her own history to be angry about. But it has been a grim day, and she is still carrying so much in the group that comes from her own workplace. She is in trouble herself as she talks and becomes tearful. We recognise that the earlier analytic quality of the language in which she spoke to Eleanor was a form of self-protection. As the need for her own defensive tone falls away and she expresses the anger behind her own tears, the atmosphere changes. Familiar qualities of kindness enter into people’s exchanges with Eleanor, who now speaks directly to Caroline, assuring her that she appreciated that she was trying to reach her. She says she really wants to thank her, and Eleanor’s gratitude touches everyone.

Commentary The pattern in the previous vignette describing a relational moment is also present here. Everyone hears what is said to one person. In a cohesive group like this people are close and, through the exchanges, reflective moments transpose cohesion into terms of coherence, generating a set of symbolic references that can provide new sources of meaning. What the coherence means is that the group replaces need with nurture, anchors the homeless mind in new bonds of security, providing new explanatory sources for the repetitive and fixed patterns that blight people’s lives and so cultivates the groundwork for change.

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Mutative metaphors: From reflection to reparation Construction in the reflective dimension We struggled with Eleanor’s suffering in the relational dimension, providing containment, compassion and understanding. But when little of this seemed to get taken in, we eventually found a construction at the reflective level by which to bring a mirror to the way she generated and maintained her anguish. In the image of the cow and its calf forcibly separated and calling to each other in distress, the metaphor provided a reflective moment of understanding that had acute meaning. Containment and understanding provided a first-line constructive response to her predicament in a set of important relational moments. And then, in the reflective moments that followed, the image provided Eleanor and the others with a central metaphor for self-understanding through which her own fixed and repetitive compulsions could be challenged. Reflective moments can serve such depth of purpose. The groundwork of new meaning held by the metaphor’s challenge would go on to frame the task of inner deconstruction that lay ahead of her in the months to come. It was to run concurrently with the process of reparation as she slowly made new friends with herself and the others in the group. The expressed gratitude was the first sign of reparation, and much was built upon it in the months of reconstruction that followed. Deconstruction and reconstruction in the reparative dimension Eleanor was likely to have discarded or even forgotten some of the key details of this exchange by the next meeting, but the idiomatic detail gained resolving access to areas of unconscious conflict and determination. ‘A sleeping man’, said Freud, is not roused by an indifferent word, ‘but if called by name he wakes’ (Freud 1900:53). We are not here in search of names but of words that hold emblematic meaning that can deliver people from resistances that otherwise hold them to fixed and fruitless positions. So equipped, they can come out of their own dark places and begin to construct their lives anew. The dynamics here moved the process from tears to the recognition of rage as their prevailing, source emotion. This is the voice of protest expressing unreachable misery to which Eleanor holds the group for some time. She lets go of it intermittently and – to begin with – only occasionally. Only later is she able to appreciate the experience of being reached by the others, who provide metaphorical sources that offer analogues for her anguish. The reflective progression allows these analogues to be looked at outside the self in the metaphor of the separated cow and calf. During the session the sense of angry protest subsides and is later replaced with gratitude, the first sign of concern for the others in the group that Eleanor has been able to show. The reparative dimension grows out of the reflective

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one when gratitude and concern have expression as real emotions. This forms the basis of the progression described in Table 1.2 on page 62 that guides this book through a group’s movement from the experience of bearing witness to the development of reciprocity and from the group’s identity as an auxiliary ego for each of its members to a pro-social matrix that cultivates ego training through playful enactments.

Notes 1 Different sections of this paper were presented to the Annual Meeting of the Eastern Group Psychotherapy Society, New York, November 2010; to the Reading and Application Seminar of the Israeli Society for Group Psychotherapy, Haifa, December 2010 and 2011; and to the Danish Society for Psychoanalytic Psychotherapy April  2013. Acknowledgements are gratefully extended to Claudia Arlo, Barbara Feld and Peter Taylor in New York, to Robi Friedman in Israel and to Tove Mathiesen in Denmark and to all whose responses have helped to shape the work presented here. 2 Billow, R. (2010) Resistance, Refusal and Rebellion in Groups: The Three R’s. Karnac, London. This new catalogue of Rs is offered with grateful appreciation to the author of its original one. 3 I am indebted to Morris Nitsun for his early help in formulating terms for the three Rs and to Sylvia Hutchinson, whose language has enriched my own. 4 ‘Due to the mirroring possibilities the insight may be less (than in psychoanalysis), but must be contrasted with the shareability and availability of the outsight provided by the group setting, which becomes transferable and exchangeable’ (De Maré 1972:159). 5 Boundary events are defined by Foulkes in his last text, Group Analytic Psychotherapy: Method and Principles (1975:134). Boundary events are considered here in Chapters 4, 7, 8, 9, 10 and 12, where the conductor’s convening responsibility for managing them is discussed.

Bibliography Adshead, G., and Pfafflin, F. (2004). A Matter of Security: The Application of Attachment Theory to Forensic Psychiatry and Psychotherapy. London, Jessica Kingsley. Alexander, F., and French, T. M. (1946). Psychoanalytic Therapy. New York, Ronald Press. Arlo, C. (2014). ‘Pay It Forward’  – About Siblings and Psychotherapy. Group 38 (4): 349–351. Barenboim, D. (2008). Everything Is Connected: The Power of Music. London, Orion Books. Behr, H., and Hearst, L. (2005). Group Analytic Psychotherapy: A Meeting of Minds. London, Whurr. Bennis, W. G., and Shepard, H. A. (1956). A Theory of Group Development. Human Relations 9: 415–37. Billow, R. (2010). Resistance, Refusal and Rebellion in Groups: The Three R’s. London, Karnac. Bion, W. (1959). Attacks on Linking. Int. J. Psycho-Anal. 40: 308–315. Reissued Psychoanalytic Quarterly 82 (2): 285–300. Bion, W. (1961; reissued 2000). Experiences in Groups. London, Routledge. Bloch, S., and Crouch, E. (1985). Therapeutic Factors in Group Psychotherapy. Oxford, Oxford University Press.

82  I Foundations Bollas, C. (1987). The Shadow of the Object: Psychoanalysis of the Unthought Known. London, Free Associations Press. Brown, D. (1994; 2000). Self-Development Through Subjective Interaction: A Fresh Look at Ego Training in Action. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. Routledge, London. Reissued 2000, Jessica Kingsley, London. Republished in Maratos, J., ed. (2006). Resonance and Reciprocity: Collected Papers of Denis Brown. London, Routledge, pp. 107–123. Buber, M. (1958; reissued 2000). I and Thou. Transl. Ronald Gregor Smith. New York, Scribner Classics, Simon and Schuster. Cox, M., and Theilgaard, A. (1987). Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley. De Maré,  P. (1972). Perspectives in Group Psychotherapy: A Theoretical Background. London, George, Allen and Unwin. Durkin, H. (1964). The Group in Depth. New York, International Universities Press. Ezriel, H. (1950). A Psychoanalytic Approach to Group Treatment. British Journal of Medical Psychology 23: 56–74. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Friedman, R. (2008). Dreamtelling as a Request for Containment: Three Uses of Dreams in Groups. International Journal of Group Psychotherapy 53 (3): 327–344. Friedman, R. (2011). Dreams and Dreamtelling: A Group Approach. In J. Kleinberg (Ed.), Wiley Blackwell Handbook of Group Psychotherapy. Chichester, Wiley, pp. 479–497. Freud, S. (1900). The Interpretation of Dreams, SE 4/5. London, Hogarth Press. Freud, S. (1914). Remembering, Repeating and Working-Through (Further Recommendations on the Technique of Psycho-Analysis, II), SE X 12, London, Hogarth Press, pp. 147–156. Grotjahn, M. (1971). The Voice of the Symbol. Los Angeles, Mara Books. Harwood, I., Stone, W., and Pines, M. (Eds.). (2012). Self-Experiences in Group Revisited: Affective Attachments, Intersubjective Regulations and Human Understanding. New York and London, Taylor & Francis. Holmes, J. (2010). Explorations in Security: Towards an Attachment Informed Psychoanalytic Psychotherapy. London, Karnac. Klein, M., and Riviere, J. (1964). Love, Hate and Reparation. New York, Norton. Levine, R. (2014). Progressing While Regressing in Relationships. In R. Grossmark and F. Wright (Eds.), The One and the Many: Relational Approaches in Group Psychotherapy. New York, Routledge, pp. 112–127. Millard, P. (2002). Belonging, Intimacy and Agency in Group-Analytic Psychotherapy. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Mitchell, S. (1988). Relational Concepts in Psychoanalysis. Cambridge, MA, Harvard University Press. Neeld, R. (1999). The Group as Auxiliary Ego. Theory Paper for Qualification. Institute of Group Analysis, London. Nitsun, M. (1996). The Anti-Group: Destructive Forces in the Group and Their Creative Potential. London, Routledge. Nitsun, M. (2006). The Group as an Object of Desire: Exploring Sexuality in Group Psychotherapy. London, Routledge.

2  Psychotherapy’s three dimensions  83 Pines, M. (1982, 1998). Reflections on Mirroring: Sixth Annual Foulkes Lecture. Group Analysis 15, Supplement; and in Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London, Jessica Kingsley, pp. 17–39. Roseneil, S. (2013).  Beyond ‘the Relationship Between the Individual and Society’: Broadening and Deepening Relational Thinking in Group Analysis. Group Analysis 46 (2): 197–210. Sachs, A. (2011). Transforming Negativity Into Positivity: The Truth and Reconciliation Commission in South Africa. Inaugural Address for the 2011 Symposium Cultures, Conflict and Creativity. A Man Called Henri: Truth, Reconciliation and Justice. In The Strange Alchemy of Life and Law. Oxford, Oxford University Press, pp. 63–94. Skynner, A.C.R. (1986; reissued 1994). Group Analysis and Family Therapy. In J. Schlapobersky (Ed.), Explorations With Families: Group Analysis and Family Therapy. London, Routledge, pp. 231–235. Stern, D. B. (1997). Unformulated Experience: From Dissociation to Imagination in Psychoanalysis. Hillsdale, NJ, the Analytic Press. Stern, D. B. (2010). Partners in Thought: Working with Unformulated Experience, Dissociation and Enactment. New York, Routledge. Von Fraunhofer, N. (2008). What’s in it for Me? The Development From Immature to Mature Dependence in Groups. Group Analysis 41 (3): 278–290. Whitaker, D. S. (1985). Using Groups to Help People. London, Routledge. Whitaker, D. S., and Lieberman, M. A. (1964). Psychotherapy Through the Group Process. London, Tavistock. Winnicott, D. W. (1953). Transitional Objects and Transitional Phenomena. International Journal of Psycho-Analysis 34. In D. W. Winnicott, Through Paediatrics to Psycho-Analysis. London, Hogarth Press, 1978, pp. 229–242. Reissued in D. W. Winnicott, Playing and Reality. London, Routledge, 1991, pp. 1–34. Winnicott, D. W. (1963). Dependence in Infant-Care, in Child-Care and in the Psycho-analytic Setting. International Journal of Psycho-Analysis 44: 339–344. In D. W. Winnicott, The Maturational Process and the Facilitating Environment. London, Hogarth Press, 1985, pp. 249–259. Yalom, I. (1980). Existential Psychotherapy. New York, Basic Books. Yalom, I., and Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy 5th Edition. New York, Basic Books.

Acknowledgements:  Table 2.1 from Holmes, J. (2010) Explorations In Security: Towards An Attachment Informed Psychoanalytic Psychotherapy. Karnac, London, reproduced with permission from Jeremy Holmes; Table 2.2 from Von Fraunhofer N., (2008) What's in it For Me? The Development from Immature to Mature Dependence in Groups. Group Analysis 41 (3): 278–290, reproduced with permission from Nicky von Fraunhofer; extract from Arlo (2014), ‘Pay It Forward’ – About Siblings and Psychotherapy. Group 38 (4), reproduced with permission from Claudia Arlo.

Chapter 3

Personal and group development

Developmental dialogue gives us the opportunity to look forward and not exclusively backwards and to bring movement rather than petrification to the patient’s experience in therapy. (Malcolm Pines 1996:11) Foulkes . . . opened up the transforming power of communication, theorised as the opening up, the ever-widening and deepening of a group ‘matrix’, a horizontal perspective conjoined with the more traditional vertical perspective of individual psychoanalysis. (Martin Weegmann 2014:11)

Anyone who joins a group – for therapy or for personal development – finds it takes them on a journey. The different approaches in the journey literature rest on the same principle, though the journey may be described in many different ways. What the group does for the individual is bound up with what the individual does in and for the group. If processes of growth and change are going to work they will only do so if they work in both directions. This chapter summarizes the basic reciprocity between personal and group development to explore how the developmental stages of a person’s journey through a group and of a group’s journey over time are shaped by the group’s formative purposes, individual membership, the conductor and the milieu or setting. The journey can be described in metaphorical language that captures the shared spirit of discovery like the yellow brick road in The Wizard of Oz or the yellow submarine in the Beatles’ song that features in Vignette 2.2. Others see it in terms of a pilgrimage like John Bunyan’s Pilgrim’s Progress or as an encounter with unsettling voices or empty spaces or an encounter with silence and the truths of self-discovery that are sometimes painful and sometimes relieving. The contrasts between the atmosphere of different groups’ cultures can be as different as guided meditation compared to a three-ringed circus. Some practitioners offer no tangible sense of destination and, instead, describe the discovery process of self-development as a journey in search of authenticity or a truthful self. Whilst

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people in groups for the bereaved or severely ill will be acutely aware of time as a treasure, those in groups within custodial settings will be acutely aware of time as a punishment. Some practitioners give an account of travelling with a definite goal or destination – like the resolution of a symptom or of a troubled relationship – or of recovery from a painful loss that has staging points identified along the way. Some see in the relationship between personal and group development a chance to seek freedom from a troubled past or troublesome internal world. And others see the journey as a quest for viable and creative forms of intimacy, which is especially relevant for people whose personal relations – in their family lives or at work – are troubled by repetitive conflicts or disappointments. On leaving a group in which she had spent a long time, a woman whose childhood was blighted by injury and abuse said the group helped her discover it was never too late to have a happy childhood. Part of her journey is described in Vignettes 5.2, 5.3 and 5.4. Those who learn to play for the first time in their lives through group therapy include both adults and children. In a weekly group for refugees described in Vignette 0.3 they described their ‘sipology’ meetings like visits to the launderette where they got ‘cleaned up’ so they could go home safely afterwards, love their families and give thanks to God. The commentary in Chapter 10 gives Foulkes’s description of how people placed successfully in productive groups unfold like Japanese dried flowers when placed in water. Some see the life of a group as a journey to discover the ‘sameness’ of others or the ‘otherness’ of those mistakenly thought to be the same. Group and personal development can take on a collegiate spirit and foster a sense of fellowship amongst colleagues or rivals. This book is titled From the Couch to the Circle. Gans describes the span of his work as My Journey From Shame to Courage (2010) in the recent collection of his clinical papers. There is an extensive literature about group development, and this chapter is intended to be representative of the group-analytic field and also provide an account of relevant developments in the literature of other models. It serves as a bridge between the development schemata I devised to help me in my own work, with the three dimensions of psychotherapy in Chapter 2 and the three language forms of the group in Chapter 4. The chapter summarizes the early literature on group development to identify a debate between ‘inductive’ and ‘deductive’ clinicians that recurs later in the current field. This is a debate between – on the one hand – the inductivists like Horwitz in North America and Foulkes, Pines and others in Europe who derive their principles of practice from observational criteria. On the other side are those like Ezriel, Bion and to some extent Hopper and even Nitsun, who organise their observations round pre-formed principles such as basic assumptions or the anti-group. The chapter then explores a key five-phase schematic outline devised by social theorists whose account of development phases – forming, storming, norming, performing and adjourning – stands the test of time despite its limitations. Its focus on phases of the group – at the expense of phases that arise within the person – tends to neglect individuals’ own developmental process and their subjective experience.

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So I have drawn from a range of current group analysts whose writing shares an understanding of vertical and horizontal depth, as described by Weegmann, to highlight nine different, related schemata that will help clinicians promote group and personal development. Once we are balanced by a double focus, on the person and on the group, the chapter returns to the original five-phase outline to enrich the understanding of its development tasks. Progressive and regressive dynamics, those that work for and against the group’s development, can now be seen as phase specific. Different phases can be associated with different dynamics, so progress, impasse, resistance, rebellion and regression can be seen to arise at different times, for different reasons and in different ways. This is a more inductive way of approaching group and personal development and calls into question over-reliance on the antigroup when it is used as a deductive construct (which Nitsun informs me was never his intention). His own contribution to the field is unique in its originality. There is a special section devoted to the anti-group and its history later in this chapter which is concluded with a series of clinical vignettes that describe these constructs at work.

A summary of early literature on theories of group development The systematic literature on group development is drawn from two sources. One is social psychology in which investigators including Lewin, Bennis and Shepard and Tuckman devised schemata they based on time-limited experiential and study groups that continue to provide a useful orientation. The other is group psychotherapy in which clinicians have devised their own or developed one another’s clinically based schemata.1 These developments are traced briefly in historical terms, and the chapter then concentrates on the current field. Ezriel’s deductive and Horwitz’s inductive method – the opening of a debate Ezriel published the earliest systematic account of group development at the Tavistock Clinic in London. He introduced a three-phase sequence using his theory of common group tension (1950), which was based, in turn, on the work of Bion. Although Bion was already a distinguished figure at the Tavistock Clinic even in these early years, and was highly influential as the originator of this thinking, he did not put his own theory of basic assumptions into print for another 11 years (Gordon Lawrence 1985).2 Ezriel believed all therapy groups take refuge from tension inherent in their dynamics by falling into a required state that protects against an avoided state, out of fear that this avoided state would lead inevitably to a dreaded or catastrophic state. For example, people might avoid a state in the group – say one in which they talked about sad feelings – because of the unconscious fear that talking about sadness would lead to a dreaded state – a depressive collapse. A group could be driven into unconscious, defensive organization – the required state – to keep sadness at bay. This required state might be an extended

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period of manic humour that could help prevent the avoided state, sadness, and this would in turn protect against the dreaded state – collapse. This group defence would not address or resolve the underlying fear of catastrophe that would recur if it was not resolved, and the defence would continue to impose unconscious restrictions on the group’s life. In this approach the therapist’s interventions are confined to group-based interpretations to help members become aware of the underlying catastrophic fears and reduce their need for defensive organization. This approach informs Bion’s later development of basic assumptions and, though set in the early stages of clinical theory, it remains of continuing value. Nitsun’s concept of the anti-group draws on this kind of thinking. The two approaches, those of Ezriel and Nitsun, share depth, originality and utility. They also share deductive assumptions that can be clinically restricting, because not all resistant or negative group experience belongs within the concept of the anti-group. Horwitz’s critique of common group tension opens a debate that has been with us in the field ever since. In his classic paper, A Group-Centred Approach to Group Psychotherapy, first published in 1977 and reissued in his recently collected clinical papers (2014), he called Ezriel’s approach ‘deductive’ in that, like Bion’s, it makes presumptions based on the conductor’s fixed ideas about the common group tension. Horwitz demonstrated its clinical limitations and, based on his own work at the Menninger Clinic, advanced his inductive method that he saw to be closer to Foulkes. Horwitz’s inductive understanding works from observed experience instead of fixed assumptions and influences not only his understanding of what is going on but also his basic terms of engagement in the group with different members’ own contributions to its process. He suggests that the therapist should address people as individuals in the group before a common group tension is identified. An individualised therapeutic alliance with each of its members is then melded in the group to generate an attuned and authentic understanding of underlying anxieties, without imposing a deductive logic on the group’s dynamics. I subscribe to this approach in my own practice, as do most group analysts, and it has been widely influential in the American Group Psychotherapy Association where Horwitz’s paper is a basic resource. It is only after working with patients individually in the group and with the participation of others that the therapist can then introduce his own understanding of a common theme that binds them. Thus the therapist, as in the group-analytic model, works on a figure/ground basis in which individual contributions are valued and explored in their own right before they are contextualized in the life of the group as a whole. Forming, storming, norming, performing and adjourning: From Bennis and Shephard to Yalom and Leszcz Bennis and Shephard introduced a four-phase development sequence (1956) that was later taken up and adapted by Tuckman, who describes it as a five-phase progression from forming to storming and then norming, performing and adjourning (Tuckman 1965). The schema has been adapted to clinical practice first by Yalom

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in early editions of his book and then by MacKenzie (1997), and it has been widely influential in clinical practice, emerging again in Agazarian and Gant (2003) and Wheelan, Davidson and Tillin (2003), who take a more critical view. The phases are well described in the latest edition of Yalom and Leszcz (2005:309) and have been called on regularly by group-analytic psychotherapists in Europe from Dick (1975/1983) to Lorentzen (2014). The description here is my own summary that takes account of variations in the writing of different practitioners. It begins with an opening stage of engagement or orientation involving a search for structure, goals or meaning, dependence on the leader and a concern with boundaries. The second stage is characterised as the emergence of conflict over a range of issues in the group, particularly authority and control, and leads to differentiation. The third stage involves the establishment of group norms governing some of its fundamental processes that allow for the beginning of interpersonal work. The fourth stage involves a high level of group cohesion that allows for inter- and intra-personal exploration. And the fifth stage, termination, involves reflection on separation, loss and change. The different authors acknowledge that the boundaries between phases are not clear and that a group never graduates permanently from any one phase. Bion, Durkin and Skynner Ezriel’s schema, based on the work of Bion, was followed by Bion’s own text that offered a three-phase rotation to describe the flux of basic assumptions as they move between dependency, fight-flight and pairing (1961). It is a widely influential formulation that has been extended in the work of Hopper and others (Hopper 1997). Their work is dealt with in passing here because it is discussed in some detail in Chapter 7. Durkin introduced another three-phase sequence (1964) followed by Skynner who drew up his own three-part model using it not so much to describe the movement of a dynamic group but to consider the field of practice and its literature, according to developmental principles (1986/1994). He suggested that psychoanalysis could be understood as the exercise of maternal functions, behavioural methods as the exercise of paternal functions and group and family therapy as the joint exercise of both these functions in a coupling that produced a relational therapy. Relational concepts were not well developed in his time but emerged through his own work in family therapy that has been widely influential. As described in Chapters 1 and 2, relational understanding has enjoyed rich development in the field to give us a new metapsychology today.

A group-analytic critique of linear phases Referring back now to the phases of forming, storming, norming, performing and adjourning, group analysts regularly call on this schema or its variants. Dick’s 10-year study of psychotherapy outcome is rooted in Tuckwell’s four-stage schema, and Lorentzen’s account of group therapy in Norway relies

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on MacKenzie’s five-stage one. Both of these are discussed in Chapter 6 (Dick 1975/1983; Lorentzen 2014). The uni-linear progression described in these group-based phases, accurate as it may be, does not capture the complexity of personal development. Phases described in discrete and sequential terms do not correspond to the vagaries and uncertainties of developmental life in therapy. The social theorists who devised these phases describe them as properties of the group but do so at the expense of its members’ inner lives and intersubjective relations. So this early understanding of phases needs to be augmented. I have drawn a range of schemata from the clinical practice of group analysts to create a balance between personal and group development and ensure that reciprocity between the person and the group can be understood to enrich the development of both. Current group-analytic literature on theories of group development The range of different development schemata drawn from the emerging literature across the group-analytic field is intended to be representative. As diverse as the authorship of these schemata may be and despite the diversity of their constructions, there is a striking consonance amongst them. They have been selected for consideration on the following grounds that follow in Table 3.1 below. Table 3.1  Current developmental literature in group-analytic psychotherapy: Inclusion criteria – key elements in clinical theory These theories: 1 Are drawn inductively from the conduct of group-analytic groups. 2 Describe progressive dynamics in the life of a group over time. 3 Identify group phases and phase-specific dynamics. 4 Address the developmental progress of individual members. 5 Recognise and embrace both ‘horizontal depth’ and ‘vertical depth’ and conceptualise these core issues in a range of different ways. 6 Provide working ‘tools’ for conductors and other practitioners that can be used in many applications.

Focal conflict theory Whitaker and Lieberman (1964) made early use of force fields and vectors of opposing kinds drawn from the work of Lewin (1977) to give form to the conflicting elements of group life. Their account is of classic importance and remains of lasting value. They describe how underlying disturbing motives in group behaviour are acted against by unconscious, restrictive solutions. The therapist – by focusing on such key conflicts – helps give members access to unconscious anxieties, and once these have been relieved they can construct more enabling solutions to the shared dilemmas of the group.

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The three Rs of group-analytic psychotherapy: Relational, reflective and reparative In Chapter 2, I have set out an account of the three synchronic dimensions of group-analytic psychotherapy – dimensions that arise together whenever it is practiced. The relational dimension is the foundation for the integrated use of all three dimensions. The reflective dimension is seen to ‘nest’ within it, and this in turn provides a ‘nest’ for the reparative dimension. The conductor’s challenge is to help the group first make therapeutic progress out of their personal relations, then turn relational into reflective experience and then turn reflective into reparative experience. The language of the group: Monologue, dialogue and discourse Chapter 4 is the original paper in which I described the language of the group and the challenges the conductor faces in promoting discourse. It is based on Foulkes’s ideas about free-floating discussion described in a progression from monologue through dialogue to discourse. This movement in the form of a group’s language is associated with a progression in its relational matrix from one-body through two-body to three-body psychology. The conductor’s task is to accept a group’s current language form as self-elected and then work reflexively to promote discourse with interventions that help turn monologue into dialogue and dialogue into discourse. The conductor’s interventive repertoire – in promoting group development and dealing with impasse and resistance – is discussed in this chapter and throughout the book. A detailed discussion of these interventions will be found in Chapter 12 on the role of the conductor. Intimacy, agency and belonging Millard (2002) describes how a sense of belonging plays a vital part in the formation of group cohesion. The nature of belonging in group therapy involves complexity and a process that is spontaneous and interactional, that works to first attain intimacy and then, through a sense of agency in the group, achieves belonging, which in turn feeds back to higher levels of intimacy. The initial motivation for change through interaction – contact and exchange – can transform a group into a launch pad for activating creativity and welcoming novelty, difference and change. This is described in terms of Elias’s view of the social (Elias 2009); Stacy’s complex relational theory (Stacy 2003); Pines’s account of cohesion and coherence (Pines 1998b); and through existential philosophy drawn both from Buber, who emphasises intimacy and intersubjectivity in the I-Thou relationship (Buber 1958; 2000) and from Sartre, who emphasises choice and agency in attaining authenticity (Sartre 2007). Fusion through joining to belonging: Reciprocity and mature dependency von Fraunhofer (2008) describes how anxiety on joining a group inevitably causes defensive regression. Exchange or reciprocity – which is felt to be

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threatening – is avoided by adopting either of two defences, both of which will involve distorted relations with others: self-denying fusion or narcissistic fusion. Resolution is achieved in the transition from fusion through joining and then to belonging in the group, where reciprocal exchange can then be expressed through discourse. The author calls on three theoretical sources – Foulkes’s ideas about exchange re-stated here as principles of reciprocity (see Chapter 10); Schlapobersky’s ideas about the progression from monologue through dialogue to discourse (see Chapter 4); and Fairbairn’s concept of psychological health represented by the development from immature dependence to mature interdependence between a differentiated self and a mutually related other (Fairbairn 1941: 2002). Three uses of dreams in groups: Informative, formative and transformative Friedman’s account of the three uses of dreams in groups (2008, 2011) describes dreamtelling in the setting of a group as a request for containment. He provides the conductor with a three-stage schema to move the responsive process from the informative approach, which allows for group exploration of the dreamer’s unconscious, to the formative approach, which allows for non-interpretive understanding of the dreamer and the ‘building’ of a group’s mental faculties. ‘Telling the dream “in the presence” of others (becomes) a first communication . . . testing out . . . just how secure a space will be available in the group’ (Friedman 2011:490). And then he comes to the transformative approach through which the dreamteller’s unconscious wish is understood to be a feature of their contextual location in the group. Through the work of dreamtelling, the group can ‘then “dream the dream” by resonating to and mirroring it. (The group) processes the undigested parts by echoing its emotionally unconscious aspects and functioning as a “container-on-call”’ (Friedman 2011:492). The triangle and the eye inside the circle: Dyadic and triadic dynamics in the group Marteen (2014) describes how people make first contact with a group analyst in a dyadic relationship after which their entry into a group of six to eight others can be experienced as a psychic leap across a chasm. The transition from dyad to group is equivalent to achieving a triadic capacity for relatedness. A central consideration is the maturation from predominantly linear relating and thinking to reach stable triangular figurations involving ‘threeness’ and ‘thirdness’. This development of triangular space represents reflective thinking and the capacity to observe and be observed. This is the attainment of Foulkes’s model of three introduced in Chapter 4 and then studied in Chapter 9. The model of three is relied on to help us understand a group’s underlying triadic structure involving ties among each individual, the conductor and the group as a whole, illustrated in Figures 7.4 and 9.1. Destructive processes opposing the triangular potential

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cause instability and threaten collapse of triangular figurations with a regression to two-dimensional group structures. The role of the triangle gives the key importance of the ‘third eye’ that is conceptualized in terms of a stable parental coupling to providing a corrective component of the experience for group members. The symbol of a triangle inside a circle is used to represent the combining of male and female elements to form a combined holding in the group that is containing but also developmental and which will promote a ‘parental relationship’ function. Development of culture and identity in the group There is line of understanding about the developing relationship between the person and their place amongst others that sees the culture of the group as a forum in which identification – the product of an intra-psychic field – evolves into identity as the product of a psychosocial field. The most eloquent account of ‘groups of belonging’ is given by Rouchy who sees their primary agency in their capacity to create, within a transitional space, conditions for metabolising and amending psychic reality (1995). The field has seen a succession of authors take these ideas forward by applying them to migration, identity and the social unconscious (Bledin 2003, 2004); to the culture of the group and groups from different cultures (Weinberg 2003); to the group as an object of desire (Nitsun 2006); and to relatedness and belonging that help amend identity through the analytic group (Brown 2015). These conceptions are the focus for Chapter 15 where the group’s intermediate territory is explored through longing and belonging. The Anti-group Nitsun’s conception of the anti-group is a study of developmental arrest, impasse and resistance in groups and society. The importance of his overall contribution is addressed in a special section later in this chapter. The purpose of locating a brief account of the anti-group here is to emphasise that it stands amongst these other conceptions and not outside and apart from the organic life of the group. We will get the most out of his contribution in the field by attaching a for- and against- set of qualities, pro- or anti-group, to each of a group’s threshold experiences, as will be described below. A summary and integration The nine different schemata set out above can now provide vertical and horizontal depth for the original five phases of development. Any one of the nine schematic constructions can be applied to the five development phases. These schemata are called on here to address the tension between progress and regression in each of the development tasks set out below. Each of these dynamic

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stages has a kernel of dynamic issues organised around it. Focal conflicts in a group that are stage specific like beginnings and endings, movement towards or away from intimacy or progress or regression in differentiation will all be governed by explicit or implicit and unstated tensions that move the dynamics in one direction or another. Focal conflict theory gives us a three-way understanding of underlying disturbing motives that lead to restrictive solutions, which the conductor will want to respond to with enabling solutions. This schema can be called on at any one of a group’s five developmental stages. The three dimensions of psychotherapy allow us to see that each of a group’s five stages will be more or less advanced in the progression from relational through reflective to reparative experience. The reflective and reparative dimensions will not likely arise until well into a group’s life at least in its third stage, when intimacy and differentiation arise as key issues. Most groups catering for strangers from clinical populations will take a long time to reach this third and fourth stage. But as Vignette 13.7 illustrates, a conference-based small group working on a time-limited basis can bring its members close to these key issues in as few as four sessions. The language of the group allows us to consider how any one of a group’s three language forms – monologue, dialogue or discourse – will provide a working vocabulary for its experience. The challenge for the conductor is to validate all three as legitimate forms of communication and then set a therapeutic direction that helps progressively turn monologue into dialogue and dialogue into discourse. Intimacy, agency and belonging allow us to see how intimacy will lead to agency through which a sense of belonging is achieved in the second, third, fourth or fifth of a group’s developmental stages to generate a setting that makes reflection possible and reparation safe. Progress from fusion through joining to belonging allows us to see how defensive regression in the engagement phase can lead to narcissistic or self-denying fusion that can only be resolved when the group reaches one of the later phases characterized by discourse and reciprocity. Three uses of dreams in groups allows us to take account of day dreams and fantasies in the group as reported through free-floating discussion, as well as members’ reported dreams of the night. The schema allows for informative exploration of dream and daydream content, formative holding of fragile associations and transformative use of projective identification to link the dreamteller with the listener(s). Progress from dyadic to triadic dynamics in the group sets value on a group’s maturation in seeing to the development of triangular space that allows reflective thinking and the capacity to observe and be observed. This schema is close to Foulkes’s model of three employed in Chapters 8 and 9 to study the relationship between the individual, the conductor and the group as a whole. Growing from predominantly ‘linear’ relating and thinking to stable

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triangular figurations involving ‘threeness’ and ‘thirdness’, the group can outgrow its earlier, restrictive solutions to focal conflicts. With enabling solutions in place it can work through discourse to generate reparative experience. And this brings us all the way back to the first and second of the schemata in the list above.

The anti-group – Nitsun’s contribution Group analysis has been shaped by the work of contributors who – whilst in training  – have written papers for qualification that went on to influence the field. Garland’s ‘Taking the Non-Problem Seriously’ (1982) and Roberts’s ‘Foulkes’s Concept of The Matrix’ (1982) are amongst the best known. Nitsun’s Anti-Group (1991, 1996) began in the same way but has had a more extraordinary journey. Many of us faced challenges when starting out on finding ourselves in trouble with the first groups we conducted during our training. Taking up the challenge of addressing conflict, dis-hesion and negative therapeutic reaction in groups, Nitsun has turned this study into a source book that has been a guide for practitioners for 20 years – a unique achievement. A study of the anti-group was his theory paper on qualifying at the IGA, London, where it won the Fernando Arriave Memorial Essay Prize and was published in Group Analysis in 1991. On publication as a book in 1995 it became a key resource in the working life of group analysts, and to mark its 20th anniversary it is due for reissue in a second edition in 2015. This is only one of his many important contributions. His second book, The Group as an Object of Desire (2006), cited elsewhere here, has stimulated wide interest. His third book, Beyond the Anti-Group: Survival and Transformation is published now (2015) and his recent receipt of an award by the Royal College of Psychiatrists in the UK for his services to mental health gives special honour to his contribution to group psychotherapy. The commentary that follows is addressed to his Anti-Group. Recognition of its strength – my own recognition and that of many others – and of the merits that make it essential reading for group therapists does not detract from my own concerns. I am indebted to his constructs and use them all the time. I have located my concerns here because in its strength The Anti-Group is a study of developmental arrest, impasse and resistance. First to its strength. Nitsun defines the anti-group as follows: The anti-group is a construct by which I describe and understand destructive processes that threaten the functioning of the group . . . (that) appear to have several sources. One is an underlying fear, anxiety and distrust of the group process . . . a second source is the frustration of narcissistic needs, so that . . . the group is experienced as neglectful, depriving, and undermining . . . a third source is aggression activated between members . . .  (Nitsun 1996:2)

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A recent dissertation by Papanastassiou (2011) describes a fourth source of destructive process that threatens the functioning of the group. She explores the conductor’s own negative attitude towards the group and their ambivalence about being there at all, which may be unacknowledged. She makes good use of the ground that Nitsun has broken and extends the understanding he developed. His purpose in the study, and hers following, is to empower the group facilitator and the participants . . . to contain and limit the destructive potential of the group, to harness the aggression involved, and to facilitate the transformation of the group into a therapeutic entity . . . differentiating between aggression that supports the development of the group . . . and aggression that is destructive. (Nitsun 1996:2) This book re-works some of the ground first covered by Molnos (1986), and Nitsun does this in an extended and scholarly way with depth of engagement in his subject bringing benefit to the practice of all and fully deserving of the regard he enjoys. As to the limitations of his study of the anti-group, I did not have words for the challenge that now follows until I had written this – my own chapter – on the same issues. Nitsun takes up sources for resistance against the group’s work in only primary and deeply unconscious anxieties, to which he gives ‘timeless’ and universal qualities. This then leads him to take a deductive position towards its dynamics, so observation follows precept. In an inductive approach like that of Horwitz above, precept follows observation, and precepts are arrived at through analytic ­consideration of the observed in each particular case. The nine schemata described above provide a rich and multi-faceted frame of reference through which to consider the five key challenges of a group’s life. The determinants of whether a group’s tension goes in a creative or destructive direction, whether its movement leads towards or away from progress and how the balance is tilted between progress, impasse and regression are governed by developmental processes that belong to the group and its conductor. The anti-group does not stand outside the organic life of the group – it is not something ‘apart from’ and ‘waiting to confound’ the group and its members. We can only view it in relation to any one of the group’s challenges, and there will be a range of different kinds of anti-group dynamics at each of the thresholds it lives through. In what follows here, those sympathetic to Nitsun’s anti-group can see how the introduction of a differentiated developmental dynamic can allow us to better apply his understanding. We can do so by attaching a for- and against- set of qualities, pro- or anti-group, to each of the group’s thresholds. The anti-group is thus construed as developmental rather than timeless. For those who may be critical of Manichean constructs, forand against-, life- and death-, love- and hate-, then what follows provides a more differentiated account.

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Development tasks, circular and spiral movement, logical progress We can now call on the schemata described above and make use of this depth psychology rather than sociology to re-set the five original development tasks. We can bring these tasks to focus on both group development and the personal development of its members. A group’s focal issues may vary between intimacy and affection, dominance and control, personal and group history, conflict and change. These issues are understood, struggled with and returned to repeatedly in a spiral of increasingly coherent exploration. The developing integration of a group means that it returns to the same developmental issues through increasing levels of coherence giving the spiral effect to its progress. A group understood in these terms can be seen to struggle with developmental tasks rather than phases. In its course the individuals – and not just the group as a whole – enjoy growth, healing, integration, differentiation and progressive change (Brown 1994/2000; Pines 1998a:211). Table 3.2 provides a summary of tasks described here in a five-stage logical progression. The issues do not necessarily take a sequential form. The tasks can be understood as challenges for the group as a whole or for the development of an individual through their progress in the group. These tasks are set out in a circular form in Figure 3.1. The diagram can be used to illustrate the progress of an individual through a group or the progress of a group as a whole.

Table 3.2  Developmental tasks, critical issues and focus* Stage

Developmental task

Critical issue

Focus

1

Engagement

In/out

Commitment, boundary issues, confidentiality, containment, safety, security

2

Authority

Up/down

Competition, conflict, envy, familiarity with use of the process, level of self-knowledge, capacity to relate to others

3

Intimacy

Near/far

Trust, disclosure, affiliation, attachment, exclusion and opposition, affect and hostility, level of involvement, quality of empathy and reciprocity

4

Change

Same/different

Growth, resolution, integration, individuation, differentiation, reparation

Stage

Developmental task

Critical issue

Focus

5

Termination

Cohesion/ coherence Sink/swim Move on/fall down

How understanding is this person or group? And how are they understood? Have they grown or been changed by the process? Can benefits achieved in the group be internalized and maintained? Can changes achieved in the group be sustained and extended to the outside world?

* Table 3.2 is a tabular adaptation of a figure published in Group Methods in Adult Psychiatry as Figure 6.3.6.8, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1360. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my co-author Malcolm Pines for his consent to its re-use here.

Task 1 Engagement In/Out

Task 5 Terminaon

Task 2 Authority

Sink/Swim

Up/Down

Task 4 Change

Task 3 Inmacy

Same/ Different

Near/Far

Figure 3.1  A pentangle of group development and focal issues Source: Figure 3.1 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Figure 6.3.6.8, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1360. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my co-author Malcolm Pines for his consent to their re-use here.

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The outside pentangle: Progressive and regressive dynamics in the person and the group The diagram can be used in a number of ways. We can first use the outside pentangle to link the main development tasks of a new group that shows a primary clockwise movement in the numbered sequence of its development tasks starting with engagement. The group progresses from engagement to authority issues and then through intimacy issues to those affecting people’s individuation, and differentiation, and it concludes with termination issues. Every move in the direction of coherence is progressive, but psychotherapy is never lived out in such programmatic terms. There will be inevitable cross-currents of experience, under-currents and backwash experiences – anti-group dynamics – that may take the process through long and discursive detours. Individuals, or the group as a whole, may go through a regressive rather than progressive experience at any one of these stages, and there may be powerful dynamic factors at work that take a group ‘backwards’ at one of these phases and not at another. But the five development tasks will arise in one form or another, and each will need to be addressed in order to create conditions that will allow the next one to be addressed and resolved. The outline needs to be understood as an approximation that will be of most likely value to psychotherapists in training. The development tasks as they are now described differ from their originating form in two important respects. First, they are now seen as a logical and not a phasic progression, and second, they are described in circular terms. So each development task not only stands in a dynamic relation with the one before and after but also with each of the others. For example, a group may be grappling with issues about intimacy and affects in what its members disclose, in how close they get or distant they remain with one another and with the many other considerations that ‘belong’ in this phase. These issues will stand in a dynamic relation not only to those that went before, the group’s authority issues, or those that come after which involve questions of differentiation. They will also stand in a dynamic relation to the original engagement issues that the group began with and in a dynamic relation to issues about termination and departure that have yet to be dealt with but which loom on its horizon. A review of personal progress and regression through a group’s five developmental challenges From engagement to authority issues and back again Each arrow shows movement in a clockwise direction and then also in the obverse direction so that – for example – engagement issues successfully negotiated in the opening task, leading on to issues of authority and control in the second task, will also be returned to from these authority questions. The engagement issues returned to might at first be posed as a complex set of questions about why people have joined the group at all, what they hope to gain from it, if they will be committed to reliable attendance and participation and whether they can trust one another. Many sessions on, as the group settles down, it may be dealing with its latecomers and members who are unforthcoming or otherwise ambivalent. Questions may arise

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about the conductor’s authority. Her skill and experience are first called into question and then visibly endorsed by the nature and quality of attention she gives to these boundary events. They may include people’s missed sessions and their open communication in the pre-group waiting room followed by silence in her presence once they come into the group room. By turning troublesome items into conversation topics the conductor demonstrates a keen interest in everything that is happening and greets the negative – the anti-group – with curiosity and reflective enquiry rather than with judgment or criticism. In the climate of developing trust this leads people’s attention back to their earlier, basic questions about why they signed up for the group in the first place. One of the members may express relief on finding their ambivalence identified and understood, and this could give way to a more confident engagement after anxieties about authority have been addressed. From authority issues to intimacy and back again A similar movement can then be seen emerging in the progression from authority issues to the development of relational bonds as people begin to form attachments or discover themselves in hostile opposition as they face issues about self-disclosure and intimacy. Anxiety about self-disclosure, expressed because of fears about how some other members might ‘use’ embarrassing detail against the person speaking, might lead them to raise questions about confidentiality and boundaries and return the group from the tasks of intimacy to those of authority, control and engagement. People will emerge as individuals who can be liked, appreciated, disliked, feared or avoided. As their individuality emerges they may take up positions of proximity and affiliation, or opposition, mistrust and resentment. One person might repeatedly seek one particular other person’s validation over the troublesome and sometimes toxic issues they both have to contend with in dealings with their mothers. The one from whom she constantly seeks this validation never provides it and is – in turn – seeking a ‘special’ connection with the conductor, who is the only person who seems able to furnish her with a sense of safety. As these intimacy issues are explored, negotiated and struggled with, the conductor ‘locates’ some of the group’s regular and predictable tension in the figuration of a family transference where the withholding one is seen to be re-living the position in which she grew up – she was an older sister required to give special attention to a younger sibling that she always resented. The conductor’s authority, made visible and patent by use of the principles of location, translation and interpretation studied in Chapter 17, generates a new climate of containment, and the withholding individual becomes less imploring towards her in the transference and more available to others in the room. And so the group works, from authority to intimacy and from intimacy back to authority. From intimacy to differentiation and change and back again Changes take place even during preliminary exchange when the most obvious signs of difference emerge in the way people talk and relate to one another. At

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this stage in the book’s development, we can look back to the three dimensions of psychotherapy in Chapter 2 and call on its concepts to view changes through an emerging relational dimension in the room and the progress of the group towards a reflective and then reparative dimension. Or we can look forward to Chapter 4 and the three language forms of a group’s spoken exchange and see monologue turning into dialogue and even discourse. A group’s first form of communication is most commonly serial monologue as strangers take the first uncertain steps of self-disclosure amongst other strangers, with little idea of what this might engender. Resonance and reciprocity give rise to dialogue that, cultivated by the conductor, matures into discourse. We are moving from the third to the fourth of the group’s five developmental tasks, the task of change. But there are ‘snakes and ladders’ in any such exchange. There will be group as well as individual defences that will inevitably bring people down as the current draws back to earlier polarizations and conflicts. Changes achieved will not be steadily maintained, and people will fall back to earlier, unresolved issues about intimacy, authority and even basic engagement and disengagement. From change to termination and back to engagement issues In the concluding stages of a group’s life, or in the concluding stages of a person’s stay in an ongoing group, emotions will be heightened, time will often be treasured, the impending sense of loss will engender memory of other, earlier and more serious losses and – hopefully – this can become a novel experience for many. Termination will be a loss that can be anticipated, talked about and processed as it happens. Though this may prove to be the first such loss that allows articulation, the grieving process engendered may release many more serious sorrows of the past. If the termination challenge succeeds in bringing to the surface memories of loss and lost memories of grief, then the group’s climate can be focused by grief work, and the limited time available seems to become elastic. A great deal of concluding work can be compressed into this limited amount of resolving time, as described in Vignette 3.1. Salzberger-Wittenberg’s fine text on the subject, Experiencing Endings and Beginnings (2013), is the best source book on these subjects and has found an immediate and valued place amongst our students.

The four internal connections We can choose any one of these key developmental tasks and see how they relate internally to the other tasks faced across the pentangle. Their links are not only phasic. They do not progress in a single line between those that they connect with in a linear fashion. For example, if we select intimacy, we can use the diagram to see how it is related to the authority issues by which it is preceded and to issues about change and differentiation that it leads on to. We can also look across the pentangle to consider how early neglected questions of engagement in the promise or threat of intimacy for one or several group members – a set of core

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considerations that brought them into therapy because of failed relationships in the first place – becomes increasingly urgent as termination approaches. So here we can see a developing, dynamic triangle between intimacy, engagement and termination. On facing the imminent end of the group people begin to wonder how much work they have – or have not – been able to do together in resolving their primary problems. So intimacy is related to all four of the other development tasks. Each of the five developmental tasks has this dynamic relationship with all four of the others. A group is not a sequence but a circle, and for the group as a whole any one of these focal development tasks can be chosen to highlight the cluster of dynamic figurations by which it is related to all the others. Charting the progress of an individual through the five development tasks The circular diagram has been used so far to address the five key development tasks which are faced by any group-analytic group and which belong to the group as a whole. We can also use the circular diagram to appraise the progress of an individual through a slow open group. In this case each of the development tasks can be framed as a set of dynamics that identify stages in the development of the individual’s relationship to the group as a whole, to its different members and to its aims and purposes. Bronwyn, for example, is found to be open, available and able to connect on joining. She soon engages at the relational level and before long is one amongst others. So the issue of engagement is not a major problem for her. Further into her progress in the group other dynamics emerge that reveal her complexity and inner conflicts that have to do, in particular, with secrecy, especially over intimacy. But another person – Kevin, a man who joins the same group some time later – is found to be withholding, tense about self-disclosure, troubled about what he may be revealing in the group and suspicious about others’ motives. The process of relational engagement preoccupies him for many of his first months in the group. He did not know how to negotiate these issues at all and did not even know the extent of his inner conflicts about any kind of human connection. These different terms of engagement will colour and influence Bronwyn’s and Kevin’s respective paths through the group over time. A long way into their experience, when someone new arrives with engagement problems, the original ambivalent member – the one who joined on uncertain terms – comes forward to welcome her and, in doing so, reveals to his fellow group members, that his own progress through the stages of authority, conflicts and the negotiation of intimacy, has altered him profoundly. But the full extent of the change he has undergone only emerges fully when Kevin puts himself forward to facilitate the arrival of this other person who joins in the same state of conflicted engagement that he remembers. He can now speak to her from a group he belongs to and welcome her to join in. The five developmental tasks can be seen put to use here as part of the analytic frame. They will be called on through the book to chart the progress of actual individuals through their therapy.

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In conclusion: Key phases illustrating a group’s developmental challenges This vignette is a construction based on the experience of different people seen in groups over a long span of time. They are brought together as a notional group to focus on memorable detail that illustrates each of the five key challenges described above.

Vignette 3.1  K  ey phases in the progress of individuals through a group a: Engagement

Stella showed signs of the trouble she was in on arrival. She was shy and subdued but talked breathlessly and found herself hard to contain. She was an artist and teacher. She was in her own apartment again and had been home for two months where she was settling down once more, she said. She had started to teach again at art college and was even spending time in her studio and painting once more. In her first sessions she did not answer questions about where she had been in the meantime. By her fifth session she had found a way to talk without being overwhelming and could sit still and listen without too much agitation. We learnt that she had broken up with a boyfriend some months before and carried on painting in her studio on her own as if nothing had happened until she thought the paintings were talking to her and realized she was ‘halfway out of her mind’. Her psychiatrist admitted her to an in-patient unit where she had spent several months sitting in groups and talking all the time, she said. They found her depressed and sometimes high. She was out now and though still on medication, they recommended her to this group on discharge, and here she was. The story that emerged in the following sessions gave us her own picture of herself ‘knee deep in a field of men’, as she put it, until this man she loved finally found her. He showed her what it meant to love and be loved and now he was gone. Roy, who had joined us some years before in a distraught state of unrequited love that brought him to his knees – as he put it – said to her, ‘If he really knew what it meant to love and be loved he wouldn’t be gone now’, and she began to weep. The group gave her care without more unsettling attention, and she returned to these issues in the following session. The emerging story of idealization, infatuation, disappointment and rejection gave the group staging

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points in a narrative of her own in which longing never matured into belonging – as will be explored in Chapter 16. Roy went on to speak from his own discoveries, from a state of belonging through which he was now rooted in the group where he felt confident enough to offer mature advice that informed us of what he had gained in recent times. The shift in his own position was evident in how Stella addressed hers as she slowly found her feet amongst us and he became a ‘surrogate’ for the kind of good man she had never been able to find. Their engagement laid down a sense of kinship between these two that would last until he left some time later when she gave him one of her paintings to decorate the apartment he had by then rented with his new partner. b: Authority

During his first year in the group Brian, who is described later in Vignette 13.1 on page 329, emerged with both a high level of motivation and a poor capacity to honour the group’s terms of reference. This ambivalence underlay everything about him. He wanted to be able to participate, but only when it suited him and when the demands of his busy life as a journalist were not too pressing. He took little account of the impact his lateness had on others. He engendered both enthusiasm and hostility. When he became the first to challenge someone else’s problems of financial mismanagement, as Colleen’s history of missed fee payment emerged, the conductor wrote to ask him to pay attention to his own missed payments, or he would have to raise this in the group. He was missing for his next session and by the time he attended the one following he had not settled his account and did not respond in the group, or in any other way, to the conductor’s correspondence. Colleen had by then corrected her arrears, and the conductor asked her what she would say to someone who had called her out on an issue he was in breach of himself. She took a while to consider this and then, turning to Brian, said, ‘so you haven’t been paying your fees either? Do other people know you as a hypocrite?’ He was stung by her challenge and, looking to the conductor with some alarm, acknowledged he had been messing him around on money. He had been messing everyone around, came the challenge from the group, at which point the conductor reminded him of the terms set out when he joined – attend reliably, participate and pay the fee. He behaved as if, by honouring only one condition – participation – he would have the benefit of all and it could not go on like this.

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The challenge of authority was registered at a point in Brian’s progress when he had done a year’s work on his disillusionment with his father. With the group’s help he was now able to construe boundary infractions as a protest against the history of neglect he had come through. We saw him shift his position radically in the months that followed as he settled his fee on a reliably monthly basis and slowly brought his working routines round to accommodate his group attendance. c: Intimacy

Henry, who is described again in Vignette 5.6 at a later stage in his therapy, was telling us yet again of isolated depression and inner misery. We had come to know him well. Another member said that his mood only varied between low and despair, and described the picture of him formed by the group was like Eeyore in Winnie the Pooh, who just wanted to stand with his head in the rain complaining that he had no friends. Martha – sitting beside him – had joined the group at the same time, and they were paired as allies. She was cross with the group over their attitude towards him, she said. The Eeyore challenge was humiliating, and no-one gained by being shamed. Henry had become the group’s scapegoat, and she was most angry with the conductor for allowing this. She only realized how cross she was the other night when she got back late and came into her own home full of the warmth and clutter of her family’s life and thought about him alone at home. She had been working late and had to take a night bus home. She was the only passenger, and the driver, a strong Afro-Caribbean woman, asked her if she’d like a song and she said yes of course but had no idea what was to come. The driver began singing The Streets of London and had her in tears with her big, beautiful voice. She sang it over and over again, and Martha was sorry to have to get off the bus and say goodbye. Going home from the bus stop she had Henry in mind. He was a social worker, and she knew he worked with all those poor people described in the song – the old man in the market kicking up the papers with yesterday’s news, the other old man drinking his tea alone and going home by himself and the old lady in rags. And then she turned to him and, quoting the song’s refrain, said, ‘So how can you tell me you’re lonely/And say for you the sun won’t shine?/Let me take you by the hand/And lead you through the streets of London/ I’ll show you something, to make you change your mind’. She said, ‘come now, Henry, life has a bounty for you if only you’ll face it! Let us help you change your mind’. The moment turned acquaintance

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into intimacy. He was known in a profound, relational moment that would never leave him – known by another, known by the group and known in himself. In Henry’s case the group’s work that followed turned such relational moments into reflective ones, and in due course the reflective moments grew into reparative ones. All this took place in painfully slow stages of differentiation, punctuated by regular returns to Henry’s earlier entrenched position of masochistic protest. d: Differentiation

Abbey and Nadine had been in the group for some time and were making progress with their issues. One was in her thirties and the other in her forties. They were both ‘second generation’, both born to Jewish refugee parents in London. Abbey’s mother came to London from Berlin as a child refugee in the late 1930s. Nadine’s parents had been in hiding in Budapest separately and met after WWII in a displaced persons’ camp. The psychoneurotic issues they struggled with were different, but they were better equipped to face them by their mutually identified histories that emerged in the content of their associations in the group. Both had the advantages of good education and now successful careers, but their parents’ lives had been lived out in conflict, their family lives had been difficult and they were now finding problems in their personal relationships. Nadine had been admitted for training as a counsellor to work with relationship problems that she knew had a lot to do with trying – hopelessly she said – to heal her parents’ marriage. She was going to start her course soon but was anxious and brought a dream to the group in the weeks prior to her beginning. The Nazis were coming, she said, she had to hide, so she went to her mother’s wardrobe where her clothes were hanging, and she turned herself flat, like a dress – you know, like they do in cartoons, she said – and hung herself up on one of the coat hangers in the cupboard so she wouldn’t be found. When asked in the group how she felt when she woke up, she told us her heart was pounding, she was frightened they might find her and she hoped the hiding place would do. We worked with the dream over a period during which, people said, her decision to finally do an ambitious training was for her like coming out of the cupboard, coming off the hanger and unpacking herself from the place in which she had been hiding for all those years. At a point during their review of the dream Abbey said to her, ‘You’ve got to say “to hell with the fucking Nazis”. They can’t get you now!’ This construction served her well,

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gave another lever to her movement towards change and allowed her to begin the training on good terms. In due course her personal life settled, the training was successful and she became a highly regarded marital therapist. In Abbey’s case there were major health issues in her family. As a young student she had helped to nurse her dying father through a terminal illness. Her mother carried the sequelae of displacement and struggled with a chronic sense of threat. In the period following her father’s death Abbey, unsupported by her mother and unable to apply herself to her own career, lost direction. Recurrent health concerns were at times almost crippling, and from time to time she had herself investigated. She brought a related dream in the months following Nadine’s. She was in a concentration camp where they were executing people. When her turn approached someone came up to her with a document – the warrant for her execution – and asked her to sign it. She recounted the exchange to us as if it had really just taken place, and what emerged in her demeanour in the room at that moment had a quiet, sullen but open defiance of the threat. ‘No’, she said, ‘I’m not going to sign that!’ The finality of her refusal sent them away and she woke, enraged that they had the gall to call on her for complicity in her own end. The group unpacked her dream on terms like those she had participated in with Nadine. She came to see, as Nadine had done, that her rage in the dream that entered the group was not only rage against those who harmed her people but also rage now against herself and her own negating makeup. She had been growing recently. This dream and the understanding it yielded marked out her refusal to sign her life away. In due course she gained a stronger sense of herself as a confident and capable woman. Her health anxieties abated, she settled happily in a loving relationship, went on to flourish in her career and became a distinguished health professional. Later, even when real health concerns emerged, her core resilience was secure enough to contend with them. e: Termination

Mel was described in Vignette 2.4 at an earlier point in his history. He had been making progress in his own development and was now available to his wife and children for the first time they could remember. Though his energies were diverted now – he said – to living a life and not just to his work, he was doing better than ever and no longer needed to threaten his debtors to secure payment. In the group we now found

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him real, open and generous. The group was coming to terms with a move from its location in the conductor’s home that had given them a stable setting for many years. They were notified months ago that he was moving house and, as the summer vacation approached, the sessions held in their present setting got fewer by the week. There was talk about how much they would miss the room and speculation as to what they would find in the new one. In the concluding session Mel was reminded of his father’s last hours by the group’s associations to endings. He was still a teenager, he reminded us, and was only just out of school when his dad died. We knew of the committed interest he continued to take in the welfare of his ageing mother who still lived in the same home in which his father had died 35 years ago, but we had heard little about his father. Mel had joined us with a limited emotional range and a virile, potent energy that people found both intimidating and sometimes attractive. Now he told the group of his father’s heart failure, his last hours and then of his death. Apparently it all happened in a very low-key way. Everything was like a routine. By the time he woke up to what had really happened his father was long gone, his mother was ‘in another place’ and his brothers were getting on with their lives. ‘Where did he go?’ he said to us now, and we saw emotion we had never seen before. ‘Where did my Dad go?’ One of the members said of the conductor, ‘He’s only moving up the road. He’s not going far. It’s a house move not a death’. Mel paid no attention and had to tell the group more about the day of his father’s death. He explained that he had never shared this with anyone, not even himself. We listened intently, and he crumpled into long-lost grief that overwhelmed him. There were tears round the room. Later we learnt about where his father was buried and of Mel’s visits to the cemetery to honour the family graves. The man who said earlier this wasn’t a death asked if Mel would ever visit this street again. It was a striking question of connection and, for the first time, Mel recognised the link between a loss in the past and the one that was about to happen now. This located the intersection between grief for his father who had never been mourned and sorrow over a current loss. It brought into his conscious awareness the primary loss that had itself been lost to memory. In the sessions that followed we found him gaining resources as his lost memories were re-built, memories that – he said – he never knew he didn’t have. Mel had become the focus for the group’s apprehension about losing the conductor forever. Their reassurance on finding the conductor well and inviting in the new setting provided grounds for further work on the

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resolution of early losses. Mel mellowed and people sometimes played with him over his name with kindness and affection. The woman who found him most alarming on his arrival sometimes teased him now as the work progressed with a song about ‘yellow mellow’ that he in turn reciprocated by supporting her in the issues she struggled with.

Commentary One of the many extraordinary things about slow open groups is that people occupy different nodal points on each of the pentangle’s five corners of development. They will be working on different maturational issues in the same group, so the challenges generated at each point will intersect with the work done at all the others as they potentiate each other’s changes. Another of their enriching attributes is the quality of intuitive understanding expressed horizontally between group members. Roy connects with Stella and helps her settle; Colleen challenges Brian and helps him accept the group’s boundaries; Martha understands and then challenges Henry and brings him into an intimate exchange for the first time in his life;  Abbey understands and challenges Nadine to break free of persecutory introjects and goes on to have a dream in which she is seen to renounce her own pattern of self-negation; and all the group’s members connect to Mel’s grief which, expressed for his father’s loss, is also associated with the group’s loss of the consulting room and its setting, for which Mel has a special valency.

In Chapter 7 Cohen gives an account of how Groups can perceive buried associations to long past calendar dates such as traumatic birth and death days, holidays, and past seasonal emotionally-laden responses that patients do not consciously recall or dare articulate. This heightened sensitivity to obscured commemorative syndromes can result from the group interactive process. As such the therapy group can aid in surfacing hidden ghosts far more rapidly than individual therapy might achieve . . .  (Cohen 2007:153) Experience to do with loss – that has been lost to memory itself – emerges as a key element in unexpected figurations. In Vignettes 5.2, 5.3 and 5.4 the emerging picture of Juliette’s privation, in losses that had themselves been lost to memory, is steadily retrieved from the abyss of her own otherwise absent history. The

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dynamics in her case work along similar lines to those followed by Mel in the vignette above. This work is made possible by regenerative figurations intrinsic to the dynamics of a group that can free its members from the harsh price they pay for the false solutions of dissociation that they are often entirely innocent of at the conscious level when they begin. Chapter 13 will later set out the four domains that give depth to a group’s communicative matrix – the current, transference, projective and primordial – and Chapter 16 will address the figurative detail of metaphors that work across these domains to allow a group to dredge up from the encapsulated world of primordial experience detail of hidden losses that can then be engaged with at the current level.

Notes 1 The list of clinicians responsible for devising developmental schemata is a long one and includes the following: Agazarian, Bion, Ezriel, Doran, Durkin, Friedman, Horwitz, Leszcz, Lorentzen, MacKenzie, Marteen, Schlapobersky, Skynner, von Fraunhoffer and Yalom. 2 The study here is based on Ezriel’s account because, as described on page 88, a whole section is devoted to Bion’s work on pages 205–207.

Bibliography Agazarian, Y., and Gantt, S. (2003). Phases of Group Development: Systems-Centered Hypotheses and Their Implications for Research and Practice. Group Dynamics: Theory Research and Practice 7: 238–252. Bennis, W. G., and Shepard, H. A. (1956). A Theory of Group Development. Human Relations 9: 415–437. Bion, W. (1961; reissued 2000). Experiences in Groups. London, Routledge. Bledin, K. (2003). Migration, Identity and Group Analysis. Group Analysis 36 (March): 97–110. Bledin, K. (2004). What’s in a Name? Foulkes, Identity and the Social Unconscious. Group Analysis 37: 477–489. Brown, D. (1994; 2000). Self Development Through Subjective Interaction: A Fresh Look at Ego Training in Action. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. Routledge, London. Reissued 2000, London, Jessica Kingsley. Republished in J. Maratos (Ed.). (2006), Resonance and Reciprocity: Collected Papers of Denis Brown. London, Routledge, pp. 107–123. Brown, S. (2015). Relatedness and Belonging: Altering Identity In the Analytic Group. Dissertation for the Qualifying Course, Institute of Group Analysis, London. Buber, M. (1958; reissued 2000). I and Thou. Transl. Ronald Gregor Smith. New York, Scribner Classics, Simon and Schuster. Cohen, P. (2007). “Past Time”: Anniversary Reactions That Can Confound the Group Analyst. International Journal of Group Psychotherapy 57 (2): 153–166. Dick, B. M. (1975; reissued 1983). A Ten-year Study of Out-patient Analytic Group Therapy. British Journal of Psychiatry 127 (4): 365–375. Reissued in M. Pines (Ed.). (1983), The Evolution of Group Analysis. London, Routledge. Durkin, H. (1964). The Group in Depth. New York, International Universities Press.

110  I Foundations Elias, N. (2009). Figurations in Collected Works of Norbert Elias, Vol. 16. Dublin, University College Dublin Press. Ezriel, H. (1950). A Psychoanalytic Approach to Group Treatment. British Journal of Medical Psychology 23: 56–74. Fairbairn, W.R.D. (1941). A Revised Psychopathology of the Psychoses and Psychoneuroses. International Journal of Psycho-Analysis Vol., XXII, Pts. 3 and 4. Reissued in W.D.R. Fairbairn (2002), Psychoanalytic Studies of the Personality, (eds). D.E. Scharff and E. Fairbairn Birtles. London, Routledge, pp. 28–58. Friedman, R. (2008). Dreamtelling as a Request for Containment: Three Uses of Dreams in Groups. International Journal of Group Psychotherapy 53 (3): 327–344. Friedman, R. (2011). Dreams and Dreamtelling: A Group Approach. In J. Kleinberg (Ed.), Wiley Blackwell Handbook of Group Psychotherapy. Chichester, Wiley, pp. 479–497. Gans, J. (2010). Difficult Topics in Group Psychotherapy: My Journey From Shame to Courage. London, Karnac. Garland, C. (1982). Taking the Non-Problem Seriously. Group Analysis 15: 4–14. Gordon Lawrence, W. (1985). Beyond The Frames. In M. Pines (Ed.) Bion and Group Psychotherapy. London, Routledge, pp. 306–329. Hopper, E. (1997). Traumatic Experience in the Unconscious Life of Groups: A  Fourth Basic Assumption. 21st S. H. Foulkes Annual Lecture. Group Analysis 30 (4): 439–470. Reissued in E. Hopper (2003), Traumatic Experience in the Unconscious Life of Groups. London, Jessica Kingsley, pp. 66–90. Horwitz, L. (1977; reissued 2014). An Inductive Group-Centred Approach to Group Psychotherapy. International Journal Group Psychotherapy 27: 423–439. Reissued in (2014), Listening With the Fourth Ear: Collected Papers. London, Karnac, pp. 83–98. Horwitz, L. (2014). Listening With the Fourth Ear: Collected Papers. London, Karnac. Lewin, K. (1977). Resolving Social Conflicts (1948) and Field Theory in Social Science (1951): Joint Edition 1977. Washington, DC, American Psychological Association. Lorentzen, S. (2014). Group Analytic Psychotherapy: Working With Affective, Anxiety and Personality Disorders. London, Routledge. MacKenzie, K. (1997). Clinical Applications of Group Development Ideas. Group Dynamics: Theory Research and Practice 1: 275–287. Marteen, L. (2014). The Triangle and the Eye Inside the Circle: Dyadic and Triadic Dynamics in the Group. Group Analysis 47 (1): 42–61. Millard, P. (2002). Belonging, Intimacy and Agency in Group-Analytic Psychotherapy. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Molnos, A. (1986). Anger That Destroys and Anger That Heals: Handling Hostility in Group Analysis and in Dynamic Brief Psychotherapy. Group Analysis 1986: 207–221. Nitsun, M. (1988). Early Development: Linking the Individual and the Group. Group Analysis 22: 249. Nitsun, M. (1991). The Anti-Group: Destructive Forces in the Group and Their Therapeutic Potential. Group Analysis 24 (1): 7–20. Nitsun, M. (1996). The Anti-Group: Destructive Forces in the Group and Their Creative Potential. London, Routledge. Nitsun, M. (1998). The Organizational Mirror: A Group-Analytic Approach to Organizational Consultancy. Group Analysis 31 (3): 245–267. Nitsun, M. (2001). Strength in Numbers. The Guardian. Republished (2011), Fitzrovia Group Analytic Practice Website: www.fitzgap.com/strength_in_numbers html Nitsun, M. (2006). The Group as an Object of Desire: Exploring Sexuality in Group Psychotherapy. London, Routledge.

3  Personal and group development  111 Nitsun, M. (2009). Authority and Revolt: The Challenges of Group Leadership. 33rd Foulkes Lecture. Group Analysis 42 (4): 325–348. Nitsun, M. (2015). Beyond the Anti-group: Survival and Transformation. London, Routledge. Papanastassiou, M. (2011). The Group Conductor’s Subjectivity and Identity as a Group Member in the Co-Creation of the Anti-Group. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Pines, M. (1996). Interpretation, Dialogue, Response: Changing Perspectives in Psychoanalytic Theory and Technique. Unpublished talk. Pines, M. (1998a). Circular Reflections: Selected Papers on Group Analysis and Psycho­ analysis. London, Jessica Kingsley. Pines, M. (1998b). Coherency and Disruption in the Sense of Self. In Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London, Jessica Kingsley, pp. 211–223. Roberts, J. P. (1982). Foulkes’s Concept of The Matrix. Group Analysis 15 (2): 111–126. Rouchy, J.C. (1995). Identification and Groups of Belonging. Group Analysis 28 (2): 129–141. Salzberger-Wittenberg, I. (2013). Experiencing Endings and Beginnings. London, Karnac. Sartre, J.P. (2007). Existentialism and Humanism. London, Methuen. Schlapobersky, J., and Pines, M. (2009). Group Methods in Adult Psychiatry, 2nd Edition. In M. Gelder et al. (Eds.), (2012), New Oxford Textbook of Psychiatry. Oxford, Oxford University Press, pp. 1350–1368. Skynner, A.C.R. (1986; reissued 1994). Group Analysis and Family Therapy. In J. Schlapobersky (Ed.), Explorations With Families: Group Analysis and Family Therapy. London, Routledge, pp. 231–235. Tuckman, B. (1965). Developmental Sequence in Small Groups. Psychological Bulletin 63 (6): 384–399. Von Fraunhofer, N. (2008). What’s in It for Me? The Development from Immature to Mature Dependence in Groups. Group Analysis 41 (3): 278–290. Weegman, M. (2014). The World Within the Group: Developing Theory for Group Analysis. London, Karnac. Weinberg H. (2003). The Culture of the Group and Groups From Different Cultures. Group Analysis 36 (2): 255–267. Wheelan, S., Davidson, B., and Tilin F. (2003). Group Development Across Time: Reality or Illusion? Small Group Research 34: 223–245. Whitaker, D. S. (2001). Using Groups to Help People. London, Routledge. Whitaker, D. S., and Lieberman, M. A. (1964). Psychotherapy Through the Group Process. London, Tavistock. Yalom, I., and Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy 5th Edition. New York, Basic Books.

Acknowledgements:  Figure 3.1 and Table 3.2 reproduced with permission from Malcolm Pines and Oxford University Press; extract from Pines (1996), Interpretation, Dialogue, Response: Changing Perspectives in Psychoanalytic Theory and Technique in Pines (2015), Forthcoming Papers, reproduced with permission from Malcolm Pines.

Chapter 4

The language of the group Monologue, dialogue and discourse in group analysis

A man walks across this empty space whilst someone else is watching him, and this is all that is needed for an act of theatre to be engaged. (Brook 1990 xi) A sleeping man is not roused by an indifferent word but if called by name he wakes. (Freud 1900:53) Freud’s hypothesis . . . (was) that the process of becoming conscious is closely allied to or essentially characterized by the cathexis of word representation. (Foulkes 1964:116) By replacing this ‘free association’ with ‘group association’, which the present writer was the first to have done, we make a decisive step regarding method as well as theory. (Foulkes and Anthony 1984:29)

Free-floating discussion is the group-analytic equivalent of free association.1 The term originates in Foulkes’s own writing and describes a set of key clinical concepts in therapeutic practice that distinguish the group-analytic approach. The use of association in this approach differs from its use in individual analytic practice (Kris 1990) and from the techniques used by practitioners of other group methods (Yalom and Leszcz 2005). This chapter explores these clinical concepts and the theory that underlies them. It is focussed on the language of the group – the medium of free-floating discussion. I shall differentiate between three primary forms of speech that arise in the matrix of any group. At the most basic level monologue – speaking alone (with or without an audience) – is a form of individual self-expression. At the next level dialogue – a conversation between two people – is the form of communication that distinguishes a bipersonal exchange. And at the third level discourse – the speech pattern of three or more people – allows the free interaction of all its participants in a flexible and complex exchange that distinguishes the communication of a group (Moffet 1968). These patterns of speech are universal cultural forms arising in all communication and are present in the life of every group, although in no set order. Monologue can

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be understood as a soliloquy, dialogue as the resolution of opposites or the search for intimacy, and discourse as the work of a chorus. The maturation of the group and its members involves a progression that begins with monologue in the individual’s first encounter with themselves. It moves to dialogue in the discovery of the other and then to discourse when an individual’s multiple inner objects are externalized and encountered in the group. As indicated, the progression is a logical not a descriptive one; the group process itself does not necessarily follow this pattern. The group-analytic approach is distinguished from other group methods in that neither of the two earlier speech forms are disregarded. On the contrary, both monologue and dialogue are encompassed by and integral to group-analytic experience. True discourse remains the defining attribute of group communication because the complexity of communication between two people when the introduction of a third transforms them into a group alters the nature of the original relationship in a radical and profound way. The use of free-floating discussion allows a pattern of exchange to move freely between these different speech forms, each of which constitutes a distinctive type of communication. It is through this movement – from monologue through dialogue to discourse and back again – that the group-analytic method comes into its own, creating an arena in which the dialectic between the psyche and the social world helps refashion both. The chapter continues with a section that draws on relational theory to differentiate between one-person, two-person and three-person psychologies. I then apply to these psychologies material drawn from language theory to consider the speech forms each of them allows. This is followed by a series of clinical examples that illustrate the approach with descriptions and commentaries on these speech forms as they arise in different therapy groups. It is followed with an exploration of how the use of language in clinical theory has evolved from monologue to discourse, from the couch to the circle. It traces developments from the original idea of the talking cure in Freud’s work to the first emergence of the term ‘free-floating discussion’ in Foulkes’s own writing and its subsequent development. The conclusion points towards a theory of discourse that will equip us to explore how: Psychotherapists are rediscovering that . . . The depths of the mind are reached and touched by simpler words that speak in images and metaphors . . . a universal, timeless language, pre-dating contemporary ideas . . . that touches the heart, the ancient seat of the emotions; (and) that speaks to the soul . . . (Pines, in Cox and Theilgaard 1987:xxiv) Psychological forms and the relational field ‘We are today (1950, sic!) witnessing the breakup of . . . psychology into categories according to the minimum number of persons essential to the study of each branch of the subject’ (Rickman 1950:218). One-person psychology is concerned with what goes on inside a person, two-person psychology with reciprocal relationships and three-person psychology with the relational field of the basic family constellation – and with social roles and social relations derived from it. The first

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takes the nature of internal experience as its field and gives centrality to the mind as it is located in a body. Its psychological functions include sensation, perception, cognition, mood, memory, imagination, fantasy and the psychosomatic link. The second takes the intersubjective world as its field, gives centrality to relationships – a domain beyond but including the individual – and its psychological functions include bonding and attachment, exchange, affect and the inter-personal link. The third takes social relations as its field, gives centrality to the corporate world – a domain beyond but including both the individual and the pair bond – and its psychosocial functions include social interaction, social role and social meaning. Calling on Rickman’s differentiation of psychological forms that has an almost ‘timeless’ quality, I shall proceed on the basis of an assumption made here that a truly group psychology incorporates one-person, two-person and three-person psychologies and that these three psychologies stand as an adequately differentiated range of categories to encompass all human experience. The group is a matrix of interaction, a relational field that arises between its members and between the interplay of these three different psychologies. Field theory is the discipline by which these different psychological levels are related. It provides group analysis with an integrative frame by which the higher-level functions in three-person psychology are related to more fundamental functions in one-person psychology (Agazarian and Peters 1981). Skynner, applying field theory to group and family therapy, describes the isomorphic relationship between experience at different levels. Thus in a group, changes in any one of its component psychologies will necessarily involve change in the others (Skynner 1986/1994). Speech forms and the semantic field ‘Discourse’ in one of its colloquial meanings describes the communication of thought by speech, the exchange between someone speaking, someone listening and something that is listened to. It describes relations between narrator, listener and story (Moffet 1968). The structure of discourse is this set of relations between first, second and third persons. When the speaker, listener and subject are each distinct (or potentially distinct) as persons, that is, when two people are speaking to each other in the presence of a third person, we have the rudiments of a group. For the purposes of this chapter I am using the term discourse to describe only this kind of group communication. In a two-person situation, when only the speaker and listener are present as persons, we have dialogue. And when speaker and listener are the same person, we have monologue. Figure 4.1 describes how the three psychological forms in the relational field, correspond to forms of speech in the semantic field. In one of its colloquial meanings – found in de Maré’s writing, for example, and Bakhtin’s – the term ‘dialogue’ does not refer to an exchange between only two participants (de Maré 1991). They use it in its wider, vernacular meaning to embrace all constructive, verbal exchange. But for the purposes of this book I am using the term in a more restricted sense to refer specifically to speech forms in which there are no more than two key participants who might be individuals, teams or – for example – gender groups. It thus serves to identify what is

4  The language of the group  115 Psychological Forms (Relaonal field)

Corresponding Forms of Speech (Semanc field)

One person psychology

Monologue

Two person psychology

Dialogue

Three person psychology

Discourse

Figure 4.1  Forms of speech in the group and corresponding psychologies

distinctive about a speech form based on an oppositional symmetry, reciprocity or duality in which the dialectic of the exchange is its key property. Where communication takes place between three or more participants, the term discourse is used to identify its more diffused properties. Using a theory of language to examine group psychotherapy, we can see how the developing agency of the group’s process begins at the first stage with the solitude of private encounters with the self that are allowed by the audience of the group. It leads at the second stage to greater agency for change when, through dialogue, others acquire psychic reality through conflicts over discrepant forms or levels of intimacy required of the same group experience. When the same experience has different meaning for its different participants, it exposes their different internal conflicts and can in due course help resolve them. And this leads to the third stage – discourse – when the spontaneity of public exchange expresses individuals’ primary process, allowing the emergence of archaic anxieties and their reparative resolution. This is the kind of experience that has the most far-reaching consequences in terms of personal change. The most telling description of this kind of discourse is the way an individual’s dream can be taken up in a mature group. As the last clinical example in this chapter describes, group members enter the dream together through a diversity of associations. In the discussion by which the dream content and its associations are explored in the here and now, we see the free play of words at work in the shared unconscious. As resonance in the group as a whole connects the one and the many, meaning is condensed and, in the sudden discharge of deep and primitive material, events happen in a moment that can last a lifetime. The progression is given a cogent account in Friedman’s description of dreamtelling in group therapy. As described in Chapter 3 the group progresses from informative to formative and finally to transformative process, which, at the point of ‘discharge’, works through condensation to produce deep and lasting change (Friedman 2008, 2011). Each of these speech forms can arise in a narrative form through the recounting or reconstruction of reported events or a dramatic form in people’s real experience of

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one another in the here and now of the group. The group’s process is characterised by a fluid interaction between narrative and drama, between the stories people have to tell and the drama of their roles and interactions as they do so. Progress is seen in a shift from speech patterns that are initially dominated by narrative and description to more mature forms that include reflective dialogue and discourse and then to a capacity to abstract and generalise from this experience, both inside and beyond the group. This progression recapitulates the child’s primary pattern of growth in a de-centring movement outward from the centre of the self. The self enlarges in the group, assimilating the matrix of group relations and ‘taking them in’; at the same time it accommodates itself to this matrix and adapts to it. The paradox of this progression is that, as the intersubjective domain in deepened and enriched, participants become more themselves by moving outward from themselves. The process of symbolisation originates with the most primitive sense of self in the representational schema of the infant as he differentiates for the first time between self and other. As the representational world is extended and externalised the infant’s symbolising process is codified in a language whose semantic field is charged with forms of meaning that bear a close association to the individuals and experiences through which it originates. Eliott’s, James’s and Nitsen’s papers in The Psyche and the Social World (Brown and Zinkin 2000) all give careful attention to these early formative experiences. The way in which a child talks to itself, addresses its mother, relates to a friend, speaks to a doll or stands up to talk in the classroom can be different in each case. All these speech forms can arise in a dialogue between only two people for, as William James has said, relations are of different degrees of intimacy – merely to be with another is a universe of discourse (James 1902). But whilst dialogue can generate an almost limitless range of meaning, the terms of a two-person psychology act as a constraint. Discourse in a group is extended far beyond this by a relational field that is almost as rich and indeterminate as its semantic field. Through group interaction the relational and semantic fields  – the matrix of interaction and the matrix of meaning – come to play upon one another, giving new meaning to early symbolic and representational experience. Thus language is a form of behaviour in the group, a way of referring to experience in and beyond the group and a way of transforming experience in the group.

Clinical illustrations: Monologue, dialogue and discourse Free-floating discussion proceeds through an interplay between narrative and drama, story and exchange, reconstruction and encounter. A reconstruction (by an individual or sub-group of some past event or trauma) or some other story in the group might be a defence against the anxiety of an immediate encounter between its members. Alternatively, the drama of an immediate encounter might be a defence against painful stories about past or recent experience. The examples that follow are designed to illustrate the gains to be had in clinical depth from the simple practice of establishing clarity about four questions:

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Who is talking? To whom are they talking: What are they talking about, that is, what is the subject? And what are they not talking about, that is, what is being avoided, hidden or denied?2 As one speech form in either its narrative or dramatic form becomes evident as a defence, the therapist or another group member explores the defence to widen what Foulkes called the common zone, and this moves the exploration to another speech form through which it can be taken forward. Monologue Vignette 4.1  Who are you talking to?

A man sits in the group recounting the circumstances that brought him into therapy. He has been with us now for three sessions and is beginning to find his voice. But as he talks people’s attentiveness diminishes. He looks at no one in particular; his narrative is delivered now to the floor, now to the ceiling; he is agonized but self-absorbed and the group’s resonance is against his self-absorption rather than with his agony. Despite the distress in his story about his wife’s suicide attempts, their loss of love and his concern about their children, the group of initially sympathetic listeners becomes increasingly disaffected. Initially people had been eager to ask him questions, and their responses were sometimes visible in exclamations and other reactions. But the speaker appears indifferent to his audience, whose primary value, it seems, is to provide him with the space in which to talk to himself. He has not yet recognised others. They serve him primarily as narcissistic containers. They allow this for some time, but after 10 minutes one group member seems to be dozing off, another stares out the window, another looks to the conductor. As his monologue continues, two members smile at each other and look away. After 15 minutes the conductor asks the speaker whom he is talking to. Startled and in some consternation he looks about him and says, well, to the group, and falters as he does so.

Commentary It is as if he has found himself alone on a stage without an audience. The process of decentring has begun, initiated by a conflict between the content of his narrative and the limitations of his role. He recognises the disengagement he has been responsible for but is as yet without resources to communicate

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empathically. His problem in the world has become manifest in the group. He has spent most of his adult life as a ‘marginal man’ caring for others at his own expense and often colluding with them when, despite his care, they neglected or overlooked him. Now he wants it all back, but, consumed by neediness that he has spent a lifetime disavowing, he has no resources to enter reciprocal relationships.

In order to find a voice through which to reach others he must also find himself, and the group first provides him with space and permission to discover his own psychic pain. If the therapy is successful we can expect to see, some months after its commencement, changes in his communication patterns in the group. From these changes he will be able to generalise, to effect changes in relations with his family and social network. The group is the arena in which psyche and social world acquire their first distinction from one another. It is here then that they can be reconciled in the interests of altered social relationships that are his primary therapeutic needs. On future occasions when he has something to say, he will learn from the group’s cues how to make eye contact, how to come out of himself and how to begin bringing people with him in a narrative that allows empathy – shared emotion. To have an audience whilst he tells his story, he will need to learn a different role. He will need to allow others time to respond, to establish evidence of others’ interest in him and his story and to offer a sense of collaboration in their arena of shared interest. Of course, he will not learn this all at once, and there will be many future occasions when the group recoils from his monologue. He will again use others as narcissistic containers to give him the space in which to find himself. This process of self-discovery will proceed hand in hand with his discovery of the ‘otherness’ of those around him. Other group members will keep him connected to integrative process, having themselves had cues from the conductor that his resources will allow him to tolerate the momentary discomfort and humiliation of a confronting interruption in the interest of shared experience. Vignette 4.1  continued

Two years later the same man sits in the group with a lot to say about his inner conflicts and about his problems in the world outside. In contrast to his earlier self-absorption he now chooses his moment, speaks in shorter sentences, uses shared language, relates what he has to say to what he knows others’ preoccupations will interest them in, and allows pauses for response and interruption.

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Commentary It is visibly evident that he is now able to use the group process to work on his internal one. In the progression from his early monologue to a participatory role in the group’s pattern of discourse, the man is learning to overcome his isolation in the group and is being steadily equipped to do so in the world at large. What he is learning in the group about intercourse will steadily equip him to live in the world rather than in its margins. He is now socially engaged and, whilst the nature and manner of his self-presentation continue to arouse resentment amongst other members over issues of control and detachment, his internal conflicts and anxieties are now an integral part of a shared process and are thus open to understanding and resolution.

Dialogue This progression from private alienation towards an openly identified and shared social process lies at the heart of the group-analytic enterprise. Foulkes and Anthony called this private alienation ‘the language of the symptom’ which, ‘although already a form of communication, is autistic’ as it ‘mumbles to itself secretly, hoping to be overheard’ (Foulkes and Anthony 1984:259–260). The distinctive speech form that arises through dialogue at the second level is illustrated by exchanges in two different groups that arise between two members in each case. The first describes the concepts of valency (introduced by Bion) and mirroring (introduced by Foulkes), which are defined and discussed in Chapter 10, and the second, those of projection and projective identification which are defined and discussed in Chapter 14. Valency and mirroring are defined in Chapter 10. Valency and mirroring Vignette 4.2  A good father and an abusive father 3

A man in his mid-forties who has been using the group to come to terms with his divorce shares with us towards the end of the session a poignant moment in his relationship with his teen-age daughter visiting him for the weekend. He tells us of how she has begun to talk to him about her menarche. He recounts in the group what she said about it and how she did so. People comment on how touching they find her openness with

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him and on how moving they find the trust between them. He tells us his daughter has had mixed feelings; she was pleased but also awkward and embarrassed. Her mother – his former wife – has supported her practically and emotionally and this too he is pleased to acknowledge as he relates his daughter’s narrative to the group. Sitting opposite him is a woman in her late thirties who – like him – has been in the group for some years. She is the only one of the seven who says nothing at all. But she does not take her eyes off him as his narrative unfolds whilst different members engage with him at different levels and in different ways. She watches and listens attentively and in tears but will not be drawn out about her reaction. At the next session a week later she initiates the discussion by telling us that she has not been able to get the picture of this man and his daughter out of her mind. She wishes she had had a father like him. She had not believed it possible that a young girl could trust her father so intimately with her developing sexuality. She wants to know more about their relationship and as he tells her she replies with detail – long known in the group but never explored in quite this way – about her relationship with her own father who abused her violently and sexually.

Commentary In the course of this dialogue the man opposite her becomes confirmed as the transference object for the good father she had always longed for and never known. She in turn furnishes him with the opportunity to reach and recover in the group a lost aspect of his self that can be benevolent and tender towards women. The benign quality of his generosity, as it emerges with increasing evidence of his resources as a good father, stands in dramatic contrast to the destructive person we have known about in his relations with his wife. The emotional charge – the valency – between the two of them becomes the group’s object of interest. One other woman, in particular, whose own history involved an unresolved Oedipal conflict, becomes excited and animated by what she sees happening between these two. She makes herself available to them as a facilitator and, as they talk to each other across the group, she moves their discussion forward at those points at which they reach impasse.

They are each, of course, talking to the group as a whole, but they do so by addressing each other. They generate emotions in the group as a whole, but they

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do so because of the emotions they arouse in the encounter with each other. These two people each find reflected in the other the lost ideal of their respective parental introjects. They select each other for an exchange that involves, temporarily, more intense emotion than arises elsewhere in the group, and through this they each provide a reparative mirror for a lost aspect of the other. In both these cases, however, each person’s sense of the other is derived from a principal relationship with themselves. She experiences him as her idealised father and he, similarly, relates to her as the mirror image of women all too familiar to him in his own life experience. ‘Otherness’ for each of these people is derived from their unconscious primary preoccupations with their own internal objects. There is work to be done before they can each relate to another of the opposite sex as a genuinely ‘other’ person rather than as some reflection of their own internal imagery. The next example describes an interaction involving a conflict between two individuals in a group over discrepant requirements for intimacy. It takes place at the moment at which long-standing internal conflicts acquire some resolution.

Vignette 4.3  How dare you dream about me killing your father! Projection and projective identification Two people are closely connected in a group by complementary roles in their life outside. She has a son like him with whom she is engrossed. He has a mother who, like this woman in the group, he finds strident and intrusive. The valency that emerges involves an antagonistic preoccupation between them. He reports a dream to the group in which she, clearly recognisable, suffocates his father. As the story of the dream unfolds in the group she becomes increasingly angry and distressed. She is furious at the role in which his dream life has cast her and treats the dream – in so far as it describes her – as if he had chosen its content as a conscious attack on her and could be held responsible for it. Her conduct in the group confirms her in the very forbidding role she occupied in his unconscious mind. She rounds on him and, as he defends himself against her attack, he becomes increasingly aggressive himself. The therapist eventually intercedes with a modest observation about her that has an astonishing effect on her. ‘It’s his dream, which you can learn from if you wish to, but in the last analysis it’s his dream’. In the discourse that ensues the whole group explores the hostile dialogue that followed the reported dream, and she struggles with the realization that she has been trying to control the content of his psychic life. The understanding that this generates eventually leaves her in tears as she takes back the projections by which she has maintained this man – in her mind – as if he were her son.

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Commentary The hostile cathexis between these two – what Zinkin calls malignant mirroring – is being undone. It helps resolve his anxiety that she will damage him with her projections, as his mother damaged his father. And it helps resolve her separation anxiety about losing her own son with whom she had an enmeshed relationship. Zinkin uses the term ‘malignant mirroring’ to replace, with a single process, the experience of two distinct projective identifications that have a symmetrical relationship with one another (Zinkin 1983). As we can see here, it is the experience of dialogue that links the two individuals’ experiences and resolves the negative valency they hold for one another. The dream illustrates how he lived with the fear of damage – the fear of what her projections could do to him – and identified with this fear. Projective identification has been the basis of their valency, in this case malignant mirroring, which is a hostile cathexis. Chapters 10 and 14 provide studies of these dynamics, and Table 10.4 situates malignant mirroring in the context of other mirroring dynamics.

At the point of this confrontation she experiences him for the first time as a genuinely ‘other’ person and is freed by this realization, although she is shocked by it for some time. And he undergoes a comparable experience. These events allow her to generalise from the group to her life in the world and in particular to the relationship with her son, whom she has bound with her projections for much of his life and is fearful of losing. She is distraught as she begins to take all this in and for some weeks is depressed in the group. This in turn arouses compassion in the man, who, witnessing her distress over the way in which she mis-related to him, appreciates her – for the first time – as a genuinely ‘other’ person rather than the projected representative of his damaging mother. Once he comes to appreciate her as a genuinely different person he can then relate constructively to her needs, and this in turn helps her see how she might gain rather than lose by relinquishing control of her son. The reparative quality of these exchanges affects both primary parties deeply and, through an amplified form of resonance – described in Chapters 1, 2 and 10 – reparation is extended to encompass the group as a whole. Discourse The examples above illustrate the free-floating nature of group discussion as it moves between all three speech forms, with the conductor providing a minimum

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of direction. Rather than seeking to press the group’s exchange towards one pattern or another, the conductor regards the speech form expressed by the group as a source of information as to what is happening in the matrix. In the example below discourse is initiated by information from one of the group’s members, but there is neither monologue nor dialogue. Discourse means that the group as a whole maintains the discussion, and individualistic concepts are of only limited value in our attempt to analyse it. Vignette 4.4  Envy against progress in the group

In a twice-weekly group of many years standing, events are dominated by increasing evidence of people’s development and differentiation. One evening one of the members, a man who has struggled against his parents’ envy of his youth and their attacks on his individuation, discloses that he has finally reached a crucial financial target in the business he established. The figures are startling and unexpected but  – for the moment  – his achievement does not earn the regard it might have merited in the group. One of the men, facing major financial dilemmas in his own company, is withdrawn and unresponsive; another, successful in his own career, explores the issue constructively, but for some time there is a limpness about the group’s responses and, in their reluctance to confirm evidence of this man’s progress, they behave like his parents, who resent the fact that he has been successful on his own. Discussion moves round to one of the women who is expecting a baby. She is finding her position in the group sometimes difficult to protect. What was most striking was the reaction of the two other women to news of the pregnancy. She has struggled to conceive and has finally been rewarded with a healthy pregnancy. Since then one of the women has left the group unexpectedly, and now the other woman, the mother of a small child, offers a disproportionate amount of advice, punctuated with references to ectopic pregnancies and other disasters.

Commentary The issue of envy lies beneath the narrative.4 All seven members participate in different ways, and the atmosphere is coloured by tension between affirmation on the one hand and anxiety and antagonism on the other. People have struggled for years together and are really very close – they do wish to affirm one another’s success. Despite their affirmative desires, they experience serous problems of envy. Halfway through the group, after 45 minutes, the conductor

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offers an interpretation of the tension, suggesting that people are anxious about each other’s envy of their own progress and, perhaps, ashamed of their own envy of others’ progress. The quality of the exchange alters, relief allows disclosure and the second half of the group session is taken up with a wide-ranging exploration of envy, jealousy and shame in intimate relations. These are not new subjects in this group, and people are accustomed to exploring the less acceptable aspects of their own personalities with one another. It ranges over men’s envy of women’s creativity aroused by the prospect of a woman bringing a new baby into the group and women’s envy of men’s potency or penises in their reaction to the financial and career success reported on at the outset. Neither of these envious forms is exclusive to either gender, and this too is recognised and discussed, as is the acute anxiety that a number of members acknowledge about the prospect of envious attacks from those closest to them in the outside world as they progress through their therapy. The group’s exploration is open and diffuse; there is no exclusive narrative line, and no single contributor. To understand the group we should have to consider the texture of its discourse rather than merely the text of its narrative. In a mature group at this stage we see that the ‘the conductor strives to broaden and deepen the expressive range of all members, while at the same time increasing their understanding of the deeper, unconscious levels’ (Foulkes 1964:112).

In the texture of the discourse we discover what Foulkes called the common zone that is discussed more fully in Chapter 1: A common zone in which all members can participate and learn to understand one another. The zone of communication must include the experience of every member in such a way that it can be shared and understood by the others, on whatever level it is first conveyed. (Foulkes 1964:112; my italics)

Commentary The zone of communication in this group now incorporates the shared fear of others’ envy and the shared sense of shame at acknowledging envy of one’s own. It leads on to the recognition that developmental arrest, and some of the other forms of neurosis discussed in the group are attempts at envy pre-emption (Kreege 1992). What concerns us here is the way this recognition is arrived at. One member provided information about his success at work that led through

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group association to another’s reference to her pregnancy. The first introduced a subject – ambivalence about progress associated with internal conflict and the fear of external attack – to which another resonated. This theme was amplified by resonance in the group as a whole that extended the exploration. From the introduction of this theme to its amplification, exploration, analysis and resolution, there was one focussed but brief interpretation by the conductor that set him apart from the others, but, for the rest, discourse in the group was responsible for its progress. The contributor contributed to the discourse like the other members but was always on hand. The theme that provided the group’s focal conflict (Whitaker and Lieberman 1964) in this session rested on anxiety as to whether the group could relate to its members as a generative rather than envious parent and provide them with confirmation for their progress. For the group as a whole to be experienced in such positive terms, each of its members needed to find their individual part in the destructive envy anticipated from the others.

We would fail to take advantage of the real benefits of group analysis if we confined our attention to content analysis of the text. An attempt to characterize a discussion like this requires concepts that describe context as well as content, texture as well as form, ground as well as figure and group atmosphere as well as the dynamics of the individual. The development of group-analytic theory has not, regrettably, developed to characterize group process in this way because of the difficulties we continue to experience in characterising the complexity of such exchanges (Skynner 1986/1994). ‘Our concepts and technical terms’, says Balint, ‘have been coined under the physiological bias and are, in consequence, highly individualistic; they do not go beyond the confines of the individual mind’ (Balint 1950/1985:228). A theory of discourse should help to clarify ‘how “inner (mental)” and “outer” reality merge inside the common matrix of interpersonal social reality, out of which they originally differentiated’ (Foulkes 1964:98). Our attempt to conceptualise change is now assisted by the distinction provided in this account between the relational and semantic field. By exploring their interplay: It becomes easier to understand our claim that the group associates, responds and reacts as a whole. The group as it were avails itself now of one speaker, now of another, but it is always the transpersonal network which is sensitized and gives utterance, or responds. In this sense we can postulate the existence of a group ‘mind’ in the same way as we postulate the existence of an individual mind. (Foulkes 1964:118) The group ‘mind’ can now be understood as the composite of its semantic and relational elements.

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From the couch to the circle: The evolution of technique Freud’s talking cure and the first fundamental rule of psychoanalysis Brown’s paper (1994) gives a comprehensive account of how the metapsychology of psychoanalysis has been revised by object relations theory. I am here concerned with the implications of this change for clinical theory. In his early collaboration with Breuer, Freud recognised that the crucial ingredient in their treatment of hysterics was free word association – what one of his patients called ‘her talking cure’ – rather than hypnosis. His original idea ‘that whatever comes into one’s head must be reported’ (Freud 1911–1915:107) was later set out as the ‘fundamental rule of psychoanalytic technique’ (Ibid.): A rule which structures the analytic situation: the analysand is asked to say what he thinks and feels, selecting nothing and omitting nothing from what comes into his mind, even where this seems to him unpleasant to have to communicate, ridiculous, devoid of interest or irrelevant. (Laplanche and Pontalis 1983:179) The analytic relationship dictated by this rule emphasises its linguistic content, establishes the neutrality of the analyst and helps foster the regression of the patient. It has a further consequence, which, like the use of the couch, is a remnant of the hypnotic method out of which it evolved – it confines the work of psycho­ analysis to the patient’s monologue. Freud’s original paradigm was an intrapsychic drive psychology whose formulations are those of a one-person psychology concerned with the individual in isolation. He maintained the use of the couch for the protection it afforded him from uncomfortable interaction with and exposure to his patients and for the benefits it brought to treatment, minimising the extent to which free association was contaminated by dialogue (Freud 1911–1915:134). The critique of classical theory took issue with these limitations. Balint, ‘for want of a better term’ but in language that has had momentous consequences, introduces ‘the object or object-relation bias’ on the grounds that ‘all our concepts and technical terms’ except these two ‘have been coined under the physiological bias and are . . . highly individualistic; they do not go beyond the confines of the individual mind’ (Balint 1950/1985:226, 228). Today the concept of countertransference has been recast as a valuable clinical tool. The analyst’s subjectivity has been brought into the therapeutic arena as an acknowledged resource rather than as the troublesome intrusion Freud had earlier believed it to be and free association, stripped of its unnecessary drive theory, has been reconceptualised in the context of a two-person psychology focussed upon the dialogue between patient and analyst (Lewis 1990b), ‘an interrelation between two individuals . . .

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a constantly changing and developing object-relation’, a ‘two person situation’ (Balint 1950/1985:231). Foulkes’s development of free-floating discussion Foulkes’s work has taken the same line of development one stage further, providing us with a clinical method that allows the participation of three psychological objects in the associative process. Free-floating discussion rests on what he called his ‘model of three’. Although the maximum composition of what could be properly called a group is indeterminate and controversial, its minimum number is three. Between the dyadic experience of a pair and the group experience of three there is a transition just as radical and profound as that between one and two. Whatever the size of a small therapy group, the model of three provides its underlying emotional structure. There is an indeterminate maximum in the number of individuals that can be present in any group, and there may be more than one conductor. But there are only three categories of psychological object – the individual, the conductor and the group as a whole. In the bounded space between these three objects, we find a three-person psychology at work. Like Freud before him, Foulkes worked towards and arrived at his method before naming it. Described initially as ‘a kind of group associative method’, the term enters his primary text well after his first descriptions of its use. He then returns to it frequently, refining and redefining his descriptions and, in explaining how it evolved, recounting how he initially treated people’s associations in the group individually. Only later did he become ‘aware that it was possible to consider the group’s productions as the equivalent of the individual’s free association on the part of the group-as-a-whole’ (Foulkes 1964:117). If one allows one’s ‘floating attention’ as Freud termed it, to record automatically its own observations, one begins eventually to respond to ‘pressures’ and ‘temperatures’ as sensitively as any barometric or thermometric gauge with something akin to an internal graph of change on the cerebral ‘drum’ of the therapist. (Foulkes and Anthony 1984:142) The group matrix is the ‘operational basis of all relationships and communications’ (Foulkes 1964:118). It has both a relational and a semantic field. Through the interplay of these two fields, free-floating discussion allows ‘the construction of an ever widening zone of mutual understanding within the group’ (Foulkes 1964:116), which Foulkes regards as its manifest content. This is understood to relate to the latent meaning ‘as a manifest dream relates to latent dream thoughts’ (Foulkes 1964:118). In the course of group discussion symptoms (manifest content) are translated into their meaning (latent content) and this: ‘Transforms the driving forces which lay concealed behind them into (new) emotions . . . members learn a new language . . . previously spoken only

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unconsciously’, in the course of which ‘they (become) active participants in their own healing process’ and undergo change at a number of levels. (Foulkes 1964:176) The group analyst works as conductor, therapist and group member beginning with the dynamic administration of the group and the initiation of free-floating discussion. He assumes a more active role in a new group and allows the ‘decrescendo’ of his own role as the group gains authority. He is responsible for identifying disturbances in the group’s process – what Foulkes calls location – and for providing a balance between analytic (disturbing) and integrative forces, as the manifest content is translated into language that describes the unconscious. Transference is prominent, but the work is undertaken in the dynamic present. One of Foulkes’s own descriptions of the conductor at work gives a vivid account of the clinical role which contrasts dramatically with Freud’s account of the psychoanalyst at work behind the couch (Freud 1911–1915:134). He treats the group as adults on an equal level to his own and exerts an important influence by his own example. He sets a pattern of desirable behaviour rather than having to preach . . . puts emphasis on the ‘here and now’ and promotes tolerance and appreciation of individual differences . . . (He) represents and promotes reality, reason, tolerance, understanding, insight, catharsis, independence, frankness, and an open mind for new experiences. This happens by way of a living, corrective emotional experience. (Foulkes 1964:57) In contrast to Freud’s first fundamental rule in individual practice described above, the group analyst is supportive as well as analytic, and the linguistic content of the therapy relationship is not so paramount. Regression may occur, but it is counterbalanced by a progressive role through which group members become active participants in their own healing process and in one another’s development. Finally, the group analyst’s role is neither neutral nor detached. The quality of his engagement is evident, as is his readiness to maintain a human position that will serve the group’s members as a model. Foulkes’s clinical recommendations to the conductor can be summarised as a responsibility for promoting discourse (Foulkes 1964:57).

Conclusion: Towards a theory of discourse Vignette 4.5  An empty house without sexual feeling: Desire can bring the roof down

A twice-weekly group meets for the first time after the Christmas break. Its members have common difficulties making or sustaining

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relationships. Joan reports that she had a terrible time over the holiday. It was like the roof caved in. Susan says she was also pretty shitty. Adam says he was fantastic. He had no contact at all with his recent girlfriend but went abroad on a working trip with a different girl, an old chum who doesn’t mean much to him and with whom there is no intimate relationship. He no longer finds his current girlfriend attractive and, although they speak every day on the phone, he was pleased not to have to see her over the break. Whilst abroad with the new one, they got on like a house on fire. Anne takes up the image of the house on fire in one case and the collapsing roof in another. She finds parallels between them; others agree. Adam is directed by the group to look at how he was now treating this girlfriend as an earlier partner had once treated him. The attraction he once described to us is now replaced by repulsion. He couldn’t bear the thought of being close to her body. He talks a lot about attraction and repulsion. Susan knows only too well what he meant, she says, referring to her loss of sexual desire, and when she feels this way, there is nothing her husband can do about it. They just have to wait until her sexual feelings return. Joan had described to us in the last group (before Christmas) how loved she felt by her partner. He had sent her flowers and a lovely note whilst he was away on a business trip. But once they were together over Christmas, the roof caved in. He just wasn’t there with her. In the group people know her well and question whether she wasn’t the one who vacated the house first. As the subject of attraction and repulsion, intimacy and withdrawal is taken up around the group, a new sense of acceptance and recognition enters the discussion. Adam is ready to consider how he will find someone attractive providing there’s nothing whole-hearted in how they find him. If they’re genuinely attracted to him, in ways that reflect his own attraction towards them, he loses his feeling for them. His own sense of desire becomes repulsive. He can’t tolerate two whole-hearted people in the same relationship. If they get on too well, the house on fire brings the roof down.

Commentary The group is not dealing with Adam’s manic flight nor Joan’s depression, Susan’s disorder of sexual desire or the reaction of the group as a whole to the recent Christmas break. Nor is it dealing with the common relational problems they mirror to one another. It is dealing with all this simultaneously and, as the relational matrix generates a semantic field, this in turn helps transform their

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relationships inside the group and beyond. In this semantic field meaning is condensed by a number of key images that enter the wordplay of the discussion. A disorder of sexual desire is an empty house; passion can bring the roof down; desire can become its opposite; two whole hearts can produce an empty house. The group’s subject is not simply the series of static images by which it is reproduced here. A sense of profundity accrues as the process of discourse – now a chain reaction of associated images – develops a symbolic language by which the tension between hope and fear is brought out and, over time, resolved.

Vignette 4.6  Do we discuss the nightmare or ‘the nightmare?’

In a couples’ group with three couples and two therapists one partnership was under discussion for some weeks. Prior to joining the group they separated and came together several times in a seemingly intractable pattern of conflict and reconciliation. The session reported here marks the turning point in their conflict. He has been convinced for some time they should separate, and he wants her to leave the house. He brings a dream to the group in which he is with her on a luxurious ocean liner. He leaves her inside and climbs a gangway that looks as if it is going somewhere, but it leads him over the side. He falls into the sea and the boat sails away. There is a much smaller boat nearby which he swims towards. As he struggles in the water he then sees a red flag floating nearby. He tries to secure both the red flag and the boat, but the current keeps them apart, and in the attempt to have both he loses every­thing and knows he will now drown. One of the other men invites the dreamer to offer his own associations to the dream. As he begins to do so, the third man enters the discussion with his own associations based on different imagery. The three women then enter the discussion. The woman who fears abandonment is barely interested in the dream and much more concerned with where she will live if he insists she should go. The two other women are closely identified with her. A dialogue develops between the men and the women as to where the discussion should go; the men want to discuss the dream’s imagery but the women want to address the relationship conflict at a concrete level. After a prolonged and fractious exchange that includes material from the two other couples, we are reminded by the partner that the dreamer’s son recently sent this couple some red roses as a token of hope for their reconciliation. There is a sense of startled recognition in the group as everyone sees these roses as the warning flag in the sea.

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The discourse acquires a new vitality and, towards the end of the group, the conductor offers an interpretation that extends this recognition. He suggests that the dreamer, like all the group’s members, is deeply bound to his partner and has discovered in his dream that if he gets her to walk the plank, he’ll end up in the sea himself. The man laughs with relief at being understood, but she doesn’t know whether to laugh or cry and looks from him to the therapist, saying, ‘yes, yes, yes’. The discussion continues with humour and appreciation to the end of the session. In the weeks that follow this imagery is returned to repeatedly as the couple emerge from their conflict and bring their new-found affection and good will to bear on the other couples’ conflicts.

Commentary The exchange moves between monologue, dialogue and discourse. There is both narrative and drama in each of these speech forms as we move between real and reported experience. Language is working here to generate mutative metaphors that come in a moment that can last a lifetime.

At such a moment: A sense of mystery, astonishment, and uniqueness… transcends any descriptive technicalities . . . We have a fragmentary glimpse into therapeutic space. It emphasizes the universal pull of the primordial. It is an intrinsic part of the psychotherapeutic process in which a patient comes as close to his true feelings as he dares . . . Metaphor affords the possibility of engagement with those primordial themes to which all our experience gravitates. (Cox and Theilgaard 1987:17, 9) In this group the dream is first a soliloquy, a way of thinking aloud about the viability of the partnership and the fear of separation. Then it becomes the subject of a dialogue, initially between this man and his partner and then between the men and women in the group as they are all drawn into a review of their relationships. Throughout the session it is the subject of discourse, yielding moments of profundity in which the group works like a chorus in an ancient drama, challenging private deceits with public recognition and confirming private recognitions with public affirmation. Free-floating discussion encompasses all three speech forms, but it provides more than simply direct access to primary process. It is also the means by which

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associative patterns are analysed and explored, new forms of meaning are constructed and a new sense of the individual emerges in the widening cycle of the whole.

Notes 1 This chapter was first published under the same title in The Psyche and the Social World, Eds. D. Brown and L. Zinkin, London, Routledge (1994). The book was re-issued by Jessica Kingsley Press (2000), to whom grateful acknowledgement is made for permission to republish it here. It is also due for publication in Maratos (2015). 2 These questions set the frame for this book’s study of the content of a group’s exchanges in Chapter 11, where they become six key questions applied to the promotion of narrative encounter. 3 This vignette returns to a story first narrated in Vignette 1.2 in order to consider dynamics from different sides of the reflective mirror. 4 There are two dissertations devoted to group-analytic work with envy: R. Graham (2003). Mind the Gap: A Group-Analytic Perspective on Envy. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London; and Sharp, M. (2015) A Call to Arms: Envy and Gender in the Small Group-Analytic Group. Dissertation for Qualifying Course, Institute of Group Analysis London.

Bibliography Agazarian, Y., and Peters, R. (1981). The Visible and Invisible Group. London, Routledge. Aveline, M., and Dryden, W. (Eds.). (1988). Group Therapy in Britain. Milton Keynes, Open University Press. Balint, M. (1950). Changing Therapeutical Aims and Techniques in Psychoanalysis. International Journal of Psycho-analysis 31, 117–24. Reissued in Primary Love and Psychoanalytic Technique. London, Hogarth Press. Reprinted by Maresfield Library, London 1985, pp. 221–235. Barnes, B., Ernst S., and Hyde, K. (1999). An Introduction to Groupwork: A Group-Analytic Perspective. London, Macmillan. Bateman, A., Brown, D., and Pedder J. (2010). Introduction to Psychotherapy: An Outline of Psychodynamic Principles and Practice 4th Edition. London, Routledge. Behr, H., and Hearst, L. (2005). Group Analytic Psychotherapy: A Meeting of Minds. London, Whurr. Bion, W. (1988). Attacks on Linking. In E. B. Spillius, Melanie Klein Today Vol. 1. London, Routledge, pp. 87–101. Bion, W. (1961; reissued 2000). Experiences in Groups. London, Routledge. Brook, P. (1990). The Empty Space. London, Penguin. Brown, D. (1994; 2000). Self-Development Through Subjective Interaction: A Fresh Look at Ego Training in Action. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. Routledge, London. Reissued 2000, Jessica Kingsley, London. Republished in J. Maratos (Ed.). (2006). Resonance and Reciprocity: Collected Papers of Denis Brown. London, Routledge, pp. 107–123. Brown, D., and Zinkin, L. (Eds.). (2000). The Psyche and the Social World. London, Jessica Kingsley. Cox, M., and Theilgaard, A. (1987). Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley. De Maré, P.  (1991). Koinonia: From Hate Through Dialogue to Culture in the Large Group. London, Karnac.

4  The language of the group  133 Foulkes, S. H. (1964; reissued 1986). Therapeutic Group Analysis. London, Karnac. Foulkes, S. H. (1975; reissued 1986). Group Analytic Psychotherapy: Method and Principles. London, Karnac. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Friedman, R. (2008). Dreamtelling as a Request for Containment: Three Uses of Dreams in Groups. International Journal of Group Psychotherapy 53 (3): 327–344. Friedman, R. (2011). Dreams and Dreamtelling: A Group Approach. In J. Kleinberg (Ed.), Wiley Blackwell Handbook of Group Psychotherapy. Chichester, Wiley, pp. 479–497. Freud, S. (1900). The Interpretation of Dreams, SE IV/V. London, Hogarth Press. Freud, S. (1911–1915). Papers on Technique. SE XII. London, Hogarth Press. Freud, S. (1912). The Dynamics of Transference. SE XII. London, Hogarth Press. Freud, S. (1913). On Beginning the Treatment: Further Recommendations on the Technique of Psychoanalysis. SE XII. London, Hogarth Press. Gay, P. (1989). Sigmund Freud: A Life for Our Time. London and New York, Macmillan. Graham, R. (2003). Mind the Gap: A Group-Analytic Perspective on Envy. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. James, W. (1902; reissued 2010). Varieties of Religious Experience: A  Study in Human Nature. Being the Gifford Lectures on Natural Religion Delivered at Edinburgh in 1901–1902. New York, Library of America Classics. Kohon, G. (Ed.). (1986). The British School of Psychoanalysis: The Independent Tradition. London, Free Association Books. Korzybski, A. (2002). General Semantics Seminar 1937 (3rd ed.). Brooklyn, NY, Institute of General Semantics. Kreege, L. (Ed.). (1975). The Large Group. London, Constable. Kreege, L. (1992). Envy Pre-emption in Small and Large Groups. 16th. S. H. Foulkes Lecture. Group Analysis 1992 (25): 391. Kris, A. O. (1990). The Analyst’s stance and the Method of Free Association: Sigmund Freud Birthday Lecture of the Anna Freud Centre, 1989. Psychoanalytic Study of the Child 45: 25–41. Laplanche, J., and Pontalis, J.-B. (1983). The Language of Psycho-Analysis. London, Hogarth Press. Lewis, A. (1990a). Free Association and Changing Models of Mind. Journal of the American Academy of Psychoanalysis 18 (3): 439–459. Lewis, A. (1990b). One Person and Two Person Psychologies and the Method of Psycho­ analysis. Journal of Psychoanalytic Psychology 7 (4): 475–485. Maratos, J. (Ed.). (2015). Group Analysis for the 21st Century: Foundations. London, Karnac. Moffet, J. (1968). Teaching the Universe of Discourse. Boston, Houghton Mifflin. Pines, M. (1982, 1998). Reflections on Mirroring: Sixth Annual Foulkes Lecture. Group Analysis 15, Supplement; and in Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London, Jessica Kingsley, pp. 17–39. Pines, M. (1987). Introduction. In M. Cox and A. Theilgaard. Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley, pp. xxiii–xxv. Rickman, J. (1950). The Factor of Number in Individual and Group Dynamics. In J. Rickman (1957). Selected Contributions to Psycho-Analysis. London, Hogarth Press, pp. 165–169. Rycroft, C. (1985). Psycho-Analysis and Beyond. London, Hogarth Press. Sandler, J. (Ed.). (1988). Projection, Identification, Projective Identification. London, Karnac.

134  I Foundations Scharff, D., and J. (1991). Object Relations Couple Therapy. Northvale, NJ, Jason Aaronson. Sharp, M. (2015) A Call to Arms: Envy and Gender in the Small Group-Analytic Group. Dissertation for Qualifying Course, Institute of Group Analysis London. Skynner, A.C.R. (1986; reissued 1994). Group Analysis and Family Therapy. In J. Schlapobersky (Ed.), Explorations With Families: Group Analysis and Family Therapy. London, Routledge, pp. 231–235. Whitaker, D. S. (2001). Using Groups to Help People. London, Routledge. Whitaker, D. S., and Lieberman, M. A. (1964). Psychotherapy Through the Group Process. London, Tavistock. Yalom, I., and Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy (5th ed.). New York, Basic Books. Zinkin, L. (1983). Malignant Mirroring. Group Analysis 16 (2): 113.

Acknowledgements:  This chapter was first published in an earlier form under the same title in The Psyche and the Social World, D. Brown and L. Zinkin (eds.), Routledge, London, 1995. The book was re-issued in 2000 by Jessica Kingsley Press, to whom acknowledgement is made for permission to republish the chapter here and update it for this book.

Chapter 5

Speech and silence in psychotherapy

To make a prairie To make a prairie it takes a clover and one bee, – One clover and a bee, And reverie. The reverie alone will do If bees are few. (Emily Dickinson 1959:204) The Sounds of Silence Hello darkness my old friend I’ve come to talk to you again Because a vision softly creeping Touched my mind while I was sleeping And the vision that was planted in my brain still remains Within the sounds of silence And in the naked light I saw Ten thousand people maybe more People talking without speaking People hearing without listening People writing songs that voices never share, no one dare Disturb the sounds of silence (Paul Simon 1965)

The sounds of silence The subject of silence in psychotherapy might at first sight look like an interesting paradox.1 Is there much to say about so little? But silence is hardly a small

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subject, especially when it comes to groups. Brooks provides an intriguing commentary: Silence is a common experience in group analysis. With the apparently respectful turn-taking that takes place in the free-floating dimension of this approach, at any one time there will always be more people who are silent than talking. This obvious facet of group analysis has, frustratingly, received limited attention. How can group analysis better understand and engage with silence? (Brooks 2009:5) This chapter is addressed to Brooks’s question. When is silence a retreat, when is it an advance and when is it nothing more than a time without words? When does speech lead to discovery, when are words a distraction and when is the truth of a matter hidden by the very words that describe it? Looking into these questions I shall extend the overview of the subject given by Haddock below by including in this chapter a number of other kinds of silence. There is the silence of a subject that is never discussed, of an emotion that is never recognised, a problem that is never acknowledged or a gain or achievement – in therapy or beyond – that is never affirmed. And beyond all this is the silence of our patients or clients, their sheer otherness and the full extent of what there is to their lives that we know nothing about. Analogues from other fields can shed further light. The concerns of a publisher who puts words on a page or of a musician who reads characters off a page in order to give voice to the notes has to do with space and structure. Text and music are represented by characters in space over time. These are key considerations in psychotherapy, as they are in the study of all forms of communication. Consider the structure of a wheel – a bicycle wheel. Like an atom, most of it is space. Its solid constituents are only the hub at its centre, the rim round the periphery and the thin spokes that connect them. Most of its space is empty. In group psychotherapy, the silent places of the interior and interpersonal worlds, the space within and the space between, both represented by emptiness, are connected by a seemingly flimsy structure of words. Illich suggests that The pregnant pauses between sounds and utterances become luminous points in an incredible void: as electrons in the atom, as planets in the solar system. Language is as a cord of silence with sounds the knots . . . in which the empty spaces speak. It is thus not so much the other man’s words as his silences, which we have to learn in order to understand him. It is not so much our sounds, which give meaning, but it is through the pauses that we will make ourselves understood. The learning of a language is more the learning of its silences than of its sounds. (Illich 1971:46) Haddock writes that: In attempting to understand silence in groups it is necessary to consider it from a number of different perspectives. There is the silence of the dyad

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in individual psychotherapy, the silence of the individual in the group and the silence of the whole group. There is also the therapist’s or conductor’s silence, there is silence in large groups and, moving away from therapeutic situations, there are sociocultural and religious perspectives on silence. (Haddock 1992:2) Here is a vignette: Vignette 5.1  Who says it doesn’t work? Douglas joined a twice-weekly group after 18 months of preparatory individual psychotherapy. He was a committed member for two years before sharing one of his critical reasons for joining. He was gay and, prior to his therapy, had only known relationships that were troubled. They brought him little pleasure, few comforts and neither intimacy nor companionship. We looked closely at these issues during his individual therapy, but once in the group I kept his boundaries and we lived with the silence of his secret for two years. He began as a quiet figure who lived on the margins. The little he disclosed about himself had to do with his substance abuse including drink and cocaine addiction, the financial empire he ran from his office in the city, his love of sport and speed and his passion for skiing. The disclosure of his homosexuality was greeted with surprise by others, in particular the women who had grown to find him attractive. By then he had earned the reputation of the male megaphone as he gained in confidence and stridency and learnt to deliver devastating insights with which he challenged everybody, including myself, in a voice that couldn’t be interrupted as he posed impossible questions about whether or not the process would work for him. As he softened in the group he gained the capacity for intimacy and exchange and found bonds that could hold him. We learnt that he attended a gym regularly to immerse himself in a float tank for long periods of silent darkness.

Commentary So here is another dimension to the subject, found in the different kinds of silence we turn to in order to find peace. Some like the silence of underwater snorkelling, some speak about the silence of hanging from a parachute or a hang-glider thousands of feet up in the air and others seek silence on sailing (Continued)

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(Continued) boats or in gliders. Painting is a mostly silent art. Time spent in a library or reading in private or in long-distance running or other forms of training will mostly take place in silence. Others seek silence in meditation and yoga, and others find the silence they seek in prayer or religious retreats. These are all different forms of self-imposed withdrawal that allow individuation, growth and, for some also, spiritual development.

Douglas finally left the group after five and a half years of therapy, nearly seven years after first coming to see me. He was freed from his substance abuse and on quite different terms with himself and the group’s members. He had learnt to stop sitting on the side-lines of the group, blasting people with his male megaphone and challenging us all by posing a question made impossible by its recurrence, as to whether or not the therapy process would work. By the time he left he was a cherished member of a small circle in which we struggled with early injury, isolation and abandonment that included threats to survival posed by people’s own parents. Douglas found and proffered an understanding of early injury that was profoundly consoling. The qualities of his penetrating intelligence became an asset to us all. But we still knew little about his current, closest relationships. And this leads to another kind of silence – the silence of not knowing what happens in the subsequent lives of our former patients. Two years after he left us I received a post-card from Douglas addressed to the group and myself. It was posted from a ski resort in Austria and showed a photograph of two skiers in a dramatic ski jump with a blazing trail of snow behind each pair of skis that were in perfect harmony. On the back was a question in five brief words, ‘Who says it doesn’t work?’ And then, ‘Thank you’, and his name. That was all I received and have heard nothing further. But who needs more? The silence of the picture stands in perfect symmetry as an answer to his own question.

When words fail The resolving emotions of psychotherapy that arise out of the deeper areas of engagement and change that our work makes possible – like those described in Douglas’s story – are hard to describe. Many who come to see us do so in states of pain that have many ‘missing’ features, and some have already passed through a succession of therapists’ hands with little real benefit. What role does silence

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play in these processes? There is a famous epithet we owe to Heinrich Heine: ‘Where words leave off, music begins’. Although this is commonly quoted, its source can only be found in correspondence between Tchaikovsky and Nadezhda von Meck of 17 February/1 March 1878 (Tchaikovsky 1878). It is all the more relevant as many of those we see for therapy are so lost for words that they have never known words to succeed. Cox and Theilgaard (1994) provide a fine analogy for the practice of psychotherapy in their account of narrative failure. Their picture of the therapist’s key function was to be alert to crucial moments during our patients’ narrative when they falter for words or when words fail them. They suggested we play a role at these moments similar to that of the prompter who follows the actors’ lines on the stage, furnishing them in an undertone with those words for which they become lost. On their account our profession follows Shakespeare, who created situations of intense drama on the stage and had his characters flounder in critical moments of confusion. Then, as the prompter himself, he helped them finally struggle with words through which they found new forms of insight. Not every psychotherapist would see themselves standing in Shakespeare’s footsteps, but when – in the drama of a group’s engagement – we witness narrative failure, it is vital we should help different members to come forward and do so as one another’s prompters. This chapter will investigate the relationship between silence and the spoken word at just these moments. We have first to consider silence that brings words forward in those forms of silence that make language possible in words. This is a domain of silence that I propose to call the unspoken. It is an arena of silence in psychotherapy that we need to cultivate, tolerate, explore and live with on comfortable terms. We will then go on to consider words – verbal communication – that bring us beyond the words themselves to a silence that touches on sources of distress and suffering residing in the hidden places of the self that allow for whatever forms of resolution might be possible. These resolutions are inherently paradoxical, as they require and go beyond words. I propose to call this domain of silence the unspeakable. I see it as one of the key tasks in psychotherapy, to challenge the unspeakable and find its core. I have compressed large and complex subjects into two simple phrases that, for the sake of simplicity, are offered as mirrors of one another, but we will see how this symmetry breaks down in due course. I owe these distinctions to Kane, to whose Language of Silence: On the Unspoken and the Unspeakable in Modern Drama I was first introduced by Cox (Kane 1984). The unspoken Looking first at the unspoken, at silence that brings words, the questions that face us look at the issue of silence not so much as an end-point or resolution but as a process dynamic, a recurrent stage in our engagement that can help us go beyond itself. The questions we might consider have to do with how silences during the life of a group might lead to the resolution of unconscious defences and thus allow

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the articulation of deep and often hidden emotion in the spoken resolution of people’s serious problems. We have also to consider the harder and more frustrating aspects in silences of this kind – silence that can carry the weight of despair and futility, the not knowing how to communicate, rage against the very presence of others and sometimes against life itself, all contained in the more painful and complex silences that we administer. These are some of the many different forms of isolated or fragmented silences in which the therapist’s main task is to help people find those words that bring understanding. The unspeakable Communicating silence When we turn this around and look now at words that bring silence, at the domain of the unspeakable, the questions that face us in the second case identify silence with a state or condition of being like one of resolution after weeping or of discovery after a painful and rocky journey. But it is not always peaceful and can often include great pain and sorrow. Here silence is an end-point rather than a process dynamic; it is a goal or telos, a state we hope to arrive at during the course of the process. The questions we might consider here are about how words bring us to a point at which they are no longer necessary in the groups we run. How do words bring us to a state in which they become redundant, in which understanding is extended through non-verbal forms of communication that are profound, resolving and, in due course, regenerative? We see this happening in our groups when people establish a shared emotional register which may require few words and which no one wishes to break. We could call these different kinds of communicating silences. They can have to do with the discovery of peace, the experience of love, of understanding or of being understood, the recovery of good terms, some newfound sense of redemption or other states of transcendent and healing emotion. Isolating silence The unspeakable is not always a communicating silence. It can also be an isolating silence in the grieving of a loss, the acknowledgement of insoluble or painful reality, the suffering of not being understood or not being seen, of being misunderstood, misused or abused, the experience of sorrow or of horror that goes beyond words. The group as auxiliary ego and splitting in the self and in the group The vignette that follows illustrates use of the term auxiliary ego, introduced by Moreno in 1937 and applied to group analysis by Neeld (1999), and splitting, a term introduced by Anna Freud as a defence mechanism that describes how the

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mind defends itself from the experience of otherwise unbearable pain by reducing sources of conflict to different and opposing locations of the self where they cannot come into dangerous opposition (Freud 1937). The problem inherent in this kind of defence is that these ‘split off’ aspects of the self can never enter a resolving dialogue with one another. Neeld writes that Group support serves as an auxiliary ego that can be called upon in times of stress or when individual feeling is overwhelmed’ (1980:170–172). Aid, comfort and sympathy can be given to an individual member as needed, as a mother would hold a child who was wounded in their exploration of the world. The term ‘auxiliary ego’ is used here by Agazarian and Peters. I would like to posit the view that where there is ego there is – and has been – auxiliary ego. (Neeld 1999:15) In Vignette 5.2 the group works by providing one of its members with the sense of an auxiliary ego that helps contain experience that would otherwise be overwhelming, thus helping Juliette reduce the need for defensive splitting.

Vignette 5.2  Love me or fuck off

Juliette had been in a twice-weekly group for some seven years in all and was finally working out her notice. She had given us many months notice of her intention to leave. Her career had always gone well, but now she was finally settled with a man she loved and whom she knew loved her. They were planning a home together and hoped to have children. She had lived through a childhood of tormented conflict between her parents, then their painful divorce and finally her mother’s serious mental illness, during the course of which the mother became psychotic and murderous. Juliette ran away from home at 17, left the country and after several degrees finally established herself as a business consultant abroad, where she had met this man who now promised to be her third husband. She returned with him to England and they were in the process of setting up home together. She had many adversities to overcome, and the group gave her a context in which to gather and find herself. It became an auxiliary ego. She knew that her failed earlier marriages were more than anything else a consequence of a personal history that was still alive inside her, and this brought her into a long-term group. Her early years with us were characterised by an intellectual cleverness and accomplishment with words but also by a brittle and defensive denial of her core conflicts. When we came too close to them we found

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anger, repudiation and withdrawal. People gave her the adjective ‘stony’ and described her as ‘hard as flint’. Despite the increasingly open account of a multitude of early injuries, we hardly ever saw her tears. She left the group on a number of occasions and returned after some sessions or indeed, on one occasion, after months of absence. These were the very patterns of conflict associated with her current partner and previous husbands. We came to see the angry conflicts with her partner as evidence of a kind of splitting associated with the encapsulation of her early injuries. We thought that what she did with us in the group was a mirror to the pattern she described with her partner. She seemed to give people, especially her partner but also those in the group, only one of two options: ‘love me or fuck off!’ Members described her communication pattern in the group as a kind of semaphore made up of only two signals – one for unconditional love and the other for rejection. Whoever could not give her the first got the second.

Commentary The splitting imperatives that governed attraction and rejection had ruinous implications for Juliette’s previous love relationships, but here, slowly, the holding power of the group and its members was allowing integration of these different psychic forces. Some time later her term of notice took place during a period in the group soon after the death of another woman’s father when a number of people were in tears about their lost parents.

Vignette 5.3  You cry for what you’ve lost and me for what I’ve never had

During the course of a long period of mourning in the group Juliette also began to cry bitterly but had no words for the tears that overcame her during our sessions. So here is another dimension to silence – the silence of the unspoken that comes out only in tears. People knew her intimately and had seen her through a great deal. She had become an

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affectionate, available and emotional woman. In the group she had gained a kind of emotional ballast and resilience that was to see her through many unforeseen crises still to come. Much of the defensive encapsulation was resolved, and so was some of the splitting. But now, as she was leaving, she found she had no words or explanation to offer in response to others’ concerned enquiries, and we learnt to live with the weight of her great sorrow during this unspoken silence in the group. Eventually she herself found words through her tears to put an end to a silence she had never known she was living with. Out of the blue one day she said, ‘You people are crying for what you’ve lost’. This was true. Two of them were crying for the loss of fathers where there had been a lot of love. Another was crying over the more recent death of a father with whom she was just beginning to make reparation. But, Juliette said, ‘I’m crying for what I never had. This is different’. And we all knew exactly what she meant – this was her region of the unspeakable. Then she went on to say, ‘And it makes losing you all now feel very dangerous. You’re the only family I’ve had where love has been safe’. And she looked at me in a most intense way that seemed to take me in with great meaning that was sustained throughout her concluding sessions and was to remain part of our continuing association as need arose in her later life when I would see her occasionally.

Commentary We had here entered areas of unspeakable injury that belonged to her early years and that left her feeling set apart and marked by difference. Only by denying the fear, shame and sheer madness of her history did she feel she could lead a normal life. In Juliette’s case I did hear from her subsequently – she kept us informed about her marriage, and from time to time she continues to come back for top-up sessions together with her husband. They settled to a rewarding life together and have two children. Photographs of the children are part of our correspondence at key points in their lives. The most poignant observation she made as she left the group was to share with us what she then regarded as its prime contribution to her life: she said she had discovered whilst with us that is was never too late to have a happy childhood. The phrase remains alive in the group 25 years on despite its rotating membership that has (Continued)

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(Continued) changed many times. The unspeakable silence was about an aspect of her history for which – until she found the words – she had not realized she did not understand. These words were for tears shed about deep privation. No one could have given her these words until she found them for herself by learning to play with us. The encapsulated injuries required denial to create the illusion of normality, but the price she then paid was hardness and splitting that undid any options for living through the ambiguities and uncertainties of ordinary family life. What she found in the group was that by remembering her past, penetrating the core of its injuries and the heart of stone – and then coming to terms with the facts of her radically different history – she could finally leave it behind her. The earlier silence of a dissociated history that had ruinous consequences for what she most hoped for – a happy family life – was replaced as she made a new set of terms with her own history and learnt to ‘play’ with her own and with other people’s experience. This gave her a sense of peace and allowed those she was closest to, finally, to know her on very different terms.

Human suffering – including serious early deprivation, the adult or childhood experience of grave adversity, trauma or abuse, illness or disability – creates its own areas of silence. These are the shadows of hidden injury where the numbness, the sense of betrayal or the permanent sense of living in a state of exile from the self and from society can remain deeply concealed. The earlier and the more serious the injury, the greater is the level of encapsulation or disassociation. Our task in psychotherapy is to gain access to these hidden areas of silent affliction and allow people to find their own voices. These are just some of the areas of hidden experience often dominated by early injury but familiar to us also in many areas of adult trauma described in The Sound of Silence, Paul Simon’s celebrated song (1965), in which there are: People talking without speaking People hearing without listening People writing songs that voices never share, no one dare Disturb the sounds of silence. When words do begin to really work bringing light into these dark places, they can quite often then become redundant. I have written elsewhere that: There is a correspondence between the form taken by defensive behaviour in the group, the character defence in the individual’s personality structure and

5  Speech and silence in psychotherapy  145

its manifestation as a . . . problem in their relationships (outside the group). The defence, the pathology it gives rise to in the outside world and the behaviour it is responsible for in the group are all regarded as analogues of one another. They are isomorphic and consequently change at any level will produce change at every other level. (Schlapobersky 1996:240) Painful memories that are often alive in a concealed and hidden form within the self can then be retrieved in order for them to be relinquished. When somebody can find peace with themselves; accept themselves or their parental figures; their children, partners or lovers; come to terms with issues or with causes that might have pursued them, or with driven ambitions that might have taken them a long way from themselves, or come to terms with fears and anxieties that might have prevented them from ever finding themselves; or find intimacy or love that might have eluded them for years – then the beneficial consequences can speak without words. When people in psychotherapy have found some kind of resolution for their most profound existential questions – resolutions to questions that may well have been hidden or unstated for most of their adult lives – the ensuing sense of peace can often be evident and manifest without words. It can speak for itself in silence.

Vignette 5.4  The girl who lived in the heart of stone There is a too-little known film, Camille Claudel, that describes the life and ruin of this distinguished French sculptress in the course of a relationship with her teacher, mentor and lover, Auguste Rodin. Her work excels his in many respects, but when they split up she became severely depressed and was incarcerated in an asylum by her famous brother, where she spent the rest of her life. In the course of this film, set before her incarceration, she emerges from the relationship with Rodin to try and make a go of things on her own. Working in an impoverished shed in a poor quarter of Paris she enjoys a cash windfall from the sale of her work and orders a piece of marble. We are shown its delivery in the early years of the 20th century on a horse and cart as the street urchins of the district gather to watch with wide eyes. She closes her doors on them to work and emerges months later to reveal the exquisite form of a nubile and vulnerable young girl. The street urchins are welcomed as her first audience and, as they gather to wonder, one of them says, ‘How did you know that girl was living there inside the stone?’

(Camille Claudel, 1988, Directed by Bruno Nuytten)

146  I Foundations Table 5.1  The human experience of silence: Haddock*  1

Silence is essential to communication; without space between words, spoken or written, they would be almost indecipherable.

 2

Communication occurs during silence.

 3

Silence may be the main form of communication.

 4

Silence is often an attempt to block communication.

 5

Silence, when used artistically, can be powerfully evocative.

 6

Silence has a symbolic function in many cultures and religions.

 7

Silence may be voluntary or involuntary.

 8

Silence in the presence of another is always interactive and inevitably elicits a response in the other.

 9

Meanings of silence are apparently limitless.

10

Silence of groups is not intrinsically different to silence of dyads.

* Table 5.1 is taken from Haddock, R. (1992) Silence in The Matrix in Group Psychotherapy. Theory Paper for Qualification. Institute of Group Analysis, London. IGA Library. P. 2. Grateful acknowledgements are made to the author for permitting the re-use of the table here.

Our quest as psychotherapists is to penetrate the heart of stone that holds the secrets of inner injury, and to do this we need to find form in its silence. Haddock (1992) provides an account that he uses ‘to summarize the human experience of silence’ and, quoting Susan Sontag, he suggests that silence and speech cannot exist without each other – ‘silence remains inescapably a form of speech’. He documents the human experience of silence and its relevance to psychotherapy practice in Table 5.1. In the sections that follow I will look at the subject of silence in the three different domains of a group’s life which are documented in Table 5.2. The first domain is the one of free association, of free-floating discussion that was discussed in the previous chapter. The first clinical questions this leads us to are about how we administer the expression and withholding of words in our engagement with clients and patients – to speak or not to speak – that is the therapist’s first question. The second domain is the one in which we examine speech patterns formally and raise questions about different forms of discourse and communication. In this second domain we can use discourse analysis to consider the formal structure of peoples’ communication and examine the many different kinds of silence in terms Table 5.2  Speech and silence in group psychotherapy 1

Free-floating discussion: managing spoken and silent communication.

2

Discourse: analysing the form, content and function of silences.

3

The symbolic order: the interpretation of silence, of reverie and the imaginative world.

5  Speech and silence in psychotherapy  147

of their form, content and function. The third domain addresses the language of the inner world – that of symbolic objects, poetry and prayer – which Winnicott introduced to psychotherapy as the transitional domain or intermediate territory. It is neither within the individual nor between people because it belongs both to the world within and the world between (Winnicott 1951). Bollas has now revised this domain, suggesting we should more appropriately see it as the transformational one, the world of imbued meaning in which creativity arises and in which we can each assert, express or recover our individuality (Bollas 1987). Silence is of great significance at this level, where it can be seen to nourish, reflect or avoid states of reverie and imaginative renewal. Emily Dickinson’s poem about reverie at the beginning of this chapter emphasises the imaginative world within and points to the inner resources cultivated by psychotherapy.

Free-floating discussion: Managing spoken and silent communication How do we administer the expression and withholding of words when at work with our patients? Using the resources of psychotherapy and semiotics, how do we read the silences of a group’s process, how do we recognise the voice of the symbol in the silence and what do we do with it (Grotjahn 1971; Kristeva 1995, 2010)? These are the first clinical questions. Haddock writes that: There is nothing more powerful or disconcerting to a trainee group analyst, than to be faced with a completely silent group. There is also nothing more inevitable. (Haddock 1992:2) In groups that are new, young or otherwise fragile, members will need to be helped to speak, linking communications will be important, and so will enquiries of a direct kind which, whilst kind and thoughtful, will set the pace and the pattern for the form of exchange the therapist will hope to foster, which should include the readiness to challenge and confront its membership. In such circumstances silence will have its place and members will gain confidence steadily as they see the conductor taking up an enabling position, speaking only when necessary and speaking mainly to give words to experience for which others may not yet have a voice. On the other hand, a therapist who spoke too much in an established and long-standing group, who could not tolerate silence themselves and whose own activity pre-empted the group’s sometimes silent struggle with its own experience, would be interrupting and forestalling free-floating discussion. The group-analytic method calls on the conductor of a mature and well-established group for a balanced deployment of all 12 principles of leadership and analysis in the first set of headings in Section A of Table 12.7. As the group matures one will expect to see a progressive diminution of their own active leadership in favour of a more reflective and interpretive stance in which the therapeutic principles described in Section B of Table 12.7 come into play. From this position silence will almost always be

148  I Foundations

‘golden’, should rarely be interrupted by the conductor and where possible should be explored according to the principles of location and interpretation in the second set of headings set out in Section B of Table 12.7 and further explored in Chapter 17.

Discourse: Working with the form, content and function of silences Using the language of discourse analysis we can consider the formal structure of people’s communicational activity through a second set of questions to examine the many different kinds of silence in terms of their form, content and function. The silences that arise between people who are unrelated and who cannot communicate have radically different meanings from those which arise amongst intimately connected people. In a new group amongst members who have not yet learnt to communicate or even relate to one another, the silences that will inevitably arise present the conductor with challenges for clinical management that require a more active role, along the lines set out under leadership and analysis in Table 12.7. The advice from Foulkes and Anthony is that ‘the conductor, understanding the significance of a particular silence, should feel at home in it. His calm acceptance will help rob it of much of its anxious tension’ (Foulkes and Anthony, 1984:156). On the other hand, in a long-standing group with a stable membership, silence will more frequently require of the conductor an interpretive level of understanding and engagement described in Table 12.7. Each silence, like every other pattern of speech, will take a distinctive form. It will have content and a context that is unique to the point at which it arises and can be seen to serve particular functions. Writing of silence during individual psychotherapy, Weisman (1955) suggests ways of observing silence that can be applied directly to groups by noting their onset, periodicity, frequency, duration, precipitants, termination, accompaniment, responses to questions or comments from the conductor and the patients’ conscious attitudes towards the silences. In Chapter 4 I recommend that great depth of meaning can accrue in any group whenever the conductor poses for their own clarification the simple question – at any point in time – who is talking to whom and about what? Enquiries like these are turned into a set of working clinical principles in Chapter 11. During periods of silence the same question can be posed, though it should only be voiced as an active enquiry in a group that is at a sufficiently mature stage to bear the question: who is not talking to whom, and what are they not talking about? In a group dominated by feelings of alienation and despair, in which the membership was either too fragile or too new to explore itself on these terms, a group dominated by what Hopper calls the defences of aggregation or massification, the conductor would likely be best advised to lead the group out of periods of empty torpor by direct enquiries, personal observations or linking communications. On the other hand, if a group had achieved the capacities for discourse, exchange and reflective examination, then even fraught and painful silences can be inhabited and explored. Different conductors adopt a range of strategies by which to do this.

5  Speech and silence in psychotherapy  149

Vignette 5.5  A male megaphone silent in protest against a newcomer

My own preference is to ask the membership – after a silence that might have been prolonged, bewildering or unexpected – to comment on the kind of silence we had lived through. I might ask, ‘What kind of silence has this been?’ ‘Angry’, someone might answer, and then challenge the conductor, angrily: ‘Can’t you feel it?’ We might sit through further silence. Someone’s chair shifts, another member clears their throat and finally another member says, ‘Why did you have to bring him into our group?’ Ten sessions earlier a new member joined the group, but he is away today on a vacation with his children. This is the first time the original membership have had a meeting without the newcomer and have entered a collective withdrawal that turns into a hostile silence, punishing the conductor for inflicting on them someone they find so difficult. The newcomer talks a lot, asks aggressive questions, finds it hard to listen and shows few reflective capacities. People have been working together for quite some time and share a deep level of understanding that they have had to struggle for. They feel as if the newcomer has set them back, and they finally come out of their hostile silence to say so to the conductor. Only a long way down the line, towards the end of the session, does the conductor offer them a view that they might see evidence of their own progress in the difficulties he now presents. At the moment they cannot see, let alone accept, that he is much like they were when they first joined the group. Amongst those in the prolonged and angry silence is a man who – as the previous newcomer – earned for himself the handsome title of ‘the male megaphone’. I have described him above. Now that he has been supplanted in this role he has adopted a more subdued stance in the group and is sometimes visibly startled by the way the current newcomer mirrors back to him in the group the very attributes that earned him the other members’ hostility. In a group everyone who is party to a silence is in an equal and symmetrical relationship with everyone else. A silence of this kind can be a great unifier, and in circumstances like this people are joined to one another by silence. It becomes a bond of affinity and association even when it feels like the opposite. Many weeks later people are able to share with the former ‘male megaphone’ that they feel he really joined them when he sat with them in silence to protest against someone who was even more mega then he. There is laughter, and the new mega megaphone is drawn in with curiosity to chuckle a little about whether – one year from now, they ask – he will join them to sulk at the conductor about another unpleasant new arrival and tolerate five minutes without words?

150  I Foundations

The symbolic order: Reverie, the imaginative world and the place of interpretation Winnicott describes how Transitional phenomena . . . become diffused . . . spread out over the whole intermediate territory between ‘inner psychic reality’ and ‘the external world as perceived by two persons in common’, that is to say, over the whole cultural field. The ‘cultural field’ encompasses those areas of psychic life in which relationships, the world and its objects, feelings of identity and belief – the symbolic representation of subjectivity – . . .Widens out into that of play, and of artistic creativity and appreciation, and of religious feeling, and of dreaming, and also of fetishism, lying and stealing, the origin and loss of affectionate feeling, drug addiction, the talisman of obsessional rituals, etc. (Winnicott 1951/1978:233) This is more fully addressed in Chapter 16. There is an extended psychoanalytic literature on the subject of silence, and Khan’s writing (1963) is of special significance. He examines silence as a form of transference communication whose primary function is to communicate the wordless problems of early childhood disturbance. He demonstrates through detailed case studies his own active use of countertransference to decode the complex affects contained in these archaic object relationships. In such silent periods of psychoanalytic psychotherapy the patient puts the analyst into the situations they themselves once lived through in the hopeful belief that they can now be worked through on different terms. So even long periods of blank and seemingly fruitless silence can contain hopeful elements which – by the judicious withholding of too active an interpretation – can allow the individual to discover and communicate their deepest areas of injury. This quality of understanding lends itself to further development in the groups we run. Contributions to the group therapy literature on silence build on these perspectives and contain important discussions by Slavson (1966), Yalom and Leszcz (2005) and Whitaker (1985). The most comprehensive amongst these is Lewis (1977), who concentrates on general group silences, which he discusses under several headings differentiated on the basis of their causes. They include silences early in the life of a group associated with beginnings and dynamic administration; transitional silences during movement from the world outside to the world within; silences that arise in response to revelation or disclosure, frequently involving shock; isolating silences of fragmentation and failed communication; and finally withholding silences involving passive aggression, passive dependence

5  Speech and silence in psychotherapy  151

or conspiracy. In all these cases, ‘Silence is not an absent communication’, he writes, ‘but, rather, an exquisite way of communicating a state of being’ (Lewis 1977:110). Hoskins (2003) studies the silences associated with the conductor’s perceived illness, which preclude members from addressing the subject matter of illness in their histories. She gives an authoritative account of the conductor as the ‘wounded healer’ who, if ready to break such silences with interventions attuned to the group’s own capacity to tolerate transference interpretations, can release profoundly healing resolutions in what Foulkes called ‘the common zone’ – the arena of the group’s preoccupations and anxieties described in Chapter 4. Perovšek Solinc (2002) includes an important study of splitting between the vocal and silent members of a group. She illustrates the importance of the conductor calling on her own countertransference in these situations to speak for those who appear lost in silence. Through the tolerance of silence at certain points and the readiness to speak at difficult moments on the basis of good judgement, a fruitful discourse can then arise as the group’s more silent members are equipped through the conductor’s voice to find their own.

Conclusion This chapter is concluded with a vignette taken from a long-term group in which metaphors are generated to do with ‘springing a trap’ that helps move everyone’s understanding to a new level. It is of special relevance for two members working out their notice. The potent source of change is the work done in the round by the group – this is the ‘ground’. The ‘figure’ is the mutative agency of the metaphor. Questions about how and why metaphors generate agency of this kind are explored in Section III of the book. Chapter 16 is devoted to mutative metaphors and Chapter 17 to the conductor’s use of metaphor first in the location of disturbance and then in translation and interpretation.

Vignette 5.6  Springing a trap

Two members are preparing to leave and are working out their notice given months in advance of their departure. Henry’s story begins in Vignette 3.1c. We return to it here some years later. Henry had been with us for a long time and finally held an appointment with a charitable agency as their chief executive. In the course of his career he became a capable advocate and behaved like this in the group, too. He suffered from childhood depression, was treated symptomatically with anti-depressants and got to medical school, where he dropped out. Then he nearly failed a degree when he became depressed

152  I Foundations

but was profoundly helped by a university counsellor. He went on to train as a social worker and, by the time he was referred on for group therapy, was doing excellent clinical work. However, his own personal world was empty and unhappy. When he joined us after six months of preliminary individual sessions with me, he was twitchy, agitated, secretive and untrusting. Every effort I made to engage with him resulted in an argument, and his transference with me was fraught with complexity. He was less conflictual with peers in the group but only marginally so, and his early years with us involved active investigation of his world of internalised bad relationships, including rage about his remote and persecutory father, his unavailable mother, vengeful fears and his depressive makeup that previously included self-sabotaging behaviour. During the course of his therapy he secured progressive appointments to eventually become a chief executive, but we lived through the many layers of his conflictual makeup in a chronic battle between growth and motivation on one side and depressive lapses on the other. In his current job over the last two years things had changed radically and he enjoyed – especially – the close supervision at work of a man who became the external ‘good father’ he never had, corresponding to the internal ‘good father’ he found with me. In the group he was finally able to make a close and affectionate identification with me. As he matured he came to speak for the group, to act as a supplementary conductor and to sometimes be of profound help to other members. We saw his career flourish, but his relationship world was still populated by brief physical affairs that yielded little satisfying experience of intimacy. But he had been with us longer than any one else, and he thought it was finally time to go. Karen had been with us for nearly four years and was leaving to take up an unexpected promotion to a university elsewhere in the country that had allowed her to buy a farm in the adjacent countryside. This offered her, finally, recognition for her rapid advancement in the academic world, providing a chance to move to a country location where she could bring her cats, keep bees, grow vegetables and enjoy the life she had always longed for but never had. She was in her mid-forties but had never had a physically intimate relationship. She still hoped to be able to meet a man with whom she could share this dream. We had seen her change from an angular, insular spinster to a warm and affectionate woman who was learning to speak with touching beauty and confidence about the issue she had been most silent about until now – her repressed sexuality. There are five other members in the group of seven, and we are all very active. Henry’s departure is due in two weeks and Karen will be leaving three months later. We are in a lively and vital exchange about the future plans

5  Speech and silence in psychotherapy  153

of these two, and we are focussed on the current domain. Other members of the group get their fair share of our attention as one talks about the school where she teaches, another about her counselling course, another about the computer systems he is responsible for at work, another about his PhD programme and another about tension in her office.

Commentary This is group discourse of a very real kind, a constructive, ego-supportive and problem-solving exchange that involves everybody. Why bother to intervene? At the current level the common zone of people’s occupational preoccupations is avoiding their hidden concerns about unmet needs for intimacy. This remains invisible, gets no consideration, and two of them will soon be gone.

Vignette 5.6  continued

Karen is talking about the farmhouse she has been looking at. She has a friend on the south coast to where she was moving who asked her if she wanted to be introduced to any men! She laughs to herself, makes several encouraging noises and exclamations, and one of the women in the group says, ‘Well?’ Once more she laughs, chuckles, and then dries up and stops. ‘Well’, says the woman who said it before, ‘You’re getting your farm, you’ve got your job, and maybe soon you’ll find a man with whom to share it all!’ Karen withdraws, stops talking for the first time today and retreats to a familiar place in which she is virtually inaccessible. It is of course what she wants, but as the virtual dream becomes clear she takes flight. Karen and Henry have both undergone vital forms of growth that will stand as conditions for success in the next challenge they both face and which has to do with relationships. I find myself saying to Karen that we can see how, like Henry, she remains trapped by forces at work within her which makes sure that as she approaches her dream, the goal has to retreat from her. She both longs for and is terrified by sexual intimacy. She acknowledges that as she is helped to look at ‘this man thing’, all her strength deserts her and she is back in the land of persecution. She has gone quickly pale – we have seen her shift like

154  I Foundations

wthis before. I find myself calling on the past, the present in the group and their outside experience to frame an observation that it’s our job in the group to spring this trap so they can be released to enjoy what they most long for.

Commentary All this takes place in a sequential, conversational form, and my intervention is hardly different to any one else’s. But it stops the group in its tracks, and we find ourselves sitting in a silence that lasts a long time.

Vignette 5.6  continued

After some five minutes I  ask what kind of silence we’ve been having? The other five members in turn each begin to talk about what a thoughtful time it has been. They don’t use these words, but their own states of reverie have been stimulated by this reference to traps and they tell us that they’ve have been thinking about the pits they have created for themselves in their personal lives – the traps they created and fell inside.

Commentary As they talk about their respective areas of reverie it becomes clear that the long silence had the double effect of bringing us together and separating each person out at the same time. This has been a communicative silence – one that can only arise amongst those intimately connected.

Vignette 5.6  continued

As the others talk about their life predicaments, Henry begins to twitch and Karen begins to cry. She acknowledges that she is not yet ready to end therapy, but the transfer is of greater importance to her future than this group, and she hopes she will be successful in finding a new therapist with whom she can continue. She wants someone who knows how to ‘spring the trap’. Henry declares that he too isn’t done, but it’s time to go. ‘I know’, he says, ‘I can come back if I need to. I’ve got to get set up on my own now. If I need your help when it’s time to look at relationships, you’ll hear from me’.

5  Speech and silence in psychotherapy  155

The privacy of self-declared need was found during an unexpected period of silence. The metaphor of springing the trap plunged us into a long period of deep reverie. We emerged from the silence to examine these images and relate them verbally to both the hidden, common zone of unmet personal need and to individuals’ different private areas of frustrated life experience. The image of ‘springing the trap’ is itself a piece of poetry that provides us with a relatively pure form of the imagination at work. We can see this at work in Emily Dickinson’s poem ‘To Make a Prairie’, which opens this chapter by celebrating reverie. Psychotherapy can make reverie possible and productive, but to call it productive is to give it a functionality that does damage to its subtlety, subjectivity and inner meaning. What we are about here is the creation of transformational images that arise out of and in turn foster emotional growth. For this to happen in groups we need to fashion words that bring silence. We will see more about these dynamics in Chapters 15 and 16. In the echoes of the natural world – standing in a garden, on a mountain, a coastal headland or beside a river – we might be able to hear only the wind, the distant call of the sea or the sound of a stream with its still, small voice, the voice of fine silence. Matthew Arnold (2004), describing the sound of the sea on the shingle at Dover Beach, heard in it The grating roar Of pebbles which the waves draw back, and fling, At their return, up the high strand, Begin, and cease, and then again begin, With tremulous cadence slow, and bring The eternal note of sadness in. And he describes how Sophocles long ago Heard it on the Aegean, and it brought Into his mind the turbid ebb and flow Of human misery. In Chapter 15 we will return to this poem with words from its later stanzas. For now, if we can learn to listen for ‘the turbid ebb and flow of human misery’ in the experience of our groups, we might discover the silence at their inner core that carries the same restorative potential available in the echoes of the natural world. Coming alongside our patients during their experiences of reverie and reprieve we can become witnesses in forgiving moments to experience that fosters renewal and becomes redemptive.

Note 1 This chapter was first presented as a keynote to a conference organised by the University Psychiatric Hospital of Ljubljana, Slovenia, October 2003, in an earlier form and

156  I Foundations under the title ‘Silence That Brings Words and Words That Bring Silence’. Grateful thanks are given here to Marjeta Blinc and Frank Peternel. It was later presented in a form close to its current one to a workshop of the Israeli Institute of Group Analysis, Tel Aviv, 2012. Grateful thanks are given here to Robi Friedman, Pnina Rapoport and Marit Joffe Milstein.

Bibliography Arnold, M. (2004). The Collected Poems of Matthew Arnold. London, Kessinger. Bollas, C. (1987). The Shadow of the Object: Psychoanalysis of the Unthought Known. London, Free Associations Press. Brooks, F. (2009). The Othering of Silence in Groups. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Cox, M. (1978). Structuring the Therapeutic Process: Compromise with Chaos. Oxford, Pergamon. Reissued by Jessica Kingsley Press, London, 1993. Cox, M., and Theilgaard, A. (1987). Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley. Cox, M., and Theilgaard, A. (1994). Shakespeare as Prompter: The Amending Imagination and the Therapeutic Process. London: Jessica Kingsley Publishers. Dickinson, E. (1959). Selected Poems and Letters. New York, Anchor. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Freud, A. (1937; reissued 1993). The Ego and the Mechanisms of Defense. The International Psycho-analytical Library, No. 30. London, Hogarth Press. Reissued London, Karnac. Grotjahn, M. (1971). The Voice of the Symbol. Los Angeles, Mara Books. Grotjahn, M. (1993). The Art and Technique of Analytic Group Therapy. New Jersey, Jason Aaronson Inc. Grotjahn, M. et al. (1983). Handbook of Group Therapy. New York, Van Nostrand Reinhold & Co. Haddock, R. (1992). Silence in the Matrix in Group Psychotherapy. Theory Paper for Qualification. Institute of Group Analysis, London. Hopper, E. (2003). Traumatic Experiences in the Unconscious Life of Organisations. London, Jessica Kingsley. Hoskins, J. (2003). When Reality Intrudes Into Therapeutic Space: An Exploration of Therapist Illness – Its Effect on the Group, Its Membership and the Therapeutic Process. MSc dissertation, Institute of Group Analysis, London/Birkbeck College University of London. Illich, I. (1971; 2001). The Eloquence of Silence. In I. Illich, Celebration of Awareness: A Call for Institutional Reform. London, Calder and Boyars. Kane, L. (1984). The Language of Silence: On the Unspoken and the Unspeakable in Modern Drama. London, Associated Universities Press. Khan, M. (1963). Silence as Communication. In M. Khan, Privacy of the Self. London, Hogarth Press. Kristeva, J. (1995). New Maladies of the Soul. New York, Columbia University Press. Kristeva, J. (2010). Hatred and Forgiveness. New York, Columbia University Press. Lewis, A. (1990a). Free Association and Changing Models of Mind. Journal of the American Academy of Psychoanalysis 18 (3): 439–459.

5  Speech and silence in psychotherapy  157 Lewis, A. (1990b). One-Person and Two-Person Psychologies and the Method of Psycho­ analysis. Journal of Psychoanalytic Psychology 7 (4): 475–485. Lewis, B. F. (1977). Group Silences. Small Group Behaviour 8 (1): 109–120. Neeld, R. (1999). The Group as Auxiliary Ego. Theory Paper for Qualification. Institute of Group Analysis, London. Nuytten, B. (Writer/Director). (1988). Camille Claudel [Motion picture]. USA. Perovšek Solinc, N. (2002). The Difficult Patient in the Group. Clinical paper for the Ljubljana Diploma Course in Group Analysis and the Overseas Diploma of the Institute of Group Analysis, London. Schlapobersky, J. (1996). Forensic Psychotherapy: A Group-Analytic Perspective – From the Speech of Hands to the Language of Words. In C. Cordess and M. Cox (Eds.), Crime, Psychodynamics and the Offender Patient. London, Jessica Kingsley Press, pp. 227–243. Simon, P. (1965). The Sound of Silence from Wednesday Morning at 3.00 am, Studio Album. New York, Columbia Records. Slavson, S. (1940). Group Psychotherapy. Mental Hygiene 24: 36–49 and (1953). Analytic Group Psychotherapy. New York, Columbia University Press. Slavson, S. R. (1966). The Phenomenology and Dynamics of Silence in Psychotherapy Groups. International Journal of Group Psychotherapy 16: 395–404. Tchaikovsky, P. I. (1878). Letter to Nadezhda von Meck of 17 February/1 March 1878 about his Fourth Symphony: http://wiki.tchaikovsky-research net/wiki/Symphony_ No._4#ref38 Urlić, I. (2010). The Phenomenon of Silence. A Group-Analytic Exploration of Meanings in Psychotherapy and Everyday Life. Group Analysis 43 (3): 337–353. Weisman, A. D. (1955). Silence and Psychotherapy. Psychiatry 18: 241–260. Whitaker, D.S. (1985). Using Groups to Help People. London, Routledge. Winnicott, D. W. (1951; 1978). Transitional Objects and Transitional Phenomena. International Journal of Psycho-Analysis, 34. In D. W. Winnicott, Through Paediatrics to Psycho-Analysis. London, Hogarth Press, pp. 229–242. Reissued in D. W. Winnicott, Playing and Reality. London, Routledge, 1991, pp. 1–34. Yalom, I., and Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy 5th Edition. New York, Basic Books.

Acknowledgements:  ‘To Make a Prairie’ by Emily Dickinson from The Complete Poems of Emily Dickinson. Boston: Little, Brown, 1924; reproduced with permission from Bartleby.com, 2000. www.bartleby.com/113/; lyrics from ‘The Sounds of Silence’ by Paul Simon, 1965; reproduced with permission from Universal Music Publishing; extract from Brooks (2009), The Othering of Silence in Groups. MSc Dissertation, Institute of Group Analysis, London/Birkbeck College University of London, with permission from Frederica Brooks; Table 5.1 reproduced with permission from Ray Haddock.

Chapter 6

The range of applications in ten studies Duration, frequency, setting Study 4 contributed by Gwen Adshead

As far as the group is concerned, each individual member is actively brought up against what I have called for our purposes the first basic problem of social life: his relationship to other people and to the group as a whole. He has to solve this actively. (Foulkes 1964:58)

Group-analytic psychotherapy can be open ended, may be time limited and can be brief. Basic distinctions allow a wide range of applications. There are open and closed groups, open groups that can be fast or slow, mixed and homogeneous groups, once-weekly, twice-weekly and more intensive open groups, combined and conjoint groups and block groups. Therapy can be offered as a concentrated block of sessions meeting periodically or on an on-going basis through the week. On-going groups can meet fortnightly, weekly or more intensively, twice or even three times weekly. Groups are available in private practice or in public health facilities located in out-patient or in-patient settings where they are often key resources in therapeutic communities. Groups may cater for people from one gender, for a homogeneous age range like children, adolescents or the elderly or for a homogeneous problem range like those with eating or addiction disorders, cancer, forensic problems or for traumatised refugees. Groups in this homogeneous form allow therapy to be offered to wider populations than previously considered for psychotherapy, some of whose issues place them outside the range of normal social experience, and they thus require a customised approach. Homogeneous groups are also offered to students in university health services and psychotherapists training in block groups. The vignettes that illustrate this book are drawn from the range of my own practice and – with their consent – from the work of colleagues and supervisees. I have worked with groups in in-patient and out-patient psychiatric settings in the National Health Service (NHS), in voluntary agencies with populations with special needs, in private practice and in psychotherapy training programmes and conferences. Where the setting or context is relevant to the vignette this is given

6  The range of applications  159

at its outset. Most of the vignettes are presented independently of the setting to concentrate on the model and emphasise its wider relevance. The attempt to make this book widely relevant follows Whitaker, who describes how, in writing her book about Using Groups to Help People, ‘it was necessary to devise a framework which could encompass a considerable diversity of patient and client populations, a wide range of work settings, and a range of professional backgrounds’ (Whitaker 1985:ix, x). This book will not be considering agency setting, special population need or context. A study of these crucial applications of practice will follow in another volume. This chapter traces current practice through 10 clinical applications that are intended to be representative. Foulkes’s primary recommendation was for mixed groups where possible. With heterodoxy built into their membership mixed groups can bring people together from a wide range of backgrounds or generations, even when there is a defined presenting problem like mental illness. Therapy is grounded in the first challenge its members have to face  – dealing with difference. When people discover their own kinds of problems in the lives of others whose circumstances may be very different, then the relief – what Yalom calls universality – can often provide the first source of hope. The subject of hope is discussed in the introduction. Foulkes invites us into ‘the group-analytic situation’ by emphasising its ‘peculiar features’ – being ‘composed of members who are particularly disturbed in their relationship to others’ and who – on meeting – ‘have no other object beyond that of dealing with their disturbances’ (Foulkes 1964:54). He emphasises what he calls the first basic problem of social life – people dealing with their relations with one another and with the group as a whole. Each person in the group ‘has to solve this actively’ (Foulkes 1964:58). Group structure, composition and membership are guided by the practicalities of ensuring viability for meeting this first basic problem in a process that will come to look like this: The group borrows, at first, strength from the leader’s authority and tends to integrate through him. This preliminary integration rests on immature . . . grounds . . . counteract(ing) mature . . . group-centred integration . . . As conductor, the therapist supports this group-centred integration directly . . . As the group becomes stronger and can integrate better on its own, it is less . . . in need of borrowing strength. Once the decrescendo move in the authority of the leader has set in, the weaning from the leader’s authority lends indirect support to the positive integration of the group. (Foulkes 1964:63) Across the spectrum there is a core set of principles summarised by Weegmann (2014:11) as the simultaneous presence of vertical and horizontal depth that allows the group to ‘replace the leader’s authority’ with its own as the conductor changes from being ‘a leader of the group to a leader in the group’ (Foulkes 1964:63). The model is versatile – significant changes can take place in a patient

160  I Foundations

population in just 20 or 30 sessions, and vignettes 11.3 and 13.7 demonstrate how significant change can take place in a population of health professionals at a conference in just four sessions.

Ten studies This chapter explores range, diversity and history by describing 10 studies that help define key applications. It will describe their evolution and show how these applications are put to work. They include short-term once-weekly homogeneous groups, once-weekly and twice-weekly slow-open groups conducted on an on-going basis and block groups conducted in training programmes or offered as a ‘stand-alone’ therapy. The literature for these applications is discussed, and where there is an evidence base for its benefits this is brought forward together with available measures that help evaluate the work. Eight of the studies are in public service and two in private practice. The first two public-service studies are devoted to mixed groups in out-patient psychiatric services, one in the UK in 1975 and the other in Norway in 2012. The period of some 40 years between is represented by six studies of homogeneous groups to meet special need in particular settings. The first three are in forensic psychotherapy, first at the Henderson Hospital, then at Broadmoor Hospital and then at the Portman Clinic. Three further studies of homogeneous groups include one for refugee men, one for adult female survivors of child sexual abuse and one for people in out-patient hospital care with severe psychosomatic illness. The two concluding studies are devoted to mixed groups in my own private practice. One studies block group therapy – including blocks in psychotherapy training – and the other studies twice-weekly slow-open groups.

Two applications contrasted: Slow-open and time limited Differences between two primary forms of group-analytic psychotherapy are contrasted to see what implications structural difference will have for the other core dimensions of a group – its process and content. A slow-open group can have a lifespan measured in decades with a passing membership of people, each of whom will stay for a period of time determined by need. A closed, time-limited group will start with a defined membership and is planned to end for all its members at the same time. The empty places created by those who drop out may not be filled during its lifetime. In slow-open groups the development process will be informed by people’s arrivals and departures in their shared experience of attachment, growth, differentiation and loss built into the process. At any stage in time except for its outset, members will be at different points in their therapeutic progress and, working together, they create a resource that comes to feel more like a family or psychological ‘home’ with ‘old’ and ‘young’ sharing the same space. The emerging depth and the intimacy of these

6  The range of applications  161

bonds can be so transformative that the significance of people’s presenting problems recedes as they emerge looking at their lives anew. The day on which a long-standing member leaves or a newcomer arrives is always an occasion. This is as true for private practice as it is in the slow-open groups of mixed men and women meeting weekly at the Portman Clinic or three times a week at Grendon or the Henderson Hospital in Surrey which formed the heart of their therapeutic community. All groups take on an identity as a whole at the outset. Even in a closed, time-limited group, members will inevitably differentiate during the sessions and spread out in their progress. In a time-limited group all its members will stand in an equivalent relation to the receding moment of the group’s beginning and to its approaching end. Members’ issues arising out of their first engagement, later out of termination – and everything in between – are faced together. By contrast, once a slow-open group is established the arising beginning and ending issues affect each individual’s progress as people come and go in their own time. Given these structural differences, is it inevitable that the process dynamics and the content of two such groups will also be different? Will the structure of a slow-open group generate a matrix that differs from a closed, time-limited group in which the development process takes a more uniform course for a membership who begin and should end together? This will be looked at in Section II, which considers the relationship between structure, process and content. My purpose here is to establish how different forms of group-analytic psychotherapy are defined and how they compare with one another.

Originating terms, definitions and literature Definitions: Open, closed, slow-open, mixed, homogeneous, block, combined and conjoint Open, closed, slow-open The terms and literature in practice go back to Foulkes. He defined an open group as One in which the composition changes while the Group as a whole carries on. Individuals come new into it from time to time, others leaving the Group on their own individual merits’. (Foulkes 1948:41) A ‘closed’ group stays together in the same composition once formed and is intended to finish together. A slow-open group is one in which a long-term stable membership makes up two thirds of the population ‘with slow changes on its fringes’. (Foulkes 1948:41)

162  I Foundations

Combined and conjoint A combined group can be open or closed, mixed or homogeneous, providing regular group sessions combined with individual sessions for each member on a regular basis, with the same therapist. This combined model fell into disuse in Europe, but Ormont, Foulkes’s New York-based colleague, took it up later. He took the term combined from Foulkes and augmented it with conjoint to differentiate between the first case where one conductor sees group members outside for individual sessions and the second where all the group members see an outside conductor for their parallel individual sessions (Ormont 1992, 2001). Mixed (heterogeneous) and homogeneous groups: Foulkes’s first book Foulkes developed the use of mixed, slow-open groups working first in Exeter in the early years of World War II and then immediately after the war at St. Bartholomew’s Hospital London. Between these developments he established closed homogeneous groups for a resident population of servicemen brought out of active service for a range of psychological problems, and he became the ‘architect’ of the second experiment at Northfield Military Hospital where, between March 1943 and December 1946, group therapy was first established as a hospital resource. His first book describing these years was published in 1948 (Foulkes 1948:42–54; Harrison 2000). Slow-open groups: Foulkes’s subsequent writing and its wide influence After the war Foulkes consolidated the model of slow-open groups whilst head of the Psychotherapy Department at the Maudsley Hospital and in his private practice established in London from 1950 (Roberts and Pines 1991:32–54). His second book, written with Anthony, was published in 1957 and describes their later development of theory and practice. He then extended once-weekly slow-open groups with a range of colleagues at the Group-Analytic Practice after it was established in 1963. He remained there until his death in 1976 through a period that saw the development of once-weekly and twice-weekly slow-open groups for a mixed population, once-weekly slow-open groups for different kinds of homogeneous populations and couples’ groups conducted by a pair of co-therapists. Foulkes’s two further books published in 1964 and 1975 were written in this period that also saw the creation of the Institutes of Group Analysis and Family Therapy and a range of training programmes under their different auspices. It was a time of collegiate development with notable contributions by others, some of whom became the Founder Members of the Institute of Group Analysis, established on these premises. Skynner then went on to create the Institute of Family Therapy on the same premises with a different network of colleagues. Foulkes’s work also had wide influence in North America through its impact on practitioners as varied

6  The range of applications  163

as Grotjahn in California (Grotjahn 1993:ix; Grotjahn et  al. 1983:4, 13, 221), Scheidlinger in New York (Scheidlinger 1982:67, 76, 100, 111, 190, 217, 247) and Agazarian in her systemic (Agazarian and Peters 1981:20) and Ormont in his psychoanalytic approach (Ormont 1992, 2001; Ormont and Furgeri 2001:355–371). Recent diversification of practice Diversification has seen the intensification of on-going groups. In therapeutic communities and ward-based groups in hospital practice, groups have been conducted more intensively than a once-weekly basis, some of which – using the definitions above – should be called fast-open groups because of the rapid turnover of their members. Some in-patient ward groups have been conducted twice or thrice weekly and others on a daily basis. Unfortunately, the attrition in services for those with acute and chronic need has seen these resources under attack. On the other hand more intensive slow-open groups in private practice, first introduced at the Group Analytic Practice in London in the mid-1960s as described above, continue to flourish. These twice-weekly slow-open groups became a treatment of choice for a wide range of need and are more fully described later.

Once-weekly groups in public health services: Mixed and homogeneous, slow-open and closed Eight landmark studies have been selected to represent the field of group psychotherapy as a resource in public health as it has evolved from 1975 to the pres­ent time. The studies that follow give a representative picture of the field rather than a comprehensive one. The overview begins with Dick’s study of once-weekly mixed groups in out-patient psychiatric services in the UK in 1975 and concludes some 40 years later with Lorentzen’s study of similar services in Norway. The six studies drawn from the years between examine once-weekly groups with clinical populations whose problems put them outside the range of normal social experience and make homogeneous groups the therapy of choice. In Chapter 1 indications and contra-indications for group psychotherapy provide inclusion and exclusion criteria for groups of different kinds. The account given there also makes clear that in clinical practice check lists and categories are of only passing use. Studies are cited there of work with people drawn entirely from those on the exclusion list. With homogeneous groups for special populations the range of potential candidates for groups is much wider. In this chapter six of the ten clinical studies give a representative picture of current group-analytic practice with homogeneous groups in the UK. There is much more extensive work along these lines outside the UK in, for example, the publications of Urlić, and his colleagues describing group work with war trauma in Croatia (Urlić and Tocilj-Šimunković (2009). For reasons of space alone they have not been looked at systematically in this book. Six of these UK studies describe work carried out with populations comprised entirely of people previously thought untreatable in dynamic psychotherapy. Studies 3, 4

164  I Foundations

and 5 describe the model used in forensic work in different settings; Studies 6 and 7 describe the model used in work with survivors of massive trauma; and Study 8 describes the model used in work with the physically ill. Forensic group therapy attempts to help patients find words rather than actions to express impulses and compulsions, either for corrective re-organisation in the future or to help them come to terms with transgressive conduct in the past, including serious capital offences as described in Adshead’s Study 4. A major part of the group’s work is to provide psychic space for perspective, negotiation, recognition, acceptance and verbalization of hurt suffered or afflicted. Sharing the past and present can make it accessible as internalized, persecutory and vengeful monologues are brought into dialogue and discourse. Group work with survivors of trauma is a more recent field in current clinical practice, but recognition of its relevance goes back to Foulkes at Northfield and his originating work with the traumatic sequelae of combat described in the Introduction. The field as it is emerging today has a range of vigorous and extended applications that rely on homogeneous groups. Study 7 describes groups for survivors of sexual abuse, and Study 6 describes groups for survivors of torture and other forms of organized violence. Here groups provide psychotherapy for massive psychic and physical trauma, for problems of displacement and exile and for trans-cultural problems. The diversity of different kinds of groups, including a range of activity, problem-solving and psychodynamic groups described in Chapter 7, ensures that people can be provided with an environment in which they can each realize their own potential for self-healing. Successful programmes are grounded in a commitment to human rights, to teamwork that addresses countertransference issues and to principles of positive intervention to counter emotions of hopelessness and despair. Once-weekly mixed groups in out-patient psychiatric services Studies 1 and 2 below describe groups for populations with mental health problems who are treated in a psychiatric context. Diagnostic categories for Dick’s population are given below. There are descriptions of people with psychiatric problems in mixed groups in Vignettes 2.2, 2.5, 10.9, 12.1, 13.5, 15.3, 16.3, 19.1 and 20.1. Study 1: Dick: Out-patient analytic group psychotherapy: A 10-year study of outcome This landmark early study of analytic group psychotherapy in the NHS over a 10-year period was published first in the British Journal of Psychiatry (Dick 1975) and then in Pines’s Evolution of Group Analysis (Pines 1983). Dick evaluated the work of 11

6  The range of applications  165

therapy groups that she ran providing ninety-three people with up to two years of out-patient group psychotherapy each, based on Foulkes and Anthony’s text that she describes as her ‘benchbook’ (Dick 1975:54, 62). Group therapy was seen to be ‘the end of the therapeutic road’ by those referring as well as by those referred, most of whom were defined by a long history of previous therapeutic failure. She had modest criteria to protect the population’s viability for therapy including: current employment (as housewives or outside the home), local domicile and an upper age limit of 45 to give optimal potential for change. The selection procedure provided a minimum of five preliminary individual sessions focused on symptoms that appeared to be both the cause and effect of their long-standing dependency patient role. They set out to make a therapeutic alliance with the patient, their family, their GP and the helping agencies already involved. The therapeutic ‘contract’ required regular attendance for at least 18 months, group confidentiality, readiness to bring painful material – feelings and life events – to the group, no socialisation between members outside the sessions and cessation of individual contact with the conductor. The groups offered members ‘the possibility of changing from their chronic patienthood status to that of an on-going person’. The objectives of the study were to (1) test the assumption that a closed analytic therapy group has the potential as an agent of positive change for its members, from the status of chronic patienthood to that of an on-going and coping person, independent of the psychiatric services, (2a) to define factors relevant to patients’ suitability for analytic group therapy, (2b) to define group structures suitable for patients conditioned to expect therapeutic failure and (3) to formulate change of stance and attitude and observe whether it is maintained after termination. Patients suffered from the full range of symptoms listed in the Hamilton Anxiety Rating Scale. The symptom most stressed by the patient was accepted as the predominant one. In descending order of frequency these symptoms included depression (40), anxiety (10), phobic anxiety (9), sexual (9), psychosomatic (8), obsessive compulsive problems (6), psychosis (5), aggressive anti-social behaviour (4) and alcoholism (2). The more severe of these problems included psychosis, obsessional compulsive symptoms, sexual difficulties and deviations, uncontrollable antisocial or aggressive behaviour and alcoholism. Thirteen of these people had borderline syndromes including paranoid ideas, delusions and either visual or auditory hallucinations. The group’s phase-specific dynamics are based on Tuckman’s model (Tuckman 1965) with key variations to which she makes her own contribution, which I have tabulated in Table 6.1. Dick’s method of assessing change following group therapy: She brings an ingenuity of simple construction to the evaluation of these groups that serves as a model for what can be achieved and made use of by a practising clinician. Had I been more familiar with Dick’s instrument at the time I was researching my own twice-weekly groups described below, I would have used this instrument myself. In the reported five initial interviews specific areas of disturbance were identified as they relate to eight parameters of the life situation. The parameters are listed in Table 6.2.

166  I Foundations Table 6.1  Dick’s phases in group process and content* Phase Phase name

Prevailing dynamics

1

Magical beginning

Idealisation of conductor and group as the ‘longed-for’ solution

2

Anger and rebellion

When idealisation disappointed and reality of circumstances confronted

3

Depression and hopelessness

Collectively shared despair, increased complaints about group and home, increase in suicidal rumination and threat

4

Overt sibling rivalry

In-group conflict, rivalry and mutual resentments

5

Individuation

Withdrawal of projections, on going individuation, self as separate, relating to one another as individuals

6

Reflections about time Looking back and forwards, appreciating the therapist as an individual, new-found appreciation of reality

7

Mourning and hope

Mourning for the conclusion of good time spent together; leads to mourning about past years; and hope for years to come

* Table 6.1 is adapted from Dick, B. M. (1975; reissued 1983). A Ten-year Study of Out-patient Analytic Group Therapy. Reissued in Pines M. (Ed.) (1983). The Evolution of Group Analysis. London, Routledge, p. 62. Grateful acknowledgements are made here to the editor and publisher.

Table 6.2  Specific areas of disturbance in eight parameters of life situation* 1

Marital

2

Work

3

Sex relationships

4

Physical health

5

Leisure

6

Self-image

7

Self-understanding

8

Symptoms

* Table 6.2 is adapted from Dick, B. M. (1975; reissued 1983). A Ten-year Study of Out-patient Analytic Group Therapy. Reissued in Pines M. (Ed.) (1983). The Evolution of Group Analysis. London, Routledge, p. 64. Grateful acknowledgements are made here to the editor and publisher.

The first three were based on Freud’s description of successful therapeutic outcome – ‘to be able to love and to work’ – described in the introduction to this book. Physical health relates closely to these. Leisure involves the dimension of self-actualisation, as opposed to survival (Goldstein 1939). Prior to therapy distortion and conflict were most marked in the areas of relationships, self-image and

6  The range of applications  167

self-understanding. Effective therapy implied the ability of the patient at the end of the therapy to see himself and others appropriately, in the here and now and free from the transference experience. Symptom evaluation was included specifically to enable patients to evaluate their dependence on psychiatric treatment. The therapist made the rating before the group started in the five individual sessions with the patient’s help. The post-group rating was made at the termination interview by discussion with the patient and through his questionnaire response. Change here was seen to be largely global in character. One parameter would appear to affect another, and throughout, the centrifugal effect of each on all other parameters was marked. All parameters, therefore, received equal ratings. Before the start of the group 93 patients were rated in terms of the acceptability to them of these eight aspects of their experience of themselves. Fifty (53.7 per cent) were rated C (all parameters were unacceptable); only sixteen (17 per cent) were rated above B2. No patient was rated higher than B4 (four parameters acceptable). Ratings at Conclusion of Groups: Seventy patients (75 per cent) were assessed at the termination of the group, and these included 64 who completed the full group life and six others who terminated before the end of the group by agreement with the group and therapist and who had attended more than 30 sessions. Table 6.3 shows the rating of these seventy patients after group therapy. Sixty-seven (90 per cent) were rated above B2 by contrast with 17 per cent who were rated above B2 before group therapy. From Table 6.4 it will be seen that 61 patients (87 per cent) showed positive change, and one patient showed a negative change. Eight showed no change. Change was recorded as equivalent to alteration of three or more points in rating – for example, B2 to B5 or B4 to B1. Table 6.3  Levels of satisfaction/dissatisfaction in eight parameters rated by patient/therapist* Rating

Description

A

All eight parameters of the life situation, as indicated above, acceptable to patient

B7

Seven parameters of the life situation acceptable to the patient

B6

Six parameters of the life situation acceptable to the patient

B5

Five parameters of the life situation acceptable to the patient

B4

Four parameters of the life situation acceptable to the patient

B3

Three parameters of the life situation acceptable to the patient

B2

Two parameters of the life situation acceptable to the patient

B1

One parameter of the life situation acceptable to the patient

C

All parameters of the life situation unacceptable to the patient

* Table 6.3 is adapted from Dick, B. M. (1975; reissued 1983). A Ten-year Study of Out-patient Analytic Group Therapy. Reissued in Pines M. (Ed.) (1983). The Evolution of Group Analysis. London, Routledge, p. 64–5. Grateful acknowledgements are made here to the editor and publisher.

168  I Foundations Table 6.4  Pre- and post-group rating of total series* A

B7

B6

B5

B4

B3

B2

B1

C

Total

6

10

15

12

50

93

Pre-group rating of total series Number of patients

–

–

–

–

Post-group rating of 70 patients (75%) who completed group therapy Number of patients

4

21

18

13

5

 6

 1

–

 2

70

Change** in pre- and post-group rating

Number of patients

Positive change

No change

Negative change

Total

61

8

1

70

*  Table 6.4 is adapted from Table 4.4 in Dick (1975; reissued 1983). A Ten-year Study of Out-patient Analytic Group Therapy. Reissued in Pines (1983). The Evolution of Group Analysis. London, Routledge, p. 66. Grateful acknowledgements are made here to the editor and publisher. **  Change = an alteration of 3 or more points in either direction, e.g. C-B3 or B4-1.

Dick’s evaluations are of startling significance and, though dated and lamentably overlooked, the further use of instruments like hers is critically needed. On returning now to the questions she poses at the outset of the study, a closed analytic therapy group has the potential as an agent of positive change to alter the status of its members from chronic patienthood to on-going and coping people independent of the psychiatric services. Her study defines factors relevant to patients’ suitability for analytic group therapy. It defines group structures suitable for patients conditioned to expect therapeutic failure, and it formulates change of stance and attitude through therapy. The question whether these changes are maintained after termination is not addressed. SOURCE

Dick (1975; reissued 1983) Study 2: Lorentzen: SALT-GAP studies in Norway This study was undertaken in Norway’s community psychiatric services nearly 40 years after Dick by a team of nine experienced conductors all of whom were trained group analysts and each conducted both a short- and long-term group of eight patients. It integrates clinical and research expertise to evaluate the significance of treatment duration. It ‘challenges the misconception that our field lacks empirical evidence’ (Leszcz 2014:viii). His short-term and long-term groupanalytic psychotherapy randomized controlled trial (SALT-GAP) compares two

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treatments. Closed groups were set up to offer once-weekly group therapy for a mixed population of 148 prototypic patients presenting with depression, anxiety and mild to moderate personality disorders – a representative clinical sample referred by community mental health centres or private psychiatrists or psychologists. People were randomly assigned between short-term groups with a duration of 20 sessions and long-term groups with a duration of 80 sessions. The study looked at the process and outcome of 18 groups. The conductors were supervised and monitored, and audio-taped sessions were evaluated after therapy for evaluators to see if the therapists stuck to the treatment guidelines and how competently they carried the therapies through. The other purpose of the study was ‘to try to capture central aspects of the clinical phenomena through the use of theoretically relevant, standardized measures and to relate these to treatment outcome’ (Lorentzen 2014a:xvi). Lorentzen documents what he calls ‘treatment guidelines’ by offering ‘a synopsis of central aspects and a framework for the clinical essentials (of ) . . . group psychotherapy’ (Lorentzen 2014a:xvi). From the Couch to the Circle follows Lorentzen’s account of these central aspects. ‘The group . . . is the actual treatment instrument’, he says, ‘and it is the conductor’s task to involve the group in this process . . . of an investigative therapy’ that seeks to optimize interaction between group members, raise awareness of the group’s dynamics and members’ internal conflicts and eventually contribute to correcting irrational forms of behaviour and problematic patterns in the group and beyond (Lorentzen 2014:3). Methodology focuses on structure, process and content that this book utilises in Section II. His account of common and specific group factors includes some of the concepts explored in Chapter 10. He introduces a catalogue of conductor interventions that he takes on from Roberts and Kennard that is set out in Table 1.4 in Chapter 1 in a form he revised from its original. This conductor’s repertoire is one of the therapeutic features manualised in the preparation of those participating in the study. Two observers independently and blindly listened to recordings of and rated 40 group sessions randomly selected from a pool of 54 that were representative for all conductors. The following questions were posed: 1 Are the therapies group-analytic (psychodynamic?) 2 Is it possible to reliably distinguish between the short-term and long-term format? 3 Are the therapies competently delivered, and are there quality differences between short- and long-term therapies? The evaluators concluded that the two therapies were group-analytic based on three factors in their findings: that work took place with the transference and resistance at both the group and individual levels, that the groups were process oriented and that conductor and group members worked with interpersonal issues. Short-term and long-term groups could be distinguished, as patients in the former had more work done on circumscribed problems and worked more in the here and now, as suggested in treatment manuals. Levels of conductor

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activity were found to be equal between the two groups. And a conductor competence measure was developed with eight items that were rated on the same scale. Competence turned out to be equal in both formats, ranging from moderate to high. Clinically Relevant Evidence: Findings have so far been organised in three areas – treatment outcome, process factors and mechanisms of change. 1 Outcome: They found that ‘the typical patient in the whole group had a significant change in symptoms and psychosocial functioning across the three year study period, but there was not a significant difference in change between the short-term and long-term groups, for the average patient’ (Lorentzen 2014:85). However, when the two kinds of groups were compared on the basis of patients with and without personality disorder, the picture changed. Those with personality disorders had equal change as between the two groups in their first six months, but then those with personality disorder in long-term groups changed significantly more than those with personality disorder in short-term groups. Those with personality disorder will do better in long-term therapy, and those without will do just as well in short-term as in long-term therapy. 2 Group process: They built on the work of Johnson and colleagues (2005), who found that four commonly used group relationship measures (empathy, therapeutic alliance, cohesion and group climate) identify cohesion in groups arising out of structural as well as relational or qualitative factors. Structural components (horizontal as well as vertical) are member–member, member–conductor and member–group relationship. Lorentzen’s study found that member–conductor alliance was most important early in therapy while member–member alliance became more important later in therapy. And they found that relational or qualitative factors in the groups arose out of three independent factors – positive bonding, good working relations and a negative factor made up of avoidance of conflict. 3 Change mechanisms: The study has so far provided only preliminary findings, but these are of interest. Their investigation of negative attributional style allowed them to focus on and measure patients’ tendencies towards self-criticism, self-blaming and their pessimistic outlook on future accomplishments and relationships. They found a significantly larger reduction of this tendency in long-term group patients over the two years, which – they believe – points to ‘change in negative attributional style’ as a probable mechanism of change. They are cautious with their own findings, but we can read into their conclusions much of an empirical kind to validate the scope of this handbook. Their further findings when published will make a welcome contribution to the field. SOURCES

Bakali, Baldwin and Lorentzen (2009), Lorentzen (2000, 2014a), Lorentzen et al. (2002, 2013, 2014)

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Homogeneous groups: Six specialist studies The six following studies take up the extended period of time between Dick’s and Lorentzen’s work. There are many others that could have been considered. Those selected here document the relevance of the group-analytic approach using small groups for patient populations whose needs are outside the range of normal social experience and who are best helped with a customised approach in the specialised setting of a homogeneous group. Study 3: Small groups in therapeutic communities: The Henderson Hospital and its offspring – Grendon, Main House and Webb House: Their continuation, demise and legacy Maxwell Jones was the first director of the Henderson Hospital which began as a rehabilitation unit for WWII veterans in 1947. Its evolving model of therapeutic rehabilitation is described in a renowned book by Rapoport, Community as Doctor (1960). It described milieu therapy for people with severe personality disorder with co-occurring disorders like mental illness and addiction. The milieu ‘is focal within the Unit (and) total . . . every aspect of hospital life is regarded as relevant and potentially therapeutic . . . the term “therapeutic community” is used to denote the total hospital (Unit) involvement in the treatment enterprise’ (Rapoport 1960:270). The ‘four major themes (that) comprise the core of the Unit ideology’ have gone down in clinical history as emblems for this kind of work: ‘rehabilitation through reality confrontation; democratization; permissiveness; and communalism’ (op cit.:270). The milieu and each of its now celebrated themes rely on groups. For over 60 years the Henderson, based in Sutton South West London was staffed by generations of committed clinicians many of whom passed through a group-analytic training before or after their involvement there. They saw progress with a most challenging population and ‘produced research and clinical papers on personality disorders and associated issues (and) contributed to training by providing study days, welcoming visitors on a weekly basis and . . . organising conferences on self-harm’ (Warren and Dolan 2001:1). Whitely, the second director, describes how ‘the various Henderson studies . . . identify a group . . . neither distinctly criminal nor obviously mentally ill but presenting a problem of management for both penal and medical services (who) . . . respond well to the blend of sociotherapy and psychotherapy which has evolved’ (Whitely 1980/2001:7). Threats to the integrity of the service have been a consistent feature of social policy. Whitely writes of the irony that, as the first issue of the International Journal of Therapeutic Communities goes to press and Henderson is honoured . . . to be the first therapeutic community to assess its work and influence in world psychiatry, that it is once more under threat of closure. (1980/2001:7)

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It survived at that point in 1980 and then – for a time – went on to further development. Government investigators in the UK, noting the dearth of services for this population, called in 1993 for ‘more specialist units comparable to Henderson Hospital’, which had by then developed a local outreach service (Warren and Dolan 2001:1). Recommendations progressed to ‘replicate this treatment model in the Midlands and the North West of England and new therapeutic communities, Main House and Webb House, and their associated outreach services opened in . . . 2000’ (Warren and Dolan 2001:2). Just seven years later the Henderson was closed. Main House and Webb House followed with closures in 2010. The declared grounds for closure were financial, but the reasons remain incomprehensible on any rational appraisal of service need. Society’s terms of ambivalence for and against an effective group approach to this population are visible in even this brief outline. The Henderson model was well established as the therapy of choice for some of ‘the hardest to treat’ and served the wider field by meeting ‘continual requests for day visits . . . and training . . . which are testaments to the ongoing need for training and services for this client group’ (Warren and Dolan 2001:1). Adlam and his colleagues describe the therapeutic milieu under fire for reasons that have no rational or objective foundation (Adlam et al. 2012). In seeking reasons for the destruction of these institutions we must look to deeper and darker explanations than financial ones and must infer these are invisibly lodged in the wider institutional and political context. Nitsun points us towards some of these issues in the quotation from his Antigroup that opens Chapter 7. Main applied the term ‘therapeutic community; to therapeutic rehabilitation with servicemen at Northfield during WWII. At the Henderson his ‘concept of a “culture of enquiry” is amplified’ (Norton 1992a/2001:43). Norton, their most recent director, writes about how ‘culture and structure are described in their interaction and in their combined effect to produce therapeutic change’ (Norton 1992b/2001:43). He describes how ‘the whole treatment programme can be conceived as a single analytic session with staff involved in a continuous transference-countertransference situation’ (Norton op cit.:47). The culture of enquiry is maintained through a highly structured programme in which Norton describes ‘nurturing engagement’ as ‘a paramount concern’ (op cit.:31) and indicates the centrality of small group psychotherapy. The small groups were situated in a highly structured residents’ programme involving a daily Community Meeting that took the form of a dynamic large group, followed by the small groups three times weekly. The afternoons were given over to the arts therapies, psychodrama, gardening and maintenance. On the two week-days without small group psychotherapy there were single-gender groups in the afternoons. The literature on their small groups is strangely limited. This may be explained by an early paper by Whitely and Collis (1987) in which they used Bloch’s method of assessing ‘the most important event’ in therapy. Learning from interpersonal actions, acceptance and self-understanding were the most prominent therapeutic factors. However, half of these happened outside the ‘formal therapy’ groups and within the community, emphasising the importance of 24-hour sociotherapy. The

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most promising of their papers on specific aspects of group and therapeutic process are by Collis (1987) on women’s groups and Norton (1998) on joining and leaving. GRENDON, MILLFIELDS AND THE WIDER FIELD

The contribution made by small group psychotherapy to the wider programme of therapeutic communities is better represented in work coming out of other establishments. They include Grendon, a medium-secure prison based on Henderson principles. It has five and sometimes six discrete therapeutic communities within it, each with more than 40 resident prisoners. They recently opened a unit for those with learning disabilities previously excluded from treatment. It is one of the most researched forensic establishments in the world and has established standards for good relationships between staff and residents and low levels of violence and self-harm. Small group psychotherapy run along group-analytic lines is one of its key resources, and studies show lower levels of reoffending for those who stay longer than 18 months (Tucker and Wylie 2006). Newer forensic centres like Millfields Unit at the John Howard Centre also do pioneering work. Their Dangerous and Severe Personality Disorder Programme (DSPD) was introduced in 2004 to assess, manage and treat severely personality disordered individuals who present a high risk of serious offending – a population previously thought untreatable – for whom group-analytic psychotherapy is a key resource (Verebes-Weiss 2011). SOURCES

Campling and Haigh (1998/2002), Collis (1987), Haigh (1998/2002) in Campling and Haigh (1998/2002:246–257), Jones (2004), Kennard and Haigh (2009), Norton (1998), Parker (2006), Tucker and Wylie (2006), Verebes-Weiss (2011) Study 4: Small group psychotherapy for people with a history of homicide: Written by Gwen Adshead and describing her work at Broadmoor Hospital (maximum security) 1 In 2003 the Centralised Groupwork service at Broadmoor Hospital initiated psychodynamic therapy groups for people who had killed someone close to them when they (the perpetrators) were mentally unwell. These groups were based on the pioneering work of Murray Cox, who introduced psychodynamic groups at Broadmoor, and that of Marc Hillbrand and John Young at Yale, who set up a therapy group for people who had killed a parent. The Homicide group was intended to be complementary to the cognitive behavioural parts of the risk-reduction programmes offered to patients and was also seen to be part of the rehabilitation and recovery programme offered to all patients. A second group was started in 2010 for patients who had killed a stranger when mentally ill.

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Within a traditional dynamic group therapy format the therapists were explicit about the importance of each group member’s personal ‘story’ about their offence, a story that might change over time as he (all the patients are male) came to let himself think more about his offence and how it had affected him and others around him. The therapists held in mind the concept of a ‘cover story’ (Adshead 2011) that might alter as therapy progressed, so that the ‘story’ of what took place would become deeper, ‘thicker’ and more nuanced. A key aspect of any therapy for offenders is the narrative move to agency and ownership of responsibility. Typically group members start by locating responsibility for their violence in their illness or some other ‘force’ but then come to accept their own agency for their offence, however mistaken. Therapists are also interested in the move from an incoherent narrative (the voices made me do it) to a more coherent narrative that not only articulates a sense of agency but also expresses an understanding of the impact of homicide from a wider perspective than their own. This group has had high attendance rates with few drop-outs. Most men stay in the group until they leave hospital. As in many psychodynamic groups evaluation has been complex, as there is no single discrete outcome to be aimed for, and progress is idiosyncratic. Group members have talked positively about their experience in the group, especially the sense of how the group reduces their feelings of social isolation. A study by Ferrito and colleagues (2012) looked at how group members talked about the redemptive possibilities of life after homicide and their wish that they might be able to ‘make good’ in the future. In a recent review (Adshead, Ferrito and Bose 2015), we explored the extent to which group members can demonstrate that they have ‘come to terms with their offence’: a concept which is important in the recovery process. What we have found is that the Homicide groups become a place where, in a safe and pro-social way, members can explore their identity as people who have killed and where they use dialogue to try and understand the challenge of living with having done something terrible. In his 1990 Foulkes Lecture, Murray Cox described the process whereby participants in psychotherapy groups ‘go deep’ into levels of the conscious and unconscious mind. In the process of doing so they can bring themselves to a point of asking ultimate questions: Who am I? Where am I going? What do I seek? He made reference to Paul Tillich’s concept of ‘ultimate concerns’ and emphasised how relevant this is to offenders, but he also points out that this process of exploration of ultimate concerns can be painful for offender patients. Quoting Macbeth, Cox reminds therapists who work with offenders that such men have ‘naked frailties, that suffer in exposure’, these ‘frailties’ must be ‘hidden’ (or invisibly contained and supported by the group) before any process of ‘questioning a bloody piece of work’ can begin. As therapists in these Homicide groups, we have heard men exploring questions of ultimate concern, such as ‘Can I be forgiven?’, ‘Is there life after death?’ and ‘I do not know if I feel remorse’. We are often asked how we feel about hearing such questions and how we respond to the men in the group. Although

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initially, the therapists were disconcerted by the awareness of sitting with people who had killed, it quickly became clear that these were men seeking therapy in the aftermath of a disaster where they were the disaster. Their murderousness had not only ended someone else’s life, it had also ended their former lives and eradicated their identities as ordinary people forever. What is present in the groups is not fear and threat but a deep sense of sadness and regret and a grim awareness of how hard the road is that lies ahead. As therapists, what we have noticed is how hard it is to know what to say to questions of ultimate concern and how important it is to be authentic and honest about our limitations and ignorance. Ultimately, all we can do is keep the men company on their journey along a via dolorosa and hope that they will find a way of being in the world that is both hopeful and regretful in equal measure. SOURCES

Adshead (2011), Adshead, Ferrito and Bose (2015), Ferrito, Vetere, Adshead and Moore (2012), Hillbrand and Young (2004) Study 5: Forensic group psychotherapy for people with deviant or anti-social sexuality: Work at the Portman Clinic, London Forensic psychotherapy is ‘the offspring of psychoanalytic psychotherapy and forensic psychiatry’ (Welldon 2012:39). Its development in the UK owes much to the pioneering work of Cox at Broadmoor Hospital and Welldon at the Portman Clinic. Since its inception in 1931 the Portman, an ‘outpatient setting within the Tavistock & Portman NHS Foundation Trust . . . has provided psychodynamic treatment to people of all ages who have difficulties arising from their criminal, violent, or sexually deviant behaviour’ (Woods and Williams 2014:xix). They describe their work as ‘a complex therapy . . . that has to take into account not only the individual patient’s needs, but also the impact of the patient’s behaviour on others’ (Woods and Williams 2014:xx). In the 1970s Welldon introduced group-analytic psychotherapy there that she later described in her landmark paper as ‘frequently the best form of treatment, not only for severely disturbed perverse patients but also for sexual abusers and sexually abused patients’ (Welldon 1996:63). By the time of the publication of Woods and Williams’s recent book about their work, group treatment at the Portman had become ‘an effective form of psychotherapy not for all but perhaps the majority of our patients’ (Woods 2014:3). At the time this book went to press Woods gave the numbers for people in treatment as follows: 122 patients, 54 (44.3 per cent) of whom are individual patients, 66 (54.1 per cent) are in groups and two (1.6 percent) are in couples’ therapy (personal communication). Woods and Williams describe how ‘joining a group of strangers might seem a daunting task’ but they record how they are ‘often surprised by the willingness of patients to overcome their sense of shame and fear of exposure, and begin to take

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responsibility’ (2014:xv, xvi). A group comprised of people with similar problems also seeking recovery ‘may be less threatening than a one-to-one therapy’ and there is often a hope that the group will create a new reality, although a process of disillusion might ensure . . . each individual gets to understand their personal story better and begins to create . . . a new narrative about their harmful and harmed self, in relation to others. (2014:xvi) They describe an interplay between internal and external reality in which ‘the group presents for each member the possibility of new norms, new boundaries and expectations’ (2014:xvi). The work is rooted in the recognition they describe that: Breaches of normative social boundaries . . . affect both the individual and society. For the individual, there is the harm that he or she has done, and in the background inevitably, also the damage from the trauma, neglect or actual abuse committed against him or her. For society, there is the responsibility for having allowed it. Winnicott’s concept of the antisocial tendency shows how the damaged individual brings attention to the ill he has suffered in the hope (perhaps often futile) of some recompense (1956). A social form of treatment symbolises this lifelong drama and might enable an individual to work through his conflict with other people. (Woods and Williams 2014:xv) The discussion that follows is focussed by attention to the aims of therapy, the purposes of the group, its forensic focus, the role of the therapist, the activity of the group, resolving inhibitions in the capacity to mentalise and thus reduce the pressure to act and the development of symbolic meaning in the culture of the group. Woods describes how the work begins ‘in the benefit  .  .  . derived from sharing their experiences’ amongst others with similar problems. ‘The immediate result is to reduce the shame and sense of isolation with which (they) have been burdened, in many cases, for years’ (Woods 2014:12). Group therapists tend to work without ‘curative’ aims but, rather, with the notion of gradual change ‘at the patient’s own pace (that) puts the individual in a more autonomous position’ (Woods 2014:11–12). They rely on a notion introduced by Garland as ‘taking the non-problem seriously’ (Garland 1982) that allows the group to go beyond the presenting problem ‘that fades into the background as the foreground is occupied by those aspects of the personality and behaviour that have an impact on other members of the group’ through which ‘an individual may be released from his repetitive and self-destructive mode of being’ (Woods 2014:12). The forensic focus is maintained by knowledge held in the group that each of its members has acted in breach of either the law or social boundaries in which they have been responsible for the suffering of others. So the group’s members are not only conflicted internally but are transgressive externally. In helping members face these realities, the group therapist ‘stands for reality and truth, in opposition to

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the illusions and deceptions of perversion’ (2014:14) and provides a modelling function to ‘helpfully demonstrate actively, the ways in which a group member interacts and responds to the communication of others’ (2014:15) in the here and now of the group. He describes how their ‘aim here is to promote engagement, something that would be inhibited by interpretations . . .’ (2014:15), in order to foster recognition, belonging and emotional support. The therapeutic culture of a group at work – guided by a therapist’s understanding of its members’ core complexes – will come to explore the addictive nature of sexual compulsions that are driven by attempted solutions to the problems of early injury that do not work. An understanding of core complex is a key to therapeutic work in this field, as it is of general relevance in all psychotherapy practice. The notion has its origins in the early work of Glasser, who was one of the Portman’s early directors (Glasser 1964), and it is now widely used in psychotherapy practice. The sexualisation of social relations and the sadism and masochism found in a forensic population and beyond ‘are used in varying degrees . . . to maintain an illusion of power and to triumph over and protect against, fears of loss. This pattern is seen time and again in our patients and produces distortions in everyday relationships which will also be evident in the group’ which is where they are addressed (2014:20). Woods describes the therapeutic process generating boundaries for its members that they can internalise and own, through which they can then arrive at a state of feeling for themselves and think about themselves and others without being driven to act. Symbolic meaning is the later ‘prize’ of this process, through which ‘the unattainable object may be represented and internalised, instead of becoming persecutory by its absence’ and ‘terrors of the past’ including trauma and early injury may finally be faced (2014:24). In this recent book by Woods and Williams the chapter by Williams and Zachary on containing structures provides the most helpful introductory reading to the practice of forensic group psychotherapy. It is focussed on holding, containment and the essential institutional structures that make the work possible. SOURCES

Garland (1982), Glasser (1964) in Rosen (1998), Schlapobersky (1996), Woods and Williams (2014), Woods (2014), Williams and Zachary (2014), Welldon (1996), Welldon (2012), Winnicott (1956/1958), Winnicott (1958), Yakely (2010) Study 6: Small group psychotherapy with survivors of organised violence: John Schlapobersky MASSIVE PSYCHIC TRAUMA AMONGST REFUGEES

The Medical Foundation for Victims of Torture, known now as Freedom From Torture, was established as an agency in the voluntary sector in 1985/1986 to provide therapeutic rehabilitation for survivors of organised violence. A group analyst was appointed as its first consultant psychotherapist, and I established adult

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groups from its outset. With the later creation of a children’s department groups became available for children and adolescents. Group work provides a therapy of choice for refugees from many troubled countries, or a complementary therapy running parallel with other interventions. Groups are successfully deployed for adults and children, men and women, those with English and those who speak in their mother tongue, those who can talk and those who will not, those with and without insight, victims of sexual violation and the physically ill, for victims only, and for those who were also perpetrators, those in current crisis and for the late sequelae of trauma. A comprehensive programme ensures that people with different needs can be offered a suitable therapeutic environment and is differentiated between three broad group work categories each informed by group analysis in a different way – activity and orientation, problem solving/support and psychodynamic. The programme is governed by the following principles: Group work provides therapy for (1) massive psychic and physical trauma, (2) problems of displacement and exile and (3) trans-cultural problems that often require the use of interpreters. The group-analytic model adopted provides a holistic clinical frame by (a) recognising the needs of the whole person, (b) providing a relational focus in and beyond the groups and (c) seeking change through the ordinary language of these groups in the free exchange of their members. Although group work is not a cheap resource it is by definition time and cost effective, and its principles will have general relevance for clinicians working with people in other critical transitions. Work of this kind is now on offer in other related centres like the Helen Bamber Foundation and in NHS centres like the Traumatic Stress Clinic at University College Hospital London and the Greater Glasgow & Clyde Service for Asylum Seekers and Refugees called the Compass Team (Douglas 2010a, 2010b). KEY ISSUES OF CONCERN

I first described these principles in a paper written for the Foundation with its pioneering founder Helen Bamber. They have evolved over some three decades and are now put to use in many other centres that do work of this kind. Illustrations of this work will be found in Vignettes 0.3, 2.1 and 10.8, with their associated commentaries. Bearing witness  A small group of suffering people can help relieve the problems for each. Members who may have lost just about everything – loved ones, relatives, health, home and country – can discover they have a lot to give each other. Generosity is the key. Though preoccupied with their own losses they can – through identification and compassion – rediscover their dignity as they discover their own problems in the lives of others. Generosity emerges as a quality they have not lost, and from this discovery they can begin to rebuild their worlds. The testimony they provide in the process of bearing witness carries a

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responsibility towards their past that can give them new keys to adjustment for creating a future. The recounting of narrative and people’s stories of loss and survival are at the core of a group’s life. Group psychotherapy becomes testimony with its own evidential content in the narrative that gives the group a role like the oral historian. Finding a voice  When people discover a voice with which to speak for themselves they can recover from the consequences of torture, entitlement to a lifespan that the process was intended to destroy. People driven to the edge of human experience can bear witness to one another’s testimony that can allow them to reclaim their common humanity. The concept of ‘cure’ is inappropriate. Post-­ traumatic sequelae are not only the conditions of illness but are, much more, forms of bondage through which perpetrators ensure their interventions last over time. The rehabilitative aim is centred on the purpose of freeing survivors rather than ‘curing’ them. Gravity of injury  Group work based on the group-analytic model can be undertaken with those at the extreme end of suffering. Those included have been physically mutilated, multiply bereaved, have witnessed grotesque death and were sometimes sole survivors of communities subjected to mass murder. The group members included those who underwent human rights abuses involving grave atrocity, who continued to suffer from serious physical and mental consequences, whose lives were complicated by illness or disability and who showed evidence of both need for and capacity to benefit from psychological help. The principle of positive intervention  The damage people came with was, in many respects, profound, but as in almost such cases, there was something constructive to be done. This principle helped to see members through a wide range of medical care and provided support through concurrent bereavements amongst relatives in their countries of origin. Through adversities and stresses therapy groups become people’s weekly point of coherence, the place of reckoning and the forum for relief and understanding. One compared it to the laundrette described in Vignette 0.3, but here the washing, cleaning and the drying cleaned out his mind – he said – and gave him hope and balance for the week. Sanctuary from fear  As people’s asylum applications progress, in some case to successful resolution and in others not, these groups became strengthened as places in which their members could test out continuing sources of fear and anxiety, and they could do so without the fear of retaliatory damage. Resilience in adversity  Ordinary social relationships contain those agencies for change that can, when tapped, release profound self-healing, regenerative

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resources. Groups provide an environment in which members can realise this potential. Resilience in adversity is not only a strategy for coping but also a creative challenge. Survivors’ developmental history, cognitive set, attachment and affectional base, relationship network and prior experience of mastery and self-confidence through challenge and adaptation are all determining factors in their reactions to massive trauma. We find it essential to make contact with people’s prior forms of adjustment and use groups to re-activate internal and adaptive strategies for further recovery. SOURCES

Baraitser and Melzak (2014), Blackwell (2005), Callaghan (1993, 1996), Douglas (2010a, 2010b), Schlapobersky and Bamber (1988), Schlapobersky (1993, 2005), Tucker (2004), Tucker and Price (2007), Tucker (2011), Woodcock (1977) Study 7: Small group psychotherapy for female adult survivors of child sexual abuse: Monica Doran Group-analytic psychotherapy for adults with histories of child sexual abuse has long been one of its most important applications. Hall has documented work of this kind (Hall 1992; Hall and King 1997), and the Womens Therapy Centre in London has been running groups since 1976, where the group-analytic contribution has always been significant. Women with histories of child sexual abuse are widely represented in a general psychotherapy population, as would be expected with such a high incidence of the problem in society. The incidence is documented in both the studies that follow. Work of this kind in mixed groups is described throughout this book in Vignettes 1.2, 4.2, 13.4, 14.1 and 15.2. Emerging practice favours the use of homogeneous groups for people’s opening experience of therapy followed where necessary by longer-term work in mixed groups. What follows summarises the clinical study by Doran in 2001 based on work in NHS psychotherapy services. Tyerman’s work, cited below, illustrates a similar short-term group project in an NHS setting with a more diverse population. Doran provided a short-term, 30-session group for women who suffered childhood sexual abuse, either by family members or by staff during their time in residential care. Doran documents her own first encounter with her group – they all had periods of preparatory individual therapy with her – involving surprise, fear, sadness and a determination ‘to explore how the group-analytic experience can contribute to the healing process’ (Doran 2001:1). At the outset members’ participation was compromised in ways that affected first their basic attendance, which was irregular or unreliable, then in difficulties with participation and then in the terms in which they related to others in the group that were distorted by deficits in their sense of self. Doran describes how ‘I had a group of individuals sitting looking at each other, talking but not

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sharing, speaking and not listening, attending but not feeling held, hearing but not responding’ (Doran 2001:2). During the group’s formative period the conditions for effective therapy – what is referred to in Chapter 2 as the relational dimension of therapy – were forestalled by members’ early inexperience of attachment and care. They could hardly relate to one another. With some progress, as ‘emotions were expressed, heard and the pain of others tolerated, the matrix began to take on these essential maternal qualities’. Doran goes on to describe how, through the attachment and sense of belonging experienced by all . . . the matrix takes on a maternal role through which (they) are able to begin the process of individuation and find a sense of themselves beyond the identity of someone who has been abused as a child. (Doran 2001:4) Members’ developmental histories were marred by transience of both location and attachment, and the pervasive sense of neglect left them with an overvaluation of idealised mother figures and underlying rage against the real mothers in whose care they suffered. The known sequelae of childhood sexual abuse involving a close association between love, pain, shame and humiliation, produced fragile dissociative defences, over-dependency in their ties to unsuitable partners and a ‘prostitute-nun’ dichotomy in their sexual makeup as adults, resulting in either compulsive promiscuity or complete renunciation of sexuality. Their emerging stories in the groups created selfhood out of dialogue as follows: By the outrage and concern for their fellow members, individuals . . . can begin to see their own experiences in objective terms and to locate blame and responsibility with the perpetrators, releasing themselves from their cells of blame and shame . . . This mirroring . . . is a core ingredient . . . as value and self worth is given and taken back, seen and reflected back. Those most difficult and unspeakable parts of the individuals’ experience are exchanged with one another, they resonate with others and find an expression hitherto only expressed in symptoms . . . Reality testing has its place and the individual can explore the difference between psychic and social facts. (Doran 2001:18) Doran studied her group’s dynamics by using a developmental profile that she devised based on the work of this group ‘that describes progressive stages of group development in order that the task or the work of the group can ultimately be achieved’ (Doran 2001:23). She describes the phases of initiation (sessions 1–9), mourning (sessions 7–11), toleration (sessions 10–24), and individuation (sessions 14–30), as approximations and not as a set schematic line. At every point including the group’s concluding session it could return from a more mature to an earlier phase and had then to struggle again with the maturational challenges. Their progression follows its members in stages through the ability to feel,

182  I Foundations

to express their own and feel one another’s sadness and pain, and finally to relate to themselves and each other as whole people rather than as parts. The implications for transference and countertransference are described in Vignette 14.2. Doran demonstrates the consequences of her members’ histories: ‘as infants they were left empty vessels, only to be filled with the abuser to compound the sense of worthlessness and provide an identity based on shame and self hate’ (2001:46). The group-analytic process ‘creates an environment of nurture and care in which a range of feelings can be experienced and expressed, enabling those repressed parts of the psyche to re-emerge’ (2001:46). The group represents a microcosm of society ‘in which the shame has its roots, which becomes so healing for these women. The separation process is thus facilitated: self from others, self from the abuser, and self from society’ (2001:46). SOURCES

Doran (2001), Ganzarain and Buchele (1989), Hall (1992), Hall and King (1997), Trowell and Kolvin (1999a and 1999b), Tyerman (2012) Study 8: Small group psychotherapy for patients with severe psychosomatic illness: Dennis Brown and Catherine Hayes The group-analytic contribution to therapy for those with psychosomatic illness has always been significant. Much of it takes place in mixed groups illustrated through the book in vignettes 0.3, 13.5 and 20.1. In Dick’s study described above, psychosomatic presentations in her patient population were third in frequency, and the steady remission of these symptoms during her groups was a heartening finding. Brown’s more recent contribution to group therapy for psychosomatic conditions has been the most sustained and informative in the field. It is well represented in the first three chapters of his selected papers cited below. What follows here is a single case study based on Brown’s work in which Hayes provides a dedicated group as a vehicle to complete the developmental stages missed or distorted in infancy, for those suffering from psychosomatic illness. Her group was conducted in an NHS psychotherapy service comprised of men and women with psychosomatic conditions that were both chronic and severe. She did not set out to select this population for her group but, in the desperation of their need and chronicity of difficulty, the waiting list provided this selection. They had been reliant for between five and 40 years on secondary mental health services which referred them on. They had all been through at least one CBT programme, and most had passed through groups of other kinds. This was their first experience of group-analytic psychotherapy. Calling on the work done by Brown to recast Winnicott’s ideas in group-analytic terms, she focuses on how the space between people in a group becomes a transitional arena to allow its members to re-work early injury and distortion. A key developmental line in infancy involves transitional phenomena – concrete objects, words and figures of play – that represent the formation of internal structures that enable the child’s use of fantasy and the

6  The range of applications  183

verbal expression of feeling. Those with severe psychosomatic conditions share a history of developmental distortion in their early years through which access to fantasy and the verbal expression of feeling are impaired, and so the body remains the primary site or register for emotion. Developmental problems that maintain psycho-somatisation as a primary register in adult life have other consequences. Her group members had difficulty with subjectivity and inter-subjective relationships, they showed concrete thinking, an inability to use reflective process, an inability to doubt and a seemingly reasonable disposition that was often – as she describes it – ‘aggressively reasonable’. Suffering was expressed through bodily symptoms that included states so serious as paralysis. In this pre-verbal language symptoms functioned as unconscious emblems or signs. Her group members each had one or more of the three types of psychosomatic illness described by Brown: ‘true’ psychosomatic disorders with histopathological changes that are microscopically visible like eczema, colitis or hypertension; disorders of autonomically controlled bodily functions like migraine or irritable bowel syndrome; and conversion symptoms which are ego defences against internal conflicts. At outset her members showed a high level of dissociated activity in superficial exchanges that seemed without depth or development. The initial challenge was the development of trust between each patient and the conductor and in their relations with one another, so ‘that anxiety, pain, helplessness and rage can be tolerated’ (Hayes 2014:21). She cites Brown’s discussion of maternal objects who prevented the emergence of a true self because they were either distant or impinging. Once people were settled in her group these histories emerged and the group became a transitional space to contain and integrate transference experience and facilitate movement from isolation to empathic attunement at whatever pace they could manage, so that levels of bodily and mental functioning could be explored. The group work involved the creation of meaning and the symbolisation of feelings for individuals who somatised distress as they did in early infancy. She locates the originating sources of conversion patterns in the shame and doubt experienced by infants when the platform of trust between mother and child – necessary for healthy development – is missing. Conversion symptoms, she found, provided an adaptive avoidance by generating a mask of other symptoms to help conceal the real shame and doubt that were unendurable at the time and remained so in the present. And she documents a steady progression in people’s group participation resulting from those incidents – in the group and beyond – in which members were able to identify and explore their feelings. She draws on source material in psychoanalytic developmental theory to provide understanding for a population who find it hard to be alone for fear of losing identity and hard to be in exchange for fear of being invaded. And so they create ‘a sense of emptiness which may lead to addictive ways of seeking “transitory objects” in place of “transitional objects” that would have allowed them to represent themselves and communicate symbolically and through play’ (Hayes 2014:2). She differentiates between the primary group tasks they had to face. First, her members needed to find a safe place with enough support to bear the frustration

184  I Foundations

involved in developing an internal structure that would allow them to become separate without automatically shutting down; to be able to contain aggression; learn to doubt themselves; and integrate their original part objects sufficiently well to relate to what they could still hold of their original mother, who may be represented by a mother-substitute, either the conductor or another member of the group. They needed to learn that their desperate need to be attached was not equivalent to being loved. The group-as-a-whole was created in words that were spoken, negotiated, argued over, agreed and disagreed, in which meanings were changed over time and each member’s experience was unique. The group-asa-whole did not come to represent the mother but, rather, the transitional object, the symbol of the mother’s love that can be held onto as support during the process of external separation and internal integration. In the case of people who did not have a transitional experience as a child, this love may be perverse, aggressive or fearful, and the group was there to work these feelings through. The second task they had to face involved the letting go of omnipotent fantasies that had them connected to ‘idealised good breasts’. They needed to be able to look back at themselves from the perspective of the group’s other members and find doubt in their hitherto fixed positions. Doubt enabled them to revise their thoughts in line with reality rather than attempting to hold a distorted version of reality in line with profoundly held beliefs. The primitive defences were slowly given up as they navigated a belated path through the first two developmental steps – of forming an internal concept of the mother alongside their lived experience of her and of being able to tolerate disappointing reality. A well-functioning psyche is dependent on these first steps that are eloquently described in her study. SOURCES

Archer (2005), Brown (2006a, 2006b), Erikson (1950), Foulkes and Anthony (1957), Garland (1982), Hayes (2014), McDougal (1974, 1989), Nitsun (1996), Scott (2011), Winnicott (1953)

Block and twice-weekly groups in private practice Block groups as training resources: Programme development After the institution of twice-weekly groups for the training of group analysts in London and the successful graduation of several cohorts, these graduates joined with their former teachers to develop block training programmes in Continental Europe. Initiatives have taken place over the years at the request of clinicians in Denmark, Germany, Ireland, Israel, Norway, Russia, Serbia, Slovenia and South Africa. Regional training programmes were established on a similar basis within the UK in Bristol, Exeter, Manchester, Turvey and Glasgow. One of these training programmes – Group Analysis South West based in Bristol and Exeter – has

6  The range of applications  185

introduced a further variation with therapy provided in twice-weekly groups and the supervision and teaching provision in blocks – a development that brings together the best of both models. In the block programmes small groups were established as a way of providing the therapeutic requirement in a training that allowed a small team of training group analysts to travel to a centre for a weekend of intensive block group therapy combined with supervision, teaching seminars and large groups. Block groups have grown into a standardised training resource across Europe including regional centres in the UK. Localised training development in other programmes on the European continent has allowed staff in Oslo – for example – to establish a training in nearby Vilnius, Lithuania, and for staff in Germany to establish a training in nearby Kiev, Ukraine. This chapter considers only the therapeutic component in these historical developments. Block groups have also emerged as a stand-alone therapy for people seeking help in private practice, which will be considered later. Block groups in training: Therapeutic process and content Block groups have been conducted in the context of training programmes for almost 30 years. Their conductors are training group analysts, and their participants are psychotherapists in training. The work of these groups and their benefits should constitute a worthwhile field of investigation, but I am not aware of any publications about the therapeutic standing, merit, strengths or weakness of these groups. There may be publications in Danish, German or Norwegian of which I am unaware. At the IGA in London we have trainees who progress to membership through either a block group format through their therapy in Glasgow, Manchester or Turvey or a twice-weekly format in London. Our staff, taking an overview of the work of both sets of graduates, report that their written work on graduation is comparable in all respects. Whether the same is true for their levels of personal adjustment or for the depth and quality of the clinical work they go on to do later remains open for investigation. Studies addressed to these questions are long overdue. Study 9: Block groups in private psychotherapy practice: Therapeutic process and content in mixed, slow-open groups: John Schlapobersky Group analysts have been offering block groups as a primary form of therapy in private practice for the last 20 years, on an occasional basis. I recently established a block programme at the Bloomsbury Practice that is now recruiting for its sixth annual cycle. The group has a regular membership of six or seven people who attend for a range of different reasons. Some seeking reliable psychotherapy have working hours in London that make continuous attendance impossible during the week; some live too far from London to attend for regular sessions; and some come from other countries, including psychotherapists in training seeking

186  I Foundations

further development who wish to learn more about the group-analytic model by going through it. There is a matching programme of block groups in York run in a related fashion and catering for a similar population that is nearly one year old. PROGRAMME OF MEETINGS, COMBINATION WITH INDIVIDUAL PSYCHOTHERAPY AND AUDIT

The group meets for six normal 90-minute sessions in the course of a weekend. The weekends are spaced six to eight weeks apart and are offered six times in the course of a year. The members are free to re-enrol after completing an annual cycle, and those from one cohort are given first option for a place in the next. So the block is conducted on the same slow-open basis as continuous weekly groups, with new members coming in to fill places vacated by those who leave. Blocks of this kind lend themselves to the combined approach, so people who need or choose to do so can attend for individual psychotherapy with me between the blocks. Tables 6.5 and 6.6 give demographic data for attendance including duration of therapy, numbers attending and their occupational categories. Text that follows the tables describes outcome and reasons for leaving. Four of the 10 who have enrolled have left the group with reasons for leaving as follows: In one case the person discovered that the approach did not work for her, and she left for a more active form of therapy; in another he found that he needed couples’ therapy with his partner and not group therapy for himself; in another, the group had done all she needed it to, she gained confidence about her resilience in dealing with health concerns and left to get married; and in the fourth case he found he got ‘lost’ in the gaps between blocks, could not afford to augment them with individual sessions and so transferred to a twice-weekly group with me. Table 6.5  Block group therapy: Attendance numbers Length of attendance

1 year

No. attending 4

2 years

3 years

4 years

5 years

Total men

Total women

2

1

1

2

4

6

Table 6.6  Block group therapy: Occupational categories Occupation of those attending block groups

Number of attendees

Advertising

1

Banking

1

Law

4

Medicine

1

Psychotherapy

3

6  The range of applications  187

Study 10: Twice-weekly group psychotherapy: Mixed, slow-open groups in private practice: John Schlapobersky These long-term slow-open groups allow people to progress at their own pace and move on when ready. Empty places are taken up by new members on the basis of a thoughtful match between newcomers’ personality and needs and the current status of the group. As members come and go the group itself and its conductor continue for sometimes decades on end. The slow-open principle allows the group to address processes of bonding and attachment – separation and loss – as a recurrent, cyclical dimension of everyone’s therapy. The twice-weekly forum intensifies the process and allows it to develop into a therapy that provides the group equivalent of more intensive forms of individual psychotherapy. Providing there is motivation, some indication of the capacity for self-exploration and for making links with others, twice-weekly groups cater well for more severe psychological problems. They provide a sound environment for personal growth and development and are the treatment of choice for the training analysis of group therapists. By the time the Institute of Group Analysis was established in 1973, participation in twice-weekly group therapy had become a training requirement. All of its members who have passed through the London training – some 172 in a membership of 391 – have been in twice-weekly groups with a training group analyst for a period of years. These twice-weekly groups differ from those offered in block training programmes in that they are identified as ‘patient’ groups and are comprised – in the main – of people seeking professional help for personal problems. Groups are made up both of those who enrol on the basis of declared need and those who do so to meet the requirements of a psychotherapy training. This mix is of profound benefit to both sides of the enrolment profile. ORIGINS OF TWICE-WEEKLY GROUPS

There are different claims to the initiation of twice-weekly groups. The one I believe has most veracity is by Skynner, who describes how he joined a once-weekly group with Foulkes in 1962 and was attending it when he began conducting a twice-weekly group himself. ‘So I was in this group with Foulkes and had the unpleasant experience that the (twice-weekly) group I was conducting (with patients at the Maudsley Hospital) was moving me along faster than could be processed in Foulkes’ therapy group’ (Roberts and Pines 1991:41). He describes how Foulkes until then combined group therapy with occasional individual sessions, but I said to him I couldn’t cope unless I got more therapy than I was having, and if the group didn’t become twice-weekly I would have to leave. So in effect I  forced him to make it twice-weekly. It was a measure of (his) flexibility

188  I Foundations

and openness that it was possible to have therapy with him then after our revolution . . . (Roberts and Pines 1991:41) LITERATURE ON TWICE-WEEKLY GROUPS

The only extended study of twice-weekly groups – as such – is by Roberts and Pines (1991) in a text that describes the work of the Group Analytic Practice. The practice was regarded as a centre of excellence and had large numbers attending for individual, group and couples’ therapy. Contributors to Roberts’s book give different figures to the number of twice-weekly groups at the Practice in the same year. Roberts gives a number of 23 current twice-weekly groups (Roberts and Pines 1991:13), Kreege gives 17 (ibid:73) and Mittwoch gives 22 (ibid:830). Whatever the accuracy of the different numbers – all these contributors were running such groups – there were clearly a lot of people in regular twice-weekly group therapy. One might have hoped to see some accounting of this work. But one looks in vain for any comprehensive, practical account of the practice and its work in this book or indeed anywhere else. Mittwoch insists that None of us at the Practice to my knowledge have measured statistics on the outcome of treatment. For my part I would rather not subject my patients to questionnaires at the beginning and end of treatment, and worse still at various stages of follow up. I would always regard the questions, the responses and the conclusions as suspect. (Roberts and Pines 1991:93)

EVALUATION OF TWICE-WEEKLY GROUPS: PRESENTATION OF DEMOGRAPHIC AND CLINICAL DATA

Mittwoch seems to be making a virtue out of what would today be regarded as a major liability – there is no evidence base for the work of the practice in even the simplest of terms. In order to try and meet this requirement in basic terms I have compiled demographic and clinical data for my two twice-weekly groups over many years including the period in which they were located at this practice. The basis on which the ratings were done in Table 6.8, in items 13 and 14, involved consulting the originating medical records of those leaving the groups and matching originally declared and diagnosed need against outcome in the group itself on the basis of patients’ self-perception, on the basis of my own appraisal of their status and on the basis of their fellow group members’ views. The material that follows here was prepared for submission at a succession of conferences held by the American Group Psychotherapy Association

6  The range of applications  189

and is published here for the first time. The titles of the conference presentations give a focus to the quality of peer review that this material benefitted from and included presentations as follows: American Clinicians Examine European Group Analysis (2006), Wouldn’t You Rather Do It Twice a Week  – The Benefits of Twice-Weekly Groups (2007), You Say Tomaydoes and I Say Tomahtoes: Comparison of Method Between North American and European Group Therapy (2009) and Intensive Psychotherapy in Small Groups (2010). The programme is now in its tenth year and continues. I wish to record my gratitude to fellow panellists in the Trans-Atlantic Dialogues at the Annual Meetings of the AGPA, including Phyllis Cohen, Sue Einhorn, Sheila Ernst, Robi Friedman, Molyn Leszcz and Howard Kibel. I have been conducting two twice-weekly groups in private practice since 1989. The older group, now 25 years old, was four years old when I moved it into the Group Analytic Practice. The younger one, now 20 years old, was established at that practice one year later. When I left the practice in 2009 I moved both groups into the new Bloomsbury Psychotherapy Practice. A significant majority of the vignettes that illustrate this book are drawn from these groups during their lifespan. Table 6.7 gives a clinical profile for the categories of need amongst people attending these twice-weekly groups, much of which is drawn from the excellent records that were held at the practice during this period. Grateful acknowledgement is made here to the former administrative director of the practice, June Ansell, who helped me with the records on which the following tables are based. People referred to the practice had an assessment by a clinician who was – in most cases – both a group analyst and psychiatrist or psychologist. The data below include diagnostic and descriptive material. In many cases the people described in Table 6.7 belong to more than one category. The work of these groups in their structure, process and content makes up the substance of this book. What follows is an audit of these groups over a period of time and a demonstration of their effectiveness using a personalised process and outcome measure. If readers want to know what happens between these figures they need only read the vignettes that are based on the work of these groups that have educated and informed me down the years. I meet some of the graduates of these groups as colleagues who are now members and training group analysts at the IGA in London. They now conduct their own such groups and provide teaching and supervision to later generations of students. I come across others by chance, sometimes with their partners and children, who once joined these groups out of need. They went on by their own endeavours in therapy to educate and inform us all of the true ‘gifts of adversity’ (Rosenthal 2013). Through the resolution of their own personal issues and the transformation of their lives many have made a great deal by way of personal happiness and fulfilment out of painful early beginnings, and this book is dedicated to them in gratitude.

L oss, I mmaturity and •  •  infertility, developmental disability, problems disorders •  C haotic life and illness situations •  A dult •  P roblems of sequelae of identity and child abuse meaning M assive •  •  O ccupational psychic problems trauma •  P roblems of gender, sexuality and orientation

3. Chronic and maladaptive reactions to traumatic life events including:

Psychotherapists, psychiatrists, Those seeking psychologists, social workers, personal growth clergy who might have otherwise chosen psychoanalysis

For people with insight who both need and can tolerate containment

•  I ntimacy avoidance •  R ecurrent broken relationships •  I ntractable conflict

7. Personal development

6. Training of mental health professionals including:

5. Selected borderline problems including:

4. Serious relational problems including:

* Table 6.7 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Table 6.3.6.9, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1365. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my co-author Malcolm Pines for his consent to its re-use here. Grateful acknowledgements are made here to Mrs. June Ansell, formerly Administrative Director of the Group Analytic Practice for her assistance in the compilation of Tables 6.7–6.15 from the medical records of the Practice.

R ecovery •  from mental and physical illness R esolving •  addiction and substance abuse

1. High 2. Character dependency problems need including: including:

Table 6.7  Categories of need amongst people attending twice-weekly groups*

Table 6.8  Basic demographic and clinical data for people attending twice-weekly groups Twice-Weekly Group A: May 1989–July 2005: Duration: 16 years 2 months Twice-Weekly Group B: April 1994–July 2005: Duration: 11 years 3 months Twice-Weekly Group

A

B

1

Commence

May 1989

April 1994

2

Age of group

16 yrs 2

11 yrs 3

3

Current membership

7 Women: 4 Men: 3

6 Women: 3 Men: 3

4

Total population: past and current

25

28

5

Total population by gender

Women: 11 Men: 14

Women: 16 Men: 12

6

Average age total population

41 yrs

40 yrs

7

Average duration therapy total population per group

4 yrs 6

3 yrs 8

8

Occupation

See Table 6.10

See Table 6.10

9

Family situation

See Table 6.10

See Table 6.10

10

Ref source

See Table 6.10

See Table 6.10

11

Presenting problem

See Table 6.10

See Table 6.10

12

Diagnosis

See Table 6.10

See Table 6.10

13

Leaving reason

See Table 6.10

See Table 6.10

14

Process evaluation: average

3.3

3.23

15

Outcome evaluation: average

2.94

3.23

Table 6.9  Basic clinical data for people attending twice-weekly groups: Ratings on five-point scale (14 and 15) Rating Process evaluation: 14 (Therapist’s view)

Outcome evaluation: 15 (Patients’ view)

0

Consistently negative experience of being in the group

No sense of personal resolution on leaving in any significant area

1

Minimal gains in self-understanding Minimal gains in stated therapeutic and/or personal development goals attributed to group by patient and members

2

Moderate gains in Moderate gains in stated self-understanding and/or personal therapeutic goals, attributed to development group by patient and members

3

Significant gains in selfunderstanding and/or personal development

Significant gains attributed to group by patient and other members

4

Deeply engaged by group with consequential insight and change

Major gains in stated therapeutic goals, attributed to group by patient and other members

Table 6.10  Twice-weekly group therapy: Occupational categories Twice-weekly groups

A (25)

B (28)

Health care

8

8

Medicine

1

2

Nursing

0

1

Psychotherapy/counselling

3

4

Psychology

2

0

Nursing

0

1

Social work

2

0

6

7

Executive/management Education

1

4

Schools

0

2

University

1

2

IT

3

3

Law

0

2

Banking

1

2

Media

1

1

Acting

0

1

Clergy

1

0

Design

1

0

Engineering

1

0

Prison staff

1

0

Housewife

1

0

Table 6.11  Twice-weekly group therapy: Family situation Twice-weekly groups

A (25)

B (28)

Single

10

15

Married

 8

 4

Separated

 2

 5

Divorced

 1

 3

Living with partner

 4

 1

Total number of children

11

18

Table 6.12  Twice-weekly group therapy: Referral source Twice-weekly groups

A (25)

B (28)

Self-referred

 7

17

Psychiatrist

 2

 9

Psychotherapist

16

 1

Marital agency

 0

 1

Table 6.13  Twice-weekly groups: Presenting problems Twice-weekly groups Relationship problems

A (25)

B (28)

15

21

Acute/immediate/crisis

 7

13

Chronic critical need

 8

 8

Confusion/insecurity identity/existential problem

11

 4

Depression

 5

 4

Employment crisis/problem

 6

 1

Sexual problem

 3

 1

Overdose/self-harm

 1

 1

Violence to others

 0

 1

Substance abuse

 1

 2

Eating disorder

 0

 1

Table 6.14  Twice-weekly groups: Diagnosis on presentation Twice-weekly groups

A (25)

B (28)

Character disorder

12

13

Personality disorder

 9

 5

Borderline

 6

 5

Schizoid

 2

 0

Hysterical

 1

 0

 3

 7

Unipolar depression

 2

 6

Bipolar

 1

 1

 1

 5

Mood disorder

Anxiety state: chronic/acute

(Continued)

194  I Foundations Table 6.14 (Continued) Twice-weekly groups

A (25)

B (28)

Developmental problems

 6

0

Other problems of identity

11

4

Substance abuse

 1

2

Gender confusion

 1

0

Psychotropic medication

 5

8

Temporary for acute state

 2

6

Long-term/chronic

 3

2

Table 6.15  Twice weekly groups: Leaving reasons Twice-weekly groups

A (25)

B (28)

Progression: specific to new job/relationship/home/country

10

12

Progress non-specific: enough therapy

4

4

Move to individual psychotherapy

2

2

Poor engagement

2

Drop-out

1

1

Catastrophic reaction against therapy

1

1

Continuing in therapy

7

6

14 Process evaluation average

3.3

3.23

15 Outcome evaluation average

2.94

3.23

Note 1 This account of group therapy for people with histories of homicide was specially written for this book by Gwen Adshead, to whom I extend my grateful thanks.

Bibliography Adlam, J., Aiyegbusi, A., Kleinot, P., Motz, A., and Scanlon, C. (2012). The Therapeutic Milieu Under Fire: Security and Insecurity in Forensic Mental Health. London, Jessica Kingsley. Adshead, G. (2011). The Life Sentence: Using a Narrative Approach in Group Psychotherapy with Offenders. Group Analysis 44 (2): 175–195. Adshead, G., Ferrito, M., and Bose, S. (2015). Recovery After Homicide: Narrative Shifts in Therapy With Homicide Perpetrators. Criminal Justice and Behavior 42 (1): 70–81. Agazarian, Y., and Peters, R. (1981). The Visible and Invisible Group. London, Routledge.

6  The range of applications  195 Archer, S. (2005). Shame, Doubt and the Shameless Object. Journal of the British Association of Psychotherapists 43 (99): 93–107. Bakali, J. V., Baldwin, S. A., and Lorentzen, S. (2009). Modelling Group Process Constructs at Three Stages in Group Psychotherapy. Psychotherapy Research 19 (3): 332–343. Baraitser, M., and Melzak, S. (2014). Reading and Expressive Writing With Children, Young Refugees and Asylum Seekers: Unpack My Heart With Words. London, Jessica Kingsley Press. Blackwell, D. (2005). Counselling and Psychotherapy With Refugees. London, Jessica Kingsley Press. Brown, D. (2006a). Fair Shares and Mutual Concern: The Role of Sibling Relationships. In J. Maratos (Ed.), Resonance and Reciprocity: Selected Papers by Dennis Brown. London, Routledge, pp. 124–130. Brown, D. (2006b). Psychosomatics: Introductory comments – Chapters 1, 2, 3. In J. Maratos (Ed.), Resonance and Reciprocity: Selected Papers by Dennis Brown. London, Routledge, pp. 1–34. Callaghan, K. (1993). Movement Psychotherapy with Adult Survivors of Political Torture. The Arts in Psychotherapy 20: 411–421. Callaghan, K. (1996). Torture  – the Body in Conflict: The Role of Movement Psychotherapy. In M. Liebmann (Ed.), Arts Approaches to Conflict. London, Jessica Kingsley. Campling, P., and Haigh, R. (Eds.). (1998; reissued 2002). Therapeutic Communities: Past Present and Future. London, Jessica Kingsley Press. Collis, M. (1987). Women’s Groups in the Therapeutic Community: The Henderson Experience. International Journal of Therapeutic Communities 8 (1): 175–184. Cordess, C., and Cox, M. (Eds.). (1996). Crime, Psychodynamics and the Offender Patient. London, Jessica Kingsley Press, pp. 227–243. Dick, B. M. (1975; reissued 1983). A Ten-year Study of Out-patient Analytic Group Therapy. British Journal of Psychiatry 127 (4): 365–375. Reissued in M. Pines (Ed.), (1983), The Evolution of Group Analysis. London, Routledge. Doran, M. (2001). A Clinical Study of a 30-week Homogeneous Group for Women Who Have Been Sexually Abused as Children. MSc dissertation. Institute of Group Analysis, London/ Birkbeck College University of London. Douglas, A. R. (2010a). Identities in Transition: Living as an Asylum Seeker. Advances in Psychiatric Treatment 16: 238–244. Douglas, A. R. (2010b). Working With Bereaved Asylum Seekers and Refugees. Bereavement Care 29: 5–9. Erikson, E. H. (1950). Childhood and Society. New York, Norton. Ferrito, M., Vetere, A., Adshead, G., and Moore, E. (2012). Life After Homicide: Accounts of Recovery and Redemption of Offender Patients in a High Security Hospital – a Qualitative Study. Journal of Forensic Psychiatry & Psychology 23 (3): 327–344. Foulkes, S. H. (1948; reissued 1983). Introduction to Group-Analytic Psychotherapy. London, Karnac Classics. Foulkes, S. H. (1964; reissued 1986). Therapeutic Group Analysis. London, Karnac. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Ganzarain, R., and Buchele, B. (1989). Fugitives of Incest: A Perspective From Psycho­ analysis and Groups. New York, International Universities Press.

196  I Foundations Garland, C. (1982). Taking the Non-Problem Seriously. Group Analysis 15: 4–14. Glasser, M. (1964). Aggression and Sadism in the Perversions. In I. Rosen (Ed.), (1998), Sexual Deviation (3rd edition). Oxford, Oxford University Press, pp. 279–300. Goldstein, K. (1939; 1995). The Organism: A Holistic Approach to Biology Derived From Pathological Data in Man. London and New York, Zone Books. Grotjahn, M. (1993). The Art and Technique of Analytic Group Therapy. Northvale, NJ, Jason Aaronson Inc. Grotjahn, M. et al. (1983). Handbook of Group Therapy. New York, Van Nostrand Reinhold & Co. Haigh, R. (1998; reissued 2002). The Quintessence of a Therapeutic Environment: Five Universal Qualities. In P. Campling and R. Haigh (Eds.), Therapeutic Communities: Past, Present and Future. London, Jessica Kingsley Press, pp. 246–257. Hall, Z. (1992). Group Therapy for Women Survivors of Childhood Sexual Abuse. Group Analysis 25: 463–475. Hall, Z., and King, E. (1997). Group Therapy Within the NHS: Patients’ Views on the Benefits of Group Therapy for Women Survivors of Child Sexual Abuse. Group Analysis 30: 409–427. Harrison, T. (2000). Bion, Rickman, Foulkes and the Northfield Experiment: Advancing on a Different Front. London, Jessica Kingsley. Hayes, C. (2014). The Language of the Symptom and The Velveteen Rabbit. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Hillbrand, M., and Young, J. L. (2004). Group psychotherapy for parricides: The Genesis Group. Forensische Psychiatrie und Psychotherapie Werkstattschriften 11: 89–97. Hopper, E. (1997). Traumatic Experience in the Unconscious Life of Groups: A Fourth Basic Assumption 21st S. H. Foulkes Annual Lecture. Group Analysis 30 (4): 439–470. Johnson, J. E., Burlingame, G. M., Olsen, J. A., Davies, D. R., and Gleave, R. L. (2005). Group Climate, Cohesion, Alliance, and Empathy in Group Psychotherapy: Multi-Level Structural-Equation Models. Journal of Counselling Psychology 52 (3): 310–321. Jones, D. (Ed.). (2004). Working With Dangerous People: The Psychotherapy of Violence. Abingdon, UK, Radcliffe Publishing. Kennard, D., and Haigh, R. (2009). Therapeutic Communities. In M. Gelder et al. (Eds.), (2012), New Oxford Textbook of Psychiatry. Oxford, Oxford University Press, pp. 1391–1398. Leszcz, M. (2014). Introduction. In S. Lorentzen (2014). Group Analytic Psychotherapy: Working With Affective, Anxiety and Personality Disorders. London, Routledge. Lorentzen, S. (2000). Assessment of Change After Long-Term Psychoanalytic Group Treatment. Group Analysis 33: 373–396. Lorentzen, S. (2014). Group Analytic Psychotherapy. Working with Affective, Anxiety and Personality Disorders. London, Routledge. Lorentzen, S., Bøgwald, K. P., and Høglend, P. (2002). Change During and After Long-Term Analytic Group Psychotherapy. International Journal of Group Psychotherapy 52, 419–429. Lorentzen, S., Ruud, T., Fjeldstad, A., and Høglend, P. (2013). Comparison of Short- and Long-Term Dynamic Group Psychotherapy: Randomised Clinical Trial. British Journal of Psychiatry 203, 280–287. Lorentzen, S., Ruud, T., Fjeldstad, A., and Høglend, P. (2014). Personality Disorder Moderates Outcome in Short- and Long-Term Group Analytic Psychotherapy: A Randomized Clinical Trial. British Journal of Clinical Psychology. DOI::10.1111/bjc.12065

6  The range of applications  197 McDougal, J. (1974). The Psychosoma and the Psychoanalytic Process. International Review of Psychoanalysis 1: 437–459. MacKenzie, K. R. (1997). Time-Managed Group Psychotherapy: Effective Clinical Applications. Washington, DC, American Psychiatric Association. Maratos, J. (Ed.). (2006). Resonance and Reciprocity: Collected Papers of Denis Brown. London, Routledge. McDougal, J. (1989). Theatres of the Body. London, Free Association Books. Mistry, T., and Brown, A. (Eds.). Race and Groupwork. London, Whiting and Birch. Nitsun, M. (1996). The Anti-Group: Destructive Forces in the Group and Their Creative Potential. London, Routledge. Norton, K. (1992a). A Culture of Enquiry: Its Preservation or Loss. International Journal of Therapeutic Communities 13 (1): 3–25. Reissued in F. Warren and B. Dolan (Eds.), (2001). Perspectives on the Henderson Hospital. Sutton, Henderson Hospital Publishers, pp. 43–62. Norton, K. (1992b). Personality Disordered Individuals: The Henderson Hospital Model of Treatment. Criminal Behaviour and Mental Health 2 (2): 80–191. Reissued in F. Warren and B. Dolan (Eds.), (2001). Perspectives on the Henderson Hospital. Sutton, Henderson Hospital Publishers, pp. 28–42. Norton, K. (1998). Joining and Leaving: Processing Separation, Loss and Re-Attachment. In R. Haigh and P. Campling (Eds.), Therapeutic Communities: Past, Present and Future. London, Jessica Kingsley. Ormont, L. (1992). The Group Therapy Experience: From Theory to Practice. New York, St. Martin’s Press. Ormont, L. (2001). The Technique of Group Treatment. New York, Psychosocial Press. Ormont, L., and Furgeri, L. B. (2001). The Technique of Group Treatment: The Collected Papers of Louis Ormont. New York, Psychosocial Press. Parker, M. (Ed.). (2006). Dynamic Security: The Democratic Therapeutic Community in Prison. London, Jessica Kingsley. Pines, M. (1983). The Contribution of S. H. Foulkes to Group Analysis. In M. Pines (Ed.), The Evolution of Group Analysis. London, Routledge. Pines, M. (Ed.). (1983). The Evolution of Group Analysis. London, Routledge. Rapoport, N. R. (1960). Community as Doctor: New Perspectives on a Therapeutic Community. London, Tavistock. Roberts, J., and Pines, M. (Eds.). (1991). The Practice of Group Analysis. London, Routledge. Rosen, I. (Ed.). (1998). Sexual Deviation (3rd ed.). Oxford, Oxford University Press. Rosenthal, N. E. (2013). The Gift of Adversity: The Unexpected Benefits of Life’s Difficulties, Setbacks, and Imperfections. New York, Tarcher Penguin. Scheidlinger, S. (1982). Focus on Group Psychotherapy: Clinical Essays. New York, International Universities Press. Schlapobersky, J. (1993). The Reclamation of Space and Time: Psychotherapy with Survivors of Torture and Organised Violence. In Proceedings of the Medical Foundation. Schlapobersky, J. (1996). Forensic Psychotherapy: A Group-Analytic Perspective – From the Speech of Hands to the Language of Words. In C. Cordess and M. Cox (Eds.), Crime, Psychodynamics and the Offender Patient. London, Jessica Kingsley Press, pp. 227–243. Schlapobersky, J. (2005). A Group Work Approach With Refugees and Other Traumatised Populations. In R. Tribe (Ed.), Department of Health Textbook on Health Care of Refugees (Unpublished).

198  I Foundations Schlapobersky, J., and Bamber, H. (1988). Rehabilitation With Victims of Torture. In D. Miserez (Ed.), ­Refugees – The Trauma of Exile. The Hague, Nijhoff, pp. 206–222. Scott, S. (2011). Uncovering Shame in Groups: An Exploration of Unconscious Shame Manifest as a Disturbance in Communication in the Early Stages of an Analytic Group. MSc dissertation. Institute of Group Analysis, London / Birkbeck College University of London. Trowell, J., and Kolvin, I. (1999a). Lessons From a Psychotherapy Outcome Study With Sexually Abused Girls. Clinical Child Psychology and Psychiatry 4 (1): 79–89. Trowell, J., and Kolvin, I. (1999b). Psychotherapy for Child Sexual Abuse – Individual and Group. The Mental Health Foundation Updates 1 (1). Tucker, S. (2004). From Group Norms to The Group Superego: The Therapeutic Efficacy of The Ethical and Political in Foulkes. Dissertation. Institute of Group Analysis, London/ Birkbeck College University of London. Tucker, S. (2011). Psychotherapy Groups for Traumatised Refugees and Asylum Seekers. Group Analysis 44 (1). Tucker, S., and Price, D. (2007). Find a Home: Group Psychotherapy for Traumatized Refugees and Asylum Seekers. European Journal of Psychotherapy and Counselling 9 (3). Tucker, S., and Wylie, B. (2006). Working With Trauma in a Prison Therapeutic Community: An Essentially Social and Integrative Approach. International Journal of Therapeutic Communities 27 (3). Tuckman, B. (1965). Developmental Sequence in Small Groups. Psychological Bulletin 63 (6): 384–399. Tyerman, S. (2012). Watching the Body in the Group. Theory Paper for Qualification. Institute of Group Analysis, London. Urlić, I., and Tocilj-Šimunković, G. (2009). Working Through Shame in Groups for Victims of Trauma and War. International Journal of Group Psychotherapy 59 (2): 165–178. Verebes-Weiss, J. (2011). Capacity to Be in a Group: Small Group Psychotherapy in a Forensic Therapeutic Community for People With Dangerous and Severe Personality Disorder. Theory Paper for Qualification. Institute of Group Analysis, London. Wainstein, S. (2013). An Exploration of Intimacy in Group Analytic Psychotherapy. MSc dissertation, Institute of Group Analysis, London/Birkbeck College University of London. Warren, F., and Dolan, B. (Eds.). (2001). Perspectives on the Henderson Hospital. Sutton, Henderson Hospital Publishers. Weegman, M. (2014). The World Within the Group: Developing Theory for Group Analysis. London, Karnac. Welldon, E. (1996). Group Analytic Psychotherapy in an Out-patient Setting. In C. Cordess and M. Cox (Eds.), Forensic Psychotherapy. London, Jessica Kingsley Press, pp. 63–82. Welldon, E. (2012). Playing With Dynamite: A Personal Approach to the Psychoanalytic Understanding of Perversions, Violence, and Criminality. London, Karnac. Whitaker, D.S. (1985). Using Groups to Help People. London, Routledge. Whitely, J. S. (1980). The Henderson Hospital: A Community Study. International Journal of Therapeutic Communities 1 (1): 38–58. Reissued in F. Warren and B. Dolan (Eds.), (2001). Perspectives on the Henderson Hospital. Sutton, Henderson Hospital Publishers, pp. 6–27. Whitely, J. S., and Collis, M. (1987). Therapeutic Factors Applied to Group Psychotherapy in a Therapeutic Community. International Journal of Therapeutic Communities 8 (1): 21–31.

6  The range of applications  199 Williams, A., and Zachary, A. (2014). On the Containing Structures Required by Forensic Group Psychotherapy. In J. Woods and A. Williams (Eds.), Forensic Group Psychotherapy. London, Karnac, pp. 33–51. Winnicott, D. W. (1953). Transitional Objects and Transitional Phenomena. International Journal of Psycho-Analysis 34. In D. W. Winnicott, Through Paediatrics to Psycho-Analysis. London, Hogarth Press, 1978, pp. 229–242. Winnicott, D. (1956/1958). The Antisocial Tendency. In D. W. Winnicott, Through Paediatrics to Psycho-analysis. London, Hogarth Press, pp. 306–315. Winicottt, D. (1958). Psycho-Analysis and the Sense of Guilt. In J. Sutherland (Ed.), Psycho-Analysis and Contemporary Thought. London, Hogarth Press. Reissued in The Maturational Processes and the Facilitating Environment. London, Hogarth Press, pp. 15–28. Woodcock, J. (1997). Groupwork With Refugees and Asylum Seekers. In T. Mistry and A. Brown (Eds.), Race and Groupwork. London, Whiting and Birch, pp. 254–277. Woods, J. (2014). Principles of Forensic Group Therapy. In J. Woods and A. Williams (Eds.), Forensic Group Psychotherapy. London, Karnac, pp. 3–31. Woods, J., and Williams, A. (Eds.). (2014). Forensic Group Psychotherapy: The Portman Clinic Approach. London, Karnac. Yakeley, J. (2010). Working With Violence: A Contemporary Psychoanalytic Approach. London, Palgrave Macmillan.

Acknowledgements: Extract from Foulkes (1964; reissued 1986), Therapeutic Group Analysis, with permission from the Group Analytic Society; extracts from Dick, A Ten-year Study of Out-patient Analytic Group Therapy, British Journal of Psychiatry, 127 (4): 365–375, reissued in Pines (1983), The Evolution of Group Analysis. London, Routledge, pp. 54–75, including Tables 6.2, 6.3, 6.4 and 6.5, with permission from Malcolm Pines, Editor; extracts from Lorentzen (2014), Group Analytic Psychotherapy: Working with Affective, Anxiety and Personality Disorders. London, Routledge, with permission from Steinar Lorentzen; for Study 4: A Brief Study of Small Group Psychotherapy for People With a History of Homicide written for this publication, sincere thanks to the author, Gwen Adshead; extracts from Woods (2014), Principles of Forensic Group Therapy in J. Woods and A. Williams (eds.), Forensic Group Psychotherapy, London, Karnac, pp. 3–31, with permission from John Woods; extracts from Doran (2001), A Clinical Study of a 30-week Homogeneous Group for Women Who Have Been Sexually Abused as Children. MSc. Dissertation, Institute of Group Analysis, ­London/ Birkbeck College University of London, with permission from Monica Doran; extracts from Hayes (2014), The Language of the Symptom and The Velveteen Rabbit. MSc Dissertation, Institute of Group Analysis, London/Birkbeck College University of London, with permission from Catherine Hayes; Tables 6.8, 6.9, 6.10, 6.11, 6.12, 6.13, 6.14, 6.15 and 6.16 reproduced with permission from Malcolm Pines and Oxford University Press.

Chapter 7

Methods applications and models The group-analytic model and its contemporaries (Based on an earlier chapter written jointly with Malcolm Pines)

There is a minimising, even devaluing attitude towards group therapy and its particular characteristics and needs that I see as part of a more fundamentally ambivalent view of groups . . . The lack of theoretical coherence in group psychotherapy invites further comment. What accounts for this lack? . . . What is needed is an examination of the group itself as an entity and the way its underlying characteristics are seen to be reflected in the complex tangle of conceptual and technical systems. (Morris Nitsun 1996:4–5)

This chapter develops a conceptual frame to differentiate methods, models and applications for the practice of group therapy.1 After classification of the different methods and applications I provide an outline of seven of the mainly psychodynamic models of group therapy – the Group-analytic and Tavistock models in Europe and, in North America, the Interpersonal, Modern Analytic, Psychodynamic, Relational and Systemic models, to set a context for a more detailed study of the Group-analytic model that follows in Section II.

A study of group therapy as a method: its basic applications In the diagram below, Pines and I used two simple factors – therapeutic goals and group leadership – to provide a simple classification of the different applications. Therapeutic goals Groups will be more or less specific in their therapeutic goals. Those catering for a homogeneous population with a commonly defined problem whose solution provides the basis for entry to the group – such as overcoming drink or drug dependence – are classified here with specific goals. Groups that provide psychoanalytic psychotherapy according to the Tavistock or Group-analytic models in Europe or the Interpersonal and Modern Analytic models in North America are classified here with non-specific goals. There is a wide range of variation between these applications and within each of these main psychodynamic models.

7  Methods applications and models  201

Leadership The more directed the group is by the leader, the more prominent he becomes as the group’s ‘model object’. The less directed the group is by the leader, the more scope there is for the emergence of unconscious dynamics, for attention to transference and countertransference, and therapy progresses through the development of relationships. The higher the relative level of leadership activity the more likely it is that group members are being offered a technique or skill in the setting of a group. The lower this level the stronger will be the relational content of the therapy in which the therapist’s principle skills, grounded in fostering relationships, will equip the group to work developmentally and in depth on both the hidden and obvious issues that its members bring. This stands in contrast to the more directed methods in which the leader may be experienced as advancing on the group’s members with ‘a method’. The principal psychodynamic methods discussed here share a non-directive philosophy with subtle but significant differences between their models of practice. Using these two basic indicators – ­specificity of goals and levels of leadership activity – the four quadrants in ­Figure 7.1 provide us with a simple way of ‘placing’ the different group therapies. 1

HIGHLY SPECIFIC therapeu c goals Structured groups in centres for drink and drug dependence

2

Problem solving and Psycho educa onal groups for homogeneous popula ons

Ac vity groups including occupa onal therapy

HIGHER level of leader ac vity

LOWER level of leader ac vity

Psychodrama, Drama therapy Music therapy

Support groups Art psychotherapy groups

Short term dynamic groups

Psychotherapy groups Interpersonal Tavistock Group analy c

Systems centred groups

3

NON SPECIFIC therapeu c goals

4

Figure 7.1  A simple classification of group methods Source: Figure 7.1 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Figure 6.3.6.4, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1356. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my coauthor Malcolm Pines for his consent to their re-use here.

202  I Foundations

Goal-directed therapy with higher level of leader activity: Quadrant 1 In many drug and alcohol dependency regimes, participants are required to fulfil obligations tied to each stage of treatment in a structured programme. They move forward when stage-specific obligations are fulfilled. As the novice moves up she becomes a trainer to the newcomers, with the therapist(s) directing the process in active terms. This philosophy of ‘learnt apprenticeship’ in a group culture is also cultivated in therapeutic communities whose small groups otherwise belong in quadrant 4. Cognitive therapy given in a group setting uses the group as an assembly who learn from and discuss with the expert. Dependency on a shared and valued leader and attention to group dynamics amplify the learning, and some group cohesion develops, but this is not the primary focus of the therapy. Goal-directed therapy with lower level of leader activity: Quadrant 2 Problem-solving or psycho-educational groups for homogeneous populations, such as those set up for eating disorders or offenders, which are run along analytic lines, can be placed in this category. The original groups at Northfield were run along these lines. Although there are clear and directed goals, the leader’s level of activity is confined to a facilitating, linking or enabling one, followed by analysis and interpretation. Group discussion and cohesion amplify the affective experience and enhance the learning. Non-specific goals with higher level of leader activity: Quadrant 3 In psychodrama groups, leadership is explicitly vested in the psychodrama director. The needs and goals of group members are diffuse and often diverse and, in psychiatric practice, will have to do with relief from mental suffering. The psychodrama director can draw on many techniques. Affective arousal can be high, so the power of sharing through discussion and the sympathy and empathy between group members become powerful therapeutic tools. Strong conflict arousal and its subsequent resolution is similarly therapeutic. Systems-centred therapy as developed by Agazarian similarly provides a high level of leadership activity for groups that have non-specific goals. Short-term dynamic groups are frequently constituted with non-specific goals but are run over 10 or 20 sessions by leaders who maintain a high level of involvement and direction, often demarcated according to the different stages of the group’s progress. Non-specific goals with lower level of leader activity: Quadrant 4 The goals of group-analytic or psychoanalytic group therapy are most frequently diffuse and non-specific, involving relief from symptoms and other

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forms of suffering, personal growth and psychological change. There are six main schools considered in this chapter – the Tavistock (Bion or group-asa-whole) and Group-analytic in Europe; and the Interpersonal (Yalom et al.), Psychoanalytic, Modern Analytic and Systemic in North America, though the latter – as indicated – really belongs in the quadrant above. The Relational model has been partially discussed in Chapter 2 and its bearing on the Groupanalytic model is studied throughout the text, but its most recent publications have not yet been assimilated to this chapter. They share non-specific goals and have low levels of leader activity but differ from one another in how the leadership role and function is understood and discharged. They share assumptions about the importance of unconscious individual and group dynamics and look to the group for its transformational potential. Their differences affect the way in which transference and countertransference are understood and worked with. This chapter provides a comparative appraisal of these models.

Basic applications A more detailed overview of the current field extends the picture by taking account of the client categories, context and setting in which group therapy is applied as a method. It can be divided among five basic applications – activity groups, support groups, problem-solving groups, psycho-educational groups and psychodynamic groups. The first three applications are goal specific as indicated by their descriptions, the fourth is less specific and the fifth is a non-directive analytic psychotherapy. In support and problem-solving groups therapeutic leadership can be highly directed or not, depending on the approach. Activity and psycho-­ educational groups will inevitably have a high level of directed group leadership whilst psychodynamic groups have a lower level of directed group leadership. All five applications rely on the same basic procedures – the selection and grouping of a number of people seeking help who have regular meetings together with one or more well-trained therapist(s). Activity groups The most vulnerable and disturbed patients can be placed in therapy groups defined by an activity that provides a convening function such as exercise or cooking, which can then be used to create conditions for a wide range of secondary functions that foster affiliations, develop social skills, address unspoken anxieties and express troubling emotions. Occupational therapists and nurses using art media or other socially syntonic activity like gardening or hair-dressing have been developing a wide range of group services in both acute and rehabilitation psychiatry for many years (Creek 1997). The approach has been used in a wide range of other settings including medical rehabilitation, rehabilitation with refugees, social work and fostering and adoption programmes. Groups that keep the original activity as their primary focus, working with art media, for example, need to be differentiated from those which use such media to develop an analytic focus

204  I Foundations

on psychological work. The arts psychotherapies belong to this latter group. They have non-specific therapeutic goals and might, as in the case of music therapy, have a high level of leadership activity or, in the case of art therapy, have a low level of leadership activity (Skaife and Huet 1998). Support groups They function as a form of social support providing containment, the improvement of social skills and the enhancement of participants’ capacities for social adaptation. They aim to reduce the deleterious effects of social isolation, bring people out of withdrawal into a social context and provide opportunities for problem sharing. They cater for patient populations with long-standing personality disorders not open to uncovering exploration, those with chronic mental and physical illness (Stone 1996; Urlich 2012), those with physical handicap, learning disorders and carers for those with any of these problems. They will often allow a certain amount of psycho-education through which the group leader can influence members’ attitudes as in the case, for example, of a group for young sexually active adults with learning disability who might receive guidance on contraception. Problem-solving groups Group therapy is provided for a set of referral criteria to address a defined problem. Alcoholics Anonymous, Alanon, Gamblers Anonymous and groups for people with poor impulse control, eating disorders or other habitual problems such as smoking are a few of the examples (Golden et al. 1993). These groups can take on many of the features of long-term support groups in that they offer ego-supportive and adaptive resources. They provide an extended service for monitoring by the patient or by professionals, without necessarily committing members to the deeper and more radical analytic work entailed by a psychodynamic group. In many cases the ­problem-solving focus provides a convening frame by which to engage a population who are soon drawn into psychodynamic work that can see them through profound changes in which the psycho-educational component – described below – becomes prominent. Much of the work in forensic group psychotherapy, illustrated by Studies 3, 4 and 5 in Chapter 6, works like this. Many of the groups run by clinicians in primary hospital care – occupational therapists, nurses, doctors and psychologists – take this form. The Group Work Programme at the Medical Foundation for Victims of Torture in London, illustrated by Study 6 in Chapter 6, is another example. Psycho-educational groups The original groups for servicemen with war neurosis at Northfield took this form in which people were given the role of students of their disorders rather than seen to be ‘sick’. This shift in values and orientation lent a distinctive new quality to the development of therapeutic communities that today cater for ‘residents’ rather than ‘patients’. With this revised identity people become more open

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to new information and better able to unlearn maladaptive attitudes about the nature of their problems. A more cognitive approach can be applied in homogeneous ­problem-solving groups where information can be provided through lectures, discussions and suitable reading material. There are different ways of lowering anxiety and uncovering maladaptive and inappropriate attitudes towards such problems as anxiety states, phobias, obsessions and psychosomatic disorders. Many of the groups run for those with serious physical illness take this form. And there is often a major psycho-educational component in support groups, including those for people with chronic mental illness who can be helped to understand and cope with delusions, hallucinations and the stigma of illness (Kanas 1999). Psychodynamic groups There are supportive, problem-solving and psycho-educational components in all psychodynamic groups, but the description ‘psychodynamic’ is reserved for those in which the declared goal is lasting personal change through a non-directive, free-associative therapy. The range of different group contexts is so varied that – at first sight – they might appear to have little in common. But there are principles in common when offering therapy to a group of people on an in-patient unit recovering from psychosis and meeting thrice weekly, those in a secure unit for violent offenders meeting once weekly and those – including mental health trainees – attending a group in private practice once or twice weekly. These different applications were illustrated in Chapter 6 and form the substance of Section II.

The six main models of psychodynamic group therapy The analysis that follows makes systematic comparisons among the six main models of psychodynamic group therapy illustrated in three cases by figures to help differentiate between the Tavistock, Interpersonal and Group-analytic models. Bion and the Tavistock approach The approach originates in the work of Bion (1961), who had a major influence on Ezriel and their colleagues at the Tavistock Clinic. They share with group analysis an interest in the underlying pattern of object relations in groups but, under Bion’s influence and then Ezriel’s, the therapist focuses – to the exclusion of almost everything else – on what Ezriel called common group tensions and what Bion called basic assumptions. Ezriel’s original contribution (1950) precedes Bion’s by some 11 years. This time lapse remains a puzzle given that Bion was the originator of this model, but Ezriel’s writing, considered in Chapter 3, is – like Bion’s – lucid, informative and of continuing clinical use. The discussion here goes on to consider Bion’s monograph published years later. Experiences in Groups (1961/2000) was his only publication on groups and, though it rests on slender theoretical foundations and marked the end of his interest in groups, has

206  I Foundations

had an influence on the field that is nothing less than extraordinary, like the rest of his work. Lipgar and Pines, in an edited collection of two volumes, Building on Bion: Roots and Branches (2003), consider the origins and context of Bion’s contributions to theory and practice and the contemporary development and application of his work. Malan’s study of effectiveness (1976) raised serious questions about its effectiveness as a primary psychotherapy because, when so employed, it can overlook the individuality of a group’s members and disturb some patients whose experience of the group can repeat early developmental traumas of neglect and misunderstanding by care-takers. The most recent publication in which the model is described – Garland’s edited collection The Groups Book (2010) – shows a different stance that, in line with her own original training as a group analyst, is closer to the group a analytic model. It provides a much-needed overview of practice and a clinically useful manualised section. The Tavistock approach has been especially influential in staff training and consultancy suggesting a wide responsiveness in the field to basic assumption theory. As Figure 7.2 illustrates, this is a two-body psychology that imposes a series of clinical constraints reducing the complexity of group interaction to a bi-personal

Boundary of group as a whole

THERAPIST MEMBER

MEMBER

MEMBER

Two-person psychology Therapy governed by 2-person relaonship between therapist & group as a whole, most oen distorted by basic assumpons

Intra-group dynamics governed by basic assumpons MEMBER

MEMBER

Basic assumpons Dependency Fight-Flight Pairing Massificaon/ Aggregaon

MEMBER

Figure 7.2  The elements of a Tavistock group Source: Figure 7.2 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Figure 6.3.6.4, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1356. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my coauthor Malcolm Pines for his consent to their re-use here.

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exchange between the therapist on the one hand and – on the other – the group taken as a whole. Intra-group dynamics are considered only in their entirety for what they reveal about the unconscious state of the group as a whole and for what they indicate about the nature of the group’s relationship with the therapist. The therapist remains outside the group in a stance that is not only neutral and dispassionate but also opaque and withholding of self. Ezriel and Bion have in common a deductive stance that applies pre-formulated principles to the observational field in which all understanding and analysis is deduced from what is assumed about the dynamics at issue. Despite these limitations, Bion’s ideas and those spawned by his thinking have an explanatory power and simplicity of application that continue to prove illuminating. In his account of basic assumptions, a group at any point in its culture and climate is thought governed by primitive, unconscious anxieties that impede its capacities for rational work in which the person or representation of the leader plays a crucial part. The ensuing anxieties, organised into one of three categories referred to as basic assumptions, are dependency, fight or flight and pairing. They affect the group as a whole in which only one basic assumption is believed to be operative at any point in time. Bion saw basic assumptions as interfering with the ‘work group’, the more rational, higher-level functioning of the group and its members. The therapist’s key task lies in understanding the operative basic assumption and interpreting it to the whole group. The meanings of individuals’ personal experiences are subsumed by this understanding of the whole. It is a therapist-centred approach that sees transference only as directed towards the therapist, who represents authority. In dependency the group tries to elicit protection through passive or dependent behaviour. In fight/flight the group attacks the therapist or some other issue or goes into retreat and withdraws. And in pairing the group creates a shared illusion that some magical form of rescue may arise from the dilemmas of group life through charged partnerships across the circle of members. Brown provides a commentary on the theory of basic assumptions in which he traces the development of a fourth and fifth basic assumption, first in Bion’s own thinking and then in the writing of Turquet and Lawrence, clinicians and authors associated with the Tavistock tradition who followed his work (Brown 2003/2006). Turquet described the fourth basic assumption as oneness in which members seek to join a powerful union with an omnipotent force through which they can gain a sense of well-being through an act of psychic surrender (Turquet 1975). Lawrence developed a fifth basic assumption in the complementary concept of me-ness, through which the ‘I’ becomes an object to itself a ‘me’ in isolation to pre-empt engulfment (Lawrence, Bain and Gould 1996). The fourth assumption of oneness represents a surrender of the individual to the group and the fifth a forestalling of any group-relatedness to ‘protect’ the individual. Hopper has assimilated Turquet’s fourth and Lawrence’s fifth basic assumption with the construction of his own fourth basic assumption that he calls massification/aggregation in which the defensive structures of groups or societies, particularly those in crisis, are thought to entail either a rigid fusion of identities excluding individuality or a radical withdrawal into isolated units that prevent mutuality (Hopper 1997/2003).

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The interpersonal model Sullivan (1953; 1997) and Frank (1961; 1993) have influenced Yalom’s interpersonal approach. His Theory and Practice of Group Psychotherapy, written jointly with Leszcz in its fifth edition (2005), was the first systematic account of group therapy informed by research and remains one of the most influential books in the field. Yalom’s later text on inpatient group psychotherapy (1983) systematised group work in that setting. The focus is on interpersonal learning as a primary mechanism of change. The group provides the antidote to maladaptive interpersonal beliefs and behaviours through feedback from others and encouragement to experiment with healthier

MEMBER

MEMBER

MEMBER

MEMBER

THERAPIST

MEMBER

MEMBER

Figure 7.3  The elements of an Interpersonal group Source: Figure 7.3 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Figure 6.3.6.3, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1355. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my coauthor Malcolm Pines for his consent to their re-use here.

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behaviours first within the group and then outside. The joint examination of intragroup reactions allows members to replace processes that have an historical origin in the ‘there and then’ – the dynamic past – with those more appropriate to the ‘here and now’ – the dynamic present. The approach emphasises the educational opportunities of working in the here and now of the group. The conductor takes the responsibility for leading the group towards awareness of these interpersonal dynamics and their expressions. There is greater therapist transparency than in other psychodynamic approaches with the therapist modelling desired behaviours, sharing reactions to events in the group directly and being open to feedback from other group members. As Figure 7.3 indicates, interpersonal dynamics are kept at the forefront of members’ attention by the therapist. This sets a pattern in which the content of members’ discussions and the process of their interactions gives the group its agenda. The interpersonal approach places the therapist amongst other members of the group without giving him a distinctive structural identity and omits any formal demarcation for the boundaries of the group as a whole. Yalom described the model by tabulating 11 therapeutic factors. Drawing on therapists’ views and patients’ reports and correlating a series of in-therapy variables with patient outcomes, he constructed primary categories that have found a permanent place in our literature. In the fifth edition of the book (Yalom and Leszcz 2005), his co-author Leszcz returns to questions of empirical validation and confirms the validity of these 11 factors in past and current group members’ own experience. I have taken up a new approach to the organisation of these factors using the three dimensions of psychotherapy – relational, reflective and reparative – that is set out in Chapter 2. Yalom’s original use of the term ‘cure’ for these factors did not sit comfortably with those who see the goals of therapy on different terms. He did much to address this by revising them as therapeutic factors in the third edition of the book and by singling out the last of them – existential issues – for special treatment in Existential Psychotherapy, another widely influential text (May and Yalom 1989). The group-analytic model The group-analytic model and the influence of Foulkes and Anthony on its development is documented throughout this book. What they did not provide is the name for this model of group therapy. ‘Group analysis’ is a term devised in early North American practice by Trigant Burrow whose life is the subject of a recent, excellent biography by E. Pertagatto and G. Pertagatto (2013). What also merits mention here is the range and diversity of applications today across all 10 of the clinical studies described in Chapter 6. There Foulkes’s historical influence on the development of other models in North American practice – the Psychoanalytic and Modern Analytic especially – is also described. The approach integrates important aspects of the two preceding models and introduces a number of new elements. The group is led by a conductor who is sometimes the group’s convenor, at other times one of its members but at all times its therapist. He is encouraged to address the individual as well as the whole group and considers the more conscious and individual dynamics as well as the

210  I Foundations

unconscious and potentially destructive whole-group dynamics. The approach is guided by an integrated set of concepts relating structure, process and content to one another in which the conductor works to foster and cultivate the ordinary language of shared conversational experience. He will at times take up the position of convenor by calling on the dynamics of administration to address its boundaries and terms of reference. This is responsibility that will not be shed, reduced or devolved on any one else, and he will at other times speak personally as one of the group’s members. Between the conductor’s convening role and his presence in the group as an available person with emotions like the others, is a therapeutic role that governs and conditions both the other two. Groups may begin with a relatively high level of leadership activity, crescendo, that is flexibly reduced with a decrescendo of responsibility as the group becomes the therapist and the leadership function – for therapeutic intervention – is devolved upon its membership who become active co-therapists in each other’s treatment. The most coherent single summary of the approach is by Pines, Hearst and Behr (1982). As ­Figure 7.4 indicates, the conductor is outside the group as its convenor but inside it as one member amongst the others. The group’s structural elements provide a

Triangulaon between each member, the conductor and the groupas-a-whole, gives themac focus to the matrix.

MEMBER 1

CONDUCTOR Three-person psychology There are three categories of psychological ‘object’ in the group – the individual, conductor and groupas-a-whole. A threeperson psychology works in the bounded space between them.

MEMBER 2

Structural dynamics relate Member 3 to the conductor and to groupas-a-whole.

MEMBER 6

MEMBER 3

MEMBER 4 MEMBER 5

Boundary of group-as-a-whole

Figure 7.4  The elements of a Group-analytic group Source: Figure 7.4 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Figure 6.3.6.6, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1358. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my coauthor Malcolm Pines for his consent to their re-use here.

7  Methods applications and models  211

way of understanding the crucial links between each member, the conductor and the group as a whole. Together they form a matrix, a term that represents the interconnecting latticework of relationships including all the group’s members and the conductor. The triangle by which the group’s psychological ‘objects’ are linked to each other illustrates one of the six corresponding patterns of connection for each of the group’s members. When replicated for every one of its members, the diagram produces a matrix of relational patterns, a complex relational field that will undergo change in terms of alliances, sub-groups and polarizations. This concept of the matrix allows us to accept that all events in a group become part of a network that is variously described as interpersonal, intersubjective or transpersonal. The originating literature on the matrix differentiates between its foundation features and its dynamic properties, discussed in Chapter 1. I have introduced another distinction in Chapter 4 differentiating between a group’s relational and semantic fields, the first governing affect and cohesion and the second governing meaning and coherence. In the matrix of shared experience a group generates the capacity to receive, contain and eventually transform individuals’ contributions and to foster integration at the individual level as it does so in the group as a whole. James has introduced a set of theoretical constructs that define key aspects of group life through holding and containment that derive – respectively – from Winnicott and Bion, each of which give a different emphasis to the way in which the group ‘embraces’ its members (James 1994, 2000:60–79). The psychoanalytic model in the United States Psychoanalytic group therapy in North America begins with Slavson, whose clinical influence with groups for the parents of children in difficulty and his focus on the dynamics of projection in groups has been of lasting importance. His organi­ sational efforts lead to the formation of the American Group Psychotherapy Association. Schwartz, later joined by Wolf, began to apply psychoanalytic ideas to group psychotherapy in the late 1930s. In their approach people underwent individual psychotherapy in the setting of a group, a parallel process alongside their fellow patients, with attention focused on the transferential relationship between each individual and their therapist. Foulkes’s criticism at the time was that the approach overlooked any systematic use of group-specific process, and in contrast to their ‘psychotherapy in the group’ he offered group analysis as a clinical alternative, describing it as ‘psychotherapy by the group’. A discussion of this history can be found in Schlapobersky and Pines (2009) and will not be further reviewed here. Connections of current relevance arise out of the work of Scheidlinger in New York and Grotjahn in California, both seminal figures in the development of American psychoanalytic group therapy. The former brought interest to bear on whole object relations in the transference domain of the group. His studies of the group as mother or father and of the therapist in the position of the other parent are of profound and continuing relevance (Scheidlinger 1982). Grotjahn developed

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an interest in process dynamics that governs the work he describes and, in close association with Foulkes he augmented the study of transference in groups. What stands out in his writing is the dominant person and personality of the therapist with process dynamics organised around him. From the group-analytic standpoint this presents a worrying picture, for he appears to work without structural principles so strange boundary issues seem to arise, ungoverned by the principles of dynamic administration described in Chapter 9 that are key to the group-analytic approach. His later work on ‘the voice of the symbol’ is an arresting and original contribution to the study of content cited through this book and specially relevant to Chapter 11 (Grotjahn et al. 1983; Grotjahn 1993). Modern psychoanalysis in the United States Spotnitz developed the foundations of Modern Psychoanalysis in New York with writing and clinical practice in the 1950s and 1960s focused on therapeutic use of transference, dealing with resistance and the value of countertransference especially in analysing narcissistic defences. Ormont was a leading figure in his circle who founded the Centre for Group Studies (CGS) in 1989. Its five ‘pillars of theory and method’ include the observing ego, insulation barrier, principles of generative communication, of immediacy and of the group as maturational agent. This has close bearing on the group-analytic model and his Selected Papers (Ormont and Furgeri 2001) show how derivative his ideas were of Foulkes, who was a generation older. They would meet at international conferences, and we have recorded interviews of Ormont describing Foulkes’s influence. Graduates of the CGS call themselves group analysts, which some in Europe regard as controversial. But the term ‘group analysis’ originated in North America in any event. Whether its founder, Burrow, would recognise or validate either the Modern analytic model or the European one is open to question. The Modern analytic model has much to contribute to the development of group analysis. It has a well-documented and rich, developing literature sharply focused on clinical practice. Key differences are that their model is much more leader-centred than the European one; they describe the therapist as ‘leader’ rather than ‘conductor’ and – following Ormont’s initiative – their work is often highly directed, for which they make active use of the principle of bridging. To date the only systematic comparisons between the European and Modern analytic forms of group analysis are in conference presentations described below. Current developments in their literature that have especially close bearing on group analysis in Europe include the work of Epstein and Feiner (1979), who produced an edited collection on countertransference and explore the way it can be put to use in groups. Extracts from a recent paper by Levine focus on the key issue of emotional communication and the importance of engagement that is not dominated by interpretations in the analytic space: Many of the current psychoanalytic perspectives . . . now converge on the theoretical importance of emotional communication between patients and therapists and the practical need to develop interventions beyond interpretations

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. . . the key for working with regressive experience lies within the therapeutic relationship, including the unformulated and preverbal engagements . . . Regressions can be opportunities for dialogue. Reflection replaces venting and manipulation as communication is enriched with awareness and tolerance for feeling . . . new consciousness of self and other (can) produce mutual reparative emotional communication . . . The therapy group provides opportunities for these experiences to be understood . . . (and) the maturational emotional nutrients . . . required for the development of resilience, differentiation and new ways of relating and coping. (Levine 2015:112, 118, 119) Zeizel has published extensively on the subject of immediacy. One of his most recent publications on the leader’s use of self focuses on how transference and ­countertransference dynamics can be captured in the moment and bring to the surface long-hidden and deeply repressed anxieties (Zeizel 2012). Cohen’s work extends this use of immediacy to focus on the anniversary effects of bereavements in groups, for which she draws on the writing of Epstein and Feiner. She describes group therapy as ‘particularly effective in surfacing hidden anniversary reactions that often block the course of treatment’. This is quoted in a full account in Chapter 3 of this volume (Cohen 2007:153). System-Centred Therapy for Groups (SCT) Agazarian developed a theory of Living Human Systems on which she based her System-Centred Therapy for Groups (1997). She applies constructs to the understanding of the individual, of the individual as a small group member and then to both the individual and their small group as members of a larger group and of society at large. She shows these constructs to be isomorphic across the living systems in which they arise. She has developed the notion of functional sub-grouping that can be applied to all change practices in psychotherapy, organisational development and, for example, political mediation. Her principle of functional subgrouping is called on throughout this book to understand the inevitable divisions that arise in small group psychotherapy in the polarizations and clusters of alliance, identification, opposition and counter-position that arise. Change effected at one level of a living system has inevitable consequences for the changes that will arise at the other levels, and she provides a key way of understanding what we do as group therapists and why we do it in groups. Her appreciation of the individual as a living human system and her gift for identifying that sub-grouping is functional and can have restorative benefits when worked with, has put her model at the forefront of current North American practice and generated worldwide interest in the workshops she conducts. She has been a pioneer of innovative theory and practice and has mastered a written appreciation of the systemic nature of things that was an inspiration to Robin Skynner in the last years of his life as he saw – for the first time – the systemic principles he had developed for family therapy being successfully applied to small groups.

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As well as a pioneer in the development of a theory and its practice and in its extension to the practice of other methods, she has been a prescient observer of other developments in the field. She was the first amongst North American practitioners to recognise the significance of Foulkes’s interest in resonance, even before her own theory of living systems had matured and long before others saw its significance. Her own understanding and use of resonance is now an incorporated principle of SCT. Her early recognition of its importance is called on through references to her work in Chapter 10 to help tell the developing story of group analysis.

The place of the therapist in each model: A critical comparison Writing for the Psychodynamic model in the United States, Scott Rutan, Stone and Shay provide a figure that helps frame and identify the nature of leader activity which is described here as Figure 7.5. This figure has excellent clinical utility in contrasting for immediate clarity the therapist’s stance on a number of key issues. On looking at comparisons between the Group-analytic, Interpersonal and Tavistock models, we can consider the theoretical position to which each of these different models might be expected to commit its practitioners. Beginning with the therapeutic role we can see that in the first of the two sets, the Tavistock model The Therapist’s Role ACTIVITY

NON ACTIVITY

TRANSPARENCY

OPAQUENESS

GRATIFICATION

FRUSTRATION The Therapist’s Focus

PAST

HERE AND NOW

FUTURE

GROUP AS A WHOLE

INTERPERSONAL

INDIVIDUAL

IN GROUP AFFECT PROCESS UNDERSTANDING

OUT OF GROUP COGNITION CONTENT CORRECTIVE EMOTIONAL EXPERIENCE

Figure 7.5 Tools for systematic comparison of leader activity and focus across models: Rutan, Stone and Shay

7  Methods applications and models  215

takes the therapist to an extreme position on the right for all three of the continua described – they are not active; they are opaque and regard the engendering of frustration within the group as part of what the model itself commits them to. The Group-analytic model also requires the therapist’s non-activity but not at the same extreme of this continuum, giving latitude for the exercise of discretion in taking up an active position during stressful or anxious transitions in the life of the group. This might also serve as a description of the Interpersonal therapist’s position on these continua. They will be self-disclosing in the service of the group’s progress, often taking up a position as a group member when required to do so by the dynamics of the situation. When it comes to focus, the Tavistock model does not commit its therapist to a position on the first continuum in the modality of time but it does commit the therapist to an extreme position on the left in addressing only the group as a whole and never either the interpersonal domain or the individual members. The Interpersonal model focuses actively on the interpersonal domain and the Group-analytic model allows discretion – as governed by the triangle demarcating thematic focus – between the individual, the interpersonal or the group as a whole. With the consent of its authors, I have applied Figure 7.5 to the systematic comparison of an extended number of models in order to provide a critical framework for the comparison of leadership role and focus amongst them. I have done so by sending Figure 7.5 out to a number of leading group therapists who could be seen as ‘representatives’ of the model they work to. They have contributed to the discussion by marking up this figure to identify their own position on the therapist’s role and the therapist’s focus. These responses are illustrated in Figures 7.6a and

Figure 7.6a Tools for systematic comparison of leader activity across models response profile A 1–3: therapist’s role

Figure 7.6b Tools for systematic comparison of leader activity across models: response profile B 4–9: therapist’s focus in group

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7.6b respectively. The key in Figure 7.6a shows how the models have been set out in an alphabetical sequence and then numbered from one to seven for the purpose of identifying the responses shown in both figures. Scanning the rows of boxes in both figures shows that in 1 – the Group-analytic model – there are three respondents. In 2 – the Interpersonal – there is one respondent, and so on in sequence. In Figure 7.6a, each of the respondents has identified their position on the therapist’s role defined by three sets of criteria – Activity/Nonactivity; Transparency/ Opaqueness; and Gratification/Frustration. In Figure 7.6b the therapist’s focus is defined by six sets of criteria – Past/Here and Now/Future; Group/Interpersonal/ Individual; In group/Out of group; Affect/Cognition, Process/Content; and Understanding/Corrective emotional experience. When these two tables are considered together itt is startling to find that these therapists’ responses do not correspond to the models they subscribe to with any consistent ‘grouping’ of their self-rating. Therapists’ role and focus reflect the personal style and approach of the individual therapist, regardless of the model they subscribe to. This is a small sample and its claims cannot be regarded as valid or reliable for the field as a whole but it serves as a modest comparative exercise before we move on to a more robust enquiry into the Group-analytic model in Section II.

Note 1 This chapter adapts and extends an earlier one jointly written with Malcolm Pines and published as Group Methods in Adult Psychiatry in The New Oxford Textbook of Psychiatry, M. Gelder et  al. (Eds.), Oxford University Press, 2009, pp.  1350–1368. Acknowledgements are made to Oxford University Press for permission to adapt and reissue the original material and to my co-author Malcolm Pines for his consent to its re-use here.

Bibliography Agazarian, Y. (1997). Systems-Centered Therapy for Groups. New York, Guilford. Agazarian, Y. (1999). Phases of Development in the Systems-centered Group. Small Group Research 30 (1): 82–107. Agazarian, Y. (2001). Systems-centered Therapy for Inpatients. London, Jessica Kingsley. Agazarian, Y., and Gantt, S. (2000). Autobiography of a Theory. London, Jessica Kingsley. Agazarian, Y., and Peters, R. (1981). The Visible and Invisible Group. London, Routledge. Agazarian, Y. M. (1994). The Phases of Development and the Systems-centered Group. In M. Pines and V. Schermer (Eds.), Ring of Fire: Primitive Object Relations and Affect in Group Psychotherapy. London, Routledge, Chapman & Hall, pp. 36–85. Agazarian, Y. M., and Janoff, S. (1993). Systems Theory and Small Groups. In I. Kaplan and B. Sadock (Eds.), Comprehensive Textbook of Group Psychotherapy, 3rd Edition. Baltimore, Williams & Wilkins. Ahlin, G. (1988). Reaching for the Matrix in Group Analysis. Group Analysis 21: 211–226. Bion, W. (1961; reissued 2000). Experiences in Groups. London, Routledge. Brown, D. (2003). Pairing Bion and Foulkes: Towards a Metapsychology. In R. M. Lipgar and M. Pines (Eds.), Building on Bion: Roots. London, Jessica Kingsley Press, pp. 153–180.

218  I Foundations Cohen, P. (2007). ‘Past Time’: Anniversary Reactions That Can Confound the Group Analyst. International Journal of Group Psychotherapy 57 (2):153–166. Cox, M., and Theilgaard, A. (1987). Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley. Creek, J. (Ed.). (1997). Occupational Therapy and Mental Health. Edinburgh, Churchill Livingstone. Dick, B. M. (1975; reissued 1983). A Ten-year Study of Out-patient Analytic Group Therapy. British Journal of Psychiatry 127 (4): 365–375. Reissued in M. Pines (Ed.), (1983), The Evolution of Group Analysis. London, Routledge, pp. 54–75. Epstein, L., and Feiner, A. H. (1979). Countertransference. New York, Jason Aaronson. Ezriel, H. (1950). A Psychoanalytic Approach to Group Treatment. British Journal of Medical Psychology 23: 56–74. Foulkes, S. H. (1948; reissued 1983). Introduction to Group-Analytic Psychotherapy. London, Karnac Classics. Foulkes, S. H. (1964; reissued 1986). Therapeutic Group Analysis. London, Karnac. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Frank, J. D., and Frank, J. B. (1961; 1993). Persuasion and Healing. Baltimore, Johns Hopkins University Press. Friedman, R. (2008). Dreamtelling as a Request for Containment: Three Uses of Dreams in Groups. International Journal of Group Psychotherapy 53 (3): 327–344. Garland, C. (2010). The Groups Book. London, Karnac. Golden, S. et al. (1993). Dynamic Group Therapy for Substance Abuse Patients. In A. Alonso and H. I. Swiller (Eds.), Group Therapy in Clinical Practice. Washington, DC, American Psychiatric Press, pp. 271–287. Grotjahn, M. (1993). The Art and Technique of Analytic Group Therapy. Northvale, NJ, Jason Aaronson Inc. Grotjahn, M., et al. (1983). Handbook of Group Therapy. New York, Van Nostrand Reinhold & Co. Guys, J. (1983). Foulkes’s Concept of the Matrix. Group Analysis 15: 111. Hopper, E. (1997; 2003). Traumatic Experience in the Unconscious Life of Groups: A Fourth Basic Assumption. 21st S. H. Foulkes Annual Lecture. Group Analysis 30 (4): 439–470. Reissued in E. Hopper (2003). Traumatic Experience in the Unconscious Life of Groups. London, Jessica Kingsley, pp. 66–90. Horwitz, L. (1977; reissued 2014). A Group-Centred Approach to Group Psychotherapy. International Journal Group Psychotherapy 27: 423–439. Reissued in L. Horwitz (2014). Listening With the Fourth Ear: Collected Papers. London, Karnac, pp. 83–98. James, C. (1994; 2000). ‘Holding’ and ‘Containing’ in the Group and Society. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. London, Routledge. Reissued Jessica Kingsley Press, pp. 60–79. Kanas, N. (1999). Group Therapy with Schizophrenic and Bipolar Patients. In V. Schermer and M. Pines (Eds.), Group Psychotherapy of the Psychoses. London, Jessica Kingsley, pp. 129–147. Lawrence, G. W., Bain, A., and Gould, L. J. (1996). The Fifth Basic Assumption. Free Associations 6 (37): 28–55. Levine, R. (2015). Progressing While Regressing in Relationships. In R. Grossmark and F. Wright (Eds.), The One and the Many: Relational Approaches in Group Psychotherapy. London and New York, Routledge, pp. 112–127.

7  Methods applications and models  219 Lipgar, R., and Pines, M. (2003). Building On Bion: Vol. 1: Roots; Vol. 2: Branches. London, Jessica Kingsley. Lorentzen, S. (2000). An Assessment of Change After Long-Term Psychoanalytic Group Treatment. Group Analysis 33: 373–396. Malan, D. (1976). A Follow-up Study of Group Psychotherapy. Archives of General Psychiatry 33: 1303–1315. Maratos, J. (Ed.). (2006). Resonance and Reciprocity: Collected Papers of Dennis Brown. London, Routledge. May, R., and Yalom, I. D. (1989). Existential Psychotherapy. In R. Corsini and D. Wedding (Eds.), Current Psychotherapies. Itasca, IL, F. E. Peacock, pp. 363–402. Neri, C., Pines, M., and Friedman, R. (2002). Dreams in Group Psychotherapy. London, Jessica Kingsley. Nitsun, M. (1996). The Anti-Group: Destructive Forces in the Group and Their Creative Potential. London, Routledge. Nitsun, M. (2006). The Group as an Object of Desire: Exploring Sexuality in Group Psychotherapy. London, Routledge. Ormont, L. (1992). The Group Therapy Experience: From Theory to Practice. London, Vintage; New York, St. Martin’s Press. Ormont, L., and Furgeri, L. B. (2001). The Technique of Group Treatment: The Collected Papers of Louis Ormont. New York, Psychosocial Press. Pertagato, E., and Pertagato, G. (2013). From Psychoanalysis to the Group: The Pioneering Work of Trigant Burrow. London, Karnac. Pines, M. (1982, 1998). Reflections on Mirroring: Sixth Annual Foulkes Lecture. Group Analysis 15, Supplement; and in Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London, Jessica Kingsley, pp. 17–39. Pines, M., and Hearst, L. (1993). Group Analysis. In I. Kaplan and J. Sadock (Eds.), Comprehensive Group Psychotherapy. Baltimore, Williams & Wilkins. Pines, M., Hearst, L., and Behr, H. (1982). Group Analysis (Group Analytic Psychotherapy). In G. Gazda (Ed.), Basic Approaches to Group Psychotherapy and Group Counselling. Springfield, IL, Charles C. Thomas, pp. 132–178. Rutan, J. S., Stone, W., and Shay, J. (2014). Psychodynamic Group Therapy 5th Edition. New York, Guilford Press. Scheidlinger, S. (1982). Focus on Group Psychotherapy: Clinical Essays. New York, International Universities Press. Schlapobersky, J. (1986; reissued 1990). Editor’s Introduction and Author’s Biography. In A.C.R. Skynner (1986,1990). Explorations With Families: Group Analysis and Family Therapy: Selected Clinical Papers of Robin Skynner. London, Routledge, pp. xvii–xxviii. Schlapobersky, J. (1994; 2000). The Language of the Group: Monologue, Dialogue and Discourse in Group Analysis. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. London, Routledge. Reissued Jessica Kingsley Press, pp. 211–231. Schlapobersky, J. (1996). Forensic Psychotherapy: A Group-Analytic Perspective – From the Speech of Hands to the Language of Words. In C. Cordess and M. Cox (Eds.), Crime, Psychodynamics and the Offender Patient. London, Jessica Kingsley Press, pp. 227–243. Schlapobersky, J., and Pines, M. (2009). Group Methods in Adult Psychiatry. In M. Gelder et al. (Eds.), The New Oxford Textbook of Psychiatry. Oxford, Oxford University Press, pp 1350–1368.

220  I Foundations Sigrell, B. (1992). The Long-term Effects of Group Psychotherapy. A Thirteen Year Follow Up Study. Group Analysis 25: 333–352. Skaife, S., and Huet, V. (Eds.). (1998). Art Psychotherapy Groups. London, Routledge. Spotnitz, H. (1961; reissued 2012). The Couch and the Circle: A Story of Group Psychotherapy. New York, Alfred A. Knopf. Stone, W. (1996). Group Psychotherapy for People With Chronic Mental Illness. New York, Guilford. Sullivan, H.S. (1953; 1997). The Interpersonal Theory of Psychiatry. New York, William Alanson White Psychiatric Foundation. Reissued New York, Norton. Turquet, P. M. (1975). Threats to Identity in the Large Group. In L. Kreeger (Ed.), The Large Group. London, Constable, pp. 87–144. Urlich, I. (2012). Group Psychotherapy for Patients with Psychosis: A Psychodynamic (Group-Analytic) Approach. In J. Kleinberg (Ed.), The Wiley-Blackwell Handbook of Group Psychotherapy. Chichester, UK, John Wiley and Sons, pp. 547–569. Whitaker, D. S., and Lieberman, M. A. (1964). Psychotherapy Through the Group Process. London, Tavistock. Yalom, I. (1983). In-Patient Group Psychotherapy. New York, Basic Books. Yalom, I., and Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy 5th Edition. New York, Basic Books. Zeizel, E. (2012). The Leader’s Use of Self: A Modern Analytic Approach to Working in the Intra-psychic and Interpersonal Realm. Modern Psychoanalysis 37: 2, 43–58.

Acknowledgements:  Figures 7.1, 7.2, 7.3 and 7.4 reproduced with permission from Malcolm Pines and Oxford University Press; Figure 7.5 reproduced with permission of Walter Stone; extracts from Nitsun (1996), The Anti-Group: Destructive Forces in the Group and Their Creative Potential, reproduced with permission from Morris Nitsun. Special acknowledgements also to respondents to the survey based on Figure 7.5 to Claudia Arlo, Jale Cilasun, Phyllis Cohen, Sue Einhorn, Ray Haddock, Sylvia Hutchinson, Lawrence Ladden, Ronnie Levine, Sheila Ritchie, Walter Stone and Eliot Zeisel.

Section II

The group-analytic model

Section overview This section’s five chapters explore the group-analytic model in detail. Chapter 8 introduces the three dimensions of a group – structure, process and content – giving an overview of their relevance to the work of the conductor. Each of these dimensions is then studied in detail in Chapters 9, 10 and 11, where they are taken separately. Other key group-analytic concepts are located in these different dimensions. Dynamic administration is located in a group’s structure in Chapter 9. Group-specific factors are re-named process dynamics in Chapter 10. A group’s language, imagery and thematic development are located in its content in Chapter 11. Chapter 12 brings the three dimensions together in the conductor’s work to examine therapeutic leadership. The conductor provides structure through dynamic administration, group members provide content through free-floating discussion and together they meet in the group’s process dynamics. The integration of these dimensions to work in a synchronous way relies on the conductor who is all of three people at once in any group they conduct – convenor, therapist and group member. In Chapter 12 these different role functions are first studied separately and then brought together. The newest member of a group asks, three months into his attendance, if this therapy can really work. He is not convinced and cannot understand how sitting, listening and even talking – which he has yet to do – can make any difference to the predicament of his life. The conductor provides a curious reply. All you need to do, she says, is safeguard three things. Attend reliably, participate and pay your fee. If you satisfy these three things the group will inevitably see you change. Several of the others come forward to groan about ‘that famous phrase of assurance’ and challenge the conductor for making standard use of these words. And then they smile and say, ‘Just because it’s true, you don’t need to keep on saying it’. One year later the former newcomer makes the same assurance to someone who has come in after him. Reliable attendance satisfies a structural principle. Paying the fee meets the conductor’s contract. Participation involves process and content. Structure, process, content and the conductor are explored in the five chapters that follow. The model is non-directive and neither technique based nor programmatic. A conductor who takes a manual with them into the consulting room could easily lose sight of their way and mistake the map for the territory. Still, a map is a useful guide on a journey into even familiar territory and Figure ii.1 gives a comprehensive picture of the three-dimensional model of the group and the conductor’s role functions.

222  II  The group-analytic model

The vignettes that follow in these different chapters have been selected because they illustrate vividly the dynamics of these dimensions in each case. The Story of the Wooden Spoon sheds light on structure in Chapter 9; The Story of The Four Fingers Linked to Describe Partnership sheds light on process in Chapter 10; and the two stories that illustrate content in Chapter 11 are The Story of Anger and Its Monsters and The Story of the Baby Whose Birth Saved Her Mother. Each of these stories, like the work of all our groups, can be called on to describe any of the three dimensions – they are different ways of coming at the same key issues. THREE DIMENSONS AND THEIR DYNAMICS

CONDUCTOR’S ROLE-FUNCTIONS & TASKS

A: STRUCTURE

A: CONVENOR: Dynamic administraon

Individual Member

Conductor

Establish relaonal dimension through: 1 Group selecon & composion to 2 Manage seng 3 Manage boundaries, membership & me by 4 Working with structural dynamics Group-as-awhole

B: PROCESS

B: CONDUCTOR (1) AS THERAPIST

Mirroring

Facilitate members’ parcipaon. Promote movement to reflecve dimension, working with process to: 1 Culvate free-floang discussion 2 Promote discourse 3 Locate focal conflicts & group preoccupaons 4 Translate from language of unconscious symptoms to descripve & conscious behaviour ‘ego training in acon’

Resonance

Valency Amplificaon & Condensaon Reciprocity

C: CONTENT

C: CONDUCTOR (2) AS THERAPIST & GROUP MEMBER

Shared experience of group analysed in 4 domains:

Work as therapist & group member, provide analysis, use countertransference & interpretaon to foster reparave dimension in 4 domains:

1

Current

1 Therapist’s holding, containment & reflecon

2

Transference

2 Analysis of transference issues

3

Projecve

3 Interpretaon & use of countertransference

4

Primordial/archaic

4 Mutave use of metaphor

Figure ii.1  The Conductor’s Map – Structure, process and content Source: Figure ii.1 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Figure 6.3.6.7, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1359. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my coauthor Malcolm Pines for his consent to their re-use here.

Chapter 8

A group’s three dimensions Structure, process and content

Every now and then in the history of the therapeutic sciences, certain key words suddenly appear and illuminate the intellectual landscape. Two of these words that are highly pertinent and have become the basis of metapsychology are process and structure. . . . Together (they) generate content which can be described as the stories that patients tell within the individual and group situation or the nonverbal messages that they convey. (Anthony 1978:11)

Structure, process and content, the three dimensions introduced in this chapter, are dimensions of the group rather than of its therapy. These foundation concepts lay the groundwork for this section through which they are each addressed separately in the chapters that follow. They are then brought together in Chapter 12 through the leadership role of the conductor, whose work will be most fruitful if it is an integrated and seamless involvement in a group’s life. So each of the group’s dimensions needs to be understood and worked with, though each can only be understood in relation to the others. In practice, training and supervision, primacy is given to structural issues through dynamic administration. The fruitful development of process dynamics rests on the stability and security afforded at the structural level. Whilst issues to do with content – in the metaphorical, symbolic or analogical dimensions of what people say to one another in a group – capture people’s attention in the most vivid way – this level is contingent on both the others. For example, in a hospital group the institution failed to honour its commitment to reliable space for a group’s regular meetings and there was a serious structural problem which put the conductor under pressure over the group’s boundaries. He needed to negotiate better terms with the hospital to protect the group. Whilst this was going on members’ ensuing anxieties over intrusion, relocation and conflict over space emerged in the content of their associations as they talked about shared childhood experience of war-time evacuation. It was down to the conductor to make a judgement about whether to direct the process towards the recognition of a connection between past and present anxieties. Using the principle the location of disturbance studied in Chapter 17, he could have made a construction about the link between people’s past experience of evacuation and the group’s current experience of insecurity. In doing so he would have been using his understanding

224  II  The group-analytic model

of free-floating discussion to link the content of the associations, the process by which they are shaped and the structural issues that gave rise to them. On the other hand, whilst this quality of understanding informed the conductor’s position, he chose wisely to provide a different intervention in the form of a transparent assurance to the group that he had done the necessary negotiation with the hospital and would, from now on, be able to protect their time and space and provide them with a secure environment. He used dynamic administration to make a structural intervention that was much more appropriate in the moment. Location, translation and interpretation followed later. In the first edition of the Foulkes and Anthony text of 1957, structure, process and content emerge as key considerations, much as Anthony describes them in the quotation above.1 This chapter takes these dimensions together using the outline they give as follows: The psychotherapeutic situation is analysed in terms of structure, process and content: Structure concerns patterns of relationships that are relatively stable and continuous. The therapist sees into it forms and organisation taking shape as figurations. He also notices the habitual roles adopted by the members which may not be unlike the roles they play in their usual environment. The structural or figurational analysis, as will be seen later, is especially important in the localization of persistent disturbances in the group. Process is the dynamic component of the situation and can be defined as the interaction of the elements of the situation in their reciprocal relationships and communications, verbal and non-verbal. It is the functioning segment of all human experience, and it is with the analysis of process that the analytic situation receives its fullest and most significant definition. Structure and process are the channels through which Content is transmitted, and the analysis of content – the attitudes, ideas, values, sentiments, feelings . . . Structure and process also determine in what way the communication of content takes place. (Foulkes and Anthony 1957:31) Definitions of the three dimensions Foulkes and Anthony’s definitions inform the field. I have recast them in places to bring them into line with the practice described in this book. Structure: describes the more enduring aspects of any group’s makeup, the ‘architecture’ of its interpersonal relations conceptualized first in terms of the setting and its boundaries and then in the bond between each individual, the therapist(s) and the group as a whole. In Chapter 10 I have located in this structural dimension the key concept of dynamic administration. It embraces the conductor’s role as convenor or clinical manager and gives dynamic meaning to the group’s composition, membership and the conductor’s management of its setting, boundaries and duration.

8  A group’s three dimensions  225

Process: describes the fluid and dynamic fluctuations of emotion and experience in a group, the business of relating and communicating, the changes of association, the inter-member reactions and responses to one another and to the conductor and the conductor’s own subjective experiences, including transference and countertransference. Foulkes and Anthony devised a term for these foundations of group experience, first formally described in the 1957 text. They called them group specific factors (Foulkes and Anthony 1965:149–152; Zinkin 1994/2000). They were outlined in varying ways in Foulkes’s different books and papers. The literature since then has seen a variable pattern of development with some of the key concepts – like mirroring – enjoying fruitful development in the writing of some of Foulkes’s most notable successors like Pines. Authors of distinction working with groups in other traditions like Agazarian and Peters have identified how the understanding of resonance, for example – the unconscious communication of affect – has enjoyed notable development in the work of Foulkes and the group-analytic tradition (Agazarian and Peters 1981:20). In Chapter 10 the literature on process dynamics is organised in an inclusive and coherent way around the concepts of resonance, valency, exchange, mirroring, amplification and condensation. I relate these key concepts to each of the others and show them at work in vignettes. The dimensions of structure and process are inseparable. Calling on structural principles for the composition of the group and its setting, the conductor assembles a group whose membership will foster the process dynamics described above, through which it can progress from the relational to the reflective and then reparative dimensions of experience, so people can make new terms of understanding with the hurt, the hidden and the unresolved in their own and in one another’s lives. Content: is the third dimension of a group. I have taken Foulkes’s wellknown contribution to the field in his notion of a group’s four levels – current, transference, projective and primordial levels – and explored the content of a group’s life at each of these levels in Chapters 11 and 13. The dimension of content can be viewed through narrative, on the one hand, that unfolds in stories about the past, the present – inside and beyond the group – and the whole outside world. And it can be viewed on the other hand in the drama of immediate exchange in people’s encounters with one another. So content relates to the group’s visible and audible events, the narrative line and dramatic content of members’ encounters, the topics raised in their exchange, their thematic development and the extent to which certain key issues are explored or avoided. Foulkes provided crucial ideas about the four levels at which the content of the group’s discussion can be analysed in the search for meaning (Foulkes 1964:114–116). In the Tavistock model this is the therapist’s exclusive task, whereas here the interpretative contribution is regarded as only one amongst a number of others.

226  II  The group-analytic model

Using the three-dimensional model In the group-analytic approach the conductor’s overall stance is to foster communication and educate the group’s members about the dynamic links between structure, process the content of the discussion and the form in which it takes place . This set out diagrammatically in Figure 8.1. Therapy progresses through the interplay of drama and narrative, through intense emotion based on exchanges in the present, interpolated by the narration of those past and present stories that continue to live on in its members’ memories. Fluctuations in focus will see discourse shift between conversations about the past, the dynamic present and the world outside the group. As it does so there will inevitably be a modified re-enactment by its members of those repetitive past patterns that may have blighted their histories, but it takes place now in the safety of a reflective and facilitating environment. The content of a group’s exchange, both in its narrative and in the drama of immediate exchange, involves the ordinary language of intimate conversation. This is free-floating discussion, the group equivalent of free association discussed already in Chapter 4. Through the interplay between speech and silence, different dynamics of narrative and drama bear fruit with movement between the recounting of stories and their re-enactment. The approach requires special tasks of the conductor that involve the location of a group’s preoccupations, the translation of hidden issues into a common and conscious language, and their interpretation to foster cohesion and to develop a sense of coherence, a shared understanding of what people have come to mean to one another through their relationships, during their time in the group. The tasks of location, translation and interpretation are not the sole prerogative of the conductor. Real resolutions arise when a group’s members adopt these tasks on mutual terms as the group fosters regressive and progressive dynamics and its cohesion matures into a developing sense of coherence. Figure 8.1 places the conductor in the three dimensions of a group. The conductor’s decisions about intervention will be guided through the process of location, translation and interpretation on terms described in Chapter 17. These terms will be influenced by which of the group’s four domains is the governing one at any therapeutic moment and which may provide a defensive arena of avoidance or denial. The current domain is where ‘it all begins’. The group begins and ends and its members come and go in this domain. But issues as fundamental as beginnings and endings will have deep significance in each of the other domains. Without fruitful and focussed attention given to the structure, process and content of the current domain none of the others can yield their therapeutic potential. It is at the deepest of these domains, the primordial or archaic – sometimes the most hidden and at others the most transparent – that the unconscious comes most vividly to life in the circle of exchange. The representational world that emerges through dreams, fantasies and the other constructs of the imagination can yield resolution of lasting significance when resolving dynamics – including reparation – take symbolic form. Cox calls these figurations ‘mutative metaphors’. Discourse theory can here be combined with depth psychology by focussing on critical questions that cut across these four domains: Who is talking? Who is listening? What is the message? What is not being said?

8  A group’s three dimensions  227 Group Analyc Psychotherapy 1: Group Acvity

Psychotherapy in the group, by the group, including the conductor

2: Group Conductor

As 1) Convenor 2) Therapist 3) Group member

3: Group Matrix

The ordinary language of shared conversaonal experience in which people struggle with meaning

4: The Three Dimensions of a Group: Structure, Process and Content Structure

Process

Content

Figure 8.1  Defining the group-analytic model Source: Figure 8.1 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Figure 6.3.6.6, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1358. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my coauthor Malcolm Pines for his consent to their re-use here.

The shared world constructed by a therapy group’s members includes – at the visible and current level – their repetition compulsions, fate neuroses and ongoing difficulties in life. Homogeneous groups set up to cater for – say – people with addictive problems or anti-social behaviour will have the index problem as a ‘badge of entry’. But the index problem will often be an elusive subject as patterns of avoidance and denial take the group’s enquiries away from likely resolutions. The conductor’s skill will here lie in the balance between invitation and confrontation, to move its process dynamics and content into an engagement with the unspoken and from there to the unspeakable. In mixed groups that are drawn up to create heterogeneity, the originating injuries lying behind people’s difficulties are often invisible at the outset. The group first provides a containing resource that – through mutual acceptance and then identification – deepens the enquiry and the spiral of enquiry, and development leads to the sources of each person’s complexity. These are often discovered in a range of issues that would have been

228  II  The group-analytic model

invisible to all parties at the outset in a domain that had been – seemingly – without problems. As the group comes to follow the ‘signposts’ offered by Garland in her celebrated paper, Taking the Non-Problem Seriously (Garland 1982), the matrix of experience that conditions the social unconscious of its injured members can also provide the vehicle for repair. Authority and meaning as the basis for intervention Two groups described in the following vignettes illustrate work with these dimensions. Vignette 8.1 describes a series of structural interventions to address boundary events during enactments in a new group in which members are repeating through their troubled terms of attendance the very problems that brought them for help in the first place.2 The conductor calls on their authority as convenor to work through dynamic administration and enforce the group’s boundaries. Vignette 8.2, by contrast, is taken from a group that has been running productively for many years with a slow, steady turnover of members. Its normally good attendance – one amongst other indicators of high motivation and good outcome – is currently under dynamic pressure. Here the conductor uses interpretive language to locate and explore the unconscious meaning of disturbance. Structural intervention – authority Vignette 8.1  Challenges at the broken boundary: Structural interventions establishing authority Colleen and Brian are described in Vignette 3.1b struggling with their terms of engagement in a relatively new group. The conductor set it up some months earlier to cater for people with serious mood disorders who were also in receipt of psychiatric care. There were two drop-outs from the full complement of eight people he began with, and in due course he filled those places, but neither of these new members was finding it easy to settle or accept the therapeutic terms laid out. Colleen sometimes paid her fee and sometimes did not, she sometime attended and sometimes did not and she sometimes participated and sometimes did not. Brian was always present, always involved and always late and almost never paid his fee. These two new members clearly had boundary issues that were bound up with both their mood disorders and their relational difficulties that, in both cases, took the form of Friedman’s exclusion and scapegoating dynamics introduced in Chapter 1. The conductor elected a tolerance towards them both for the opening months of therapy as the group settled, stabilised and established a capacity to hold its members on cohesive terms. As it gained

8  A group’s three dimensions  229

in the quality of understanding of self and other that allowed the location of disturbance on the group’s broken boundary, he began to focus more systematically on the two who kept breaking it and called ‘time’ on their transgressions to establish his authority.

Commentary As described in Vignette 3.1b on page 103, the conductor first took up the fee issue with Colleen, in which he was ‘helped’ by Brian, who was beginning to see her conduct as an unpleasant reflection of his own. Then he later called on Colleen to help address the hidden aggression in Brian’s continuing attacks on compliance. And finally he offered the group a clear statement of his own authority in the responsibility he held for dynamic administration. The issue was by then on a different footing, as the group had moved in its enquiries from cohesion to coherence and began to look at the hidden meaning of transgressive conduct.

Interventions that look for meaning Vignette 8.2  Poor attendance and the baby at the breast: Process-based interventions looking for meaning

The attendance pattern for the seven members of this group has been unusually troubled recently. Questions are raised each time someone else gives notice that they have to be away for a session or two, but the pattern continues. Barbara has been abroad dealing with family property, Anita has been out of town helping her dying grandmother, James has had flu, Sheila has been to see a teacher at her children’s school, Marcel had a pressing work commitment, Joanna has been helping her daughter and new grand-child who need her and only Maria – speaking now in a frank and impulsive way – says she didn’t come because she was cross and disappointed. They have not all been away at the same time, but the pattern of absenteeism has been unusually persistent. When Maria speaks up her protest follows her own absence. The conductor has been monitoring the situation and waiting for the moment to address this figuration. The words ‘cross’ and ‘disappointed’ give her the opportunity. ‘Do Maria’s

230  II  The group-analytic model

spoken emotions – feeling cross and disappointed – speak for the group as a whole? And if so, might this shed any light on our strange attendance pattern?’ She asks them this question as an enquiry rather than a challenge. James takes it up to challenge the others. He tells the group how disappointed he is over people’s recent poor attendance. He’s been here years, and it’s never been like this before. He would have been here last week had it not been for a high temperature. He was really down, like a man with serious wounds, but the rest of the group – like the walking wounded – were all avoidably absent. And yet, he says, your justifications – we’ve been over them many times – are unassailable. Who can argue with a parents’ evening at school or a grandchild’s needs or a sick grandmother? Everyone in the group has had such good reason to be away in the last month! And turning to Maria he says with a chuckle, ‘Maybe you’re the only honest one amongst us, telling us your absence is because you’ve been cross and disappointed’. Barbara asks her what she’s cross and disappointed about. ‘The group’, she says. ‘I’m not sure this is ever going to help me’. Maria is the group’s newest member. Marcel says, ‘But you’ve only just arrived!’ and Anita recounts how, during her first year in the group, she often lost any sense of hope or confidence and nearly left several times over. Maria benefits from a long period of attention from most of the group, including its conductor, addressed to her anxieties about really joining in. Half-way through the evening the conductor brings them back to the earlier question, asks them what this recent attendance pattern might mean and why it’s still being avoided. The answers lead to more conflict between different individuals and sub-groups until Sheila says to James and Anita, ‘Although James gave us all quite a bashing at the beginning about being away, you’ve both been quiet this evening, much more than you normally are, and I want you both to know that I could easily have re-arranged things at school to go in on another day but have been so cross and disappointed that you really are both leaving. I just said, “Fuck it!” when the note came from the school with an evening meeting that cut across the group, and I didn’t bother to change it. If they can just walk out on us, why should I bother to protect the time myself ?’ James and Anita have been in the group a long time, and both have given notice of departure many months before. Previously they gave and withdrew their notice, but now they are finally going to be leaving at the summer break in just six weeks. Sheila turns to them both and says, for emphasis, ‘I am so cross and disappointed that you’re going’. This becomes another voice that the group

8  A group’s three dimensions  231

organises itself around, and we spend much of the remaining half hour discussing the impending loss – the loss of the group for those going and the loss to the group for those remaining. James is acknowledged as the man with a voice for what can’t otherwise be said. It happened again this evening, people say. And they ask each other – and themselves – what will we do without him? The group has seen him through the resolution of many personal problems and through his training analysis, and he is now a qualified psychotherapist. People sometimes tease him about his adoption of a role in the group as if he were a co-therapist. Anita validates the group’s benefits in other ways. Since she joined her marriage has become intimate and rewarding, and she now has a small child who is nearly four. She joined within a year of her wedding at a time when she became sexually avoidant with her husband with whom there was a touching sincerity of feeling but with whom she could not be sexual. Many months of couples’ therapy led to the recommendation she join a group for therapeutic help in her own right for a disorder of sexual desire. The work required to address her sexual dissociation took up most of her first period in the group and led first to a happy and fulfilling sex life and then to the conception of her first child. Her months through the pregnancy gave the group its first baby, who accompanied her to the group once the baby was three months old. The baby left the group when she started walking, and now Anita thought the time had come for her to leave as well.

James and Anita both represent the rewards of successful therapy that they are now seen to be ‘taking away’ with them. The cyclical movement of people coming and going in a slow-open group is central to its progress. In due course newcomers will fill their places, but, though this cycle is so familiar and whilst everyone agrees James and Anita now have what they came for, no one wants them to leave, but no one has been able to say so. Helen goes on to tell James that his strength and goodness as a man – qualities we know she never found in her father – have become so important to her, and she begins to weep. The group will be empty without him. He is disarmed and tearful in turn and assures her she is every bit as important to him, but it really is time for him to go now. One day she’ll be in the same position, he says. We conclude with touching memories of Anita’s attendance with her baby accompanying her, sometimes at her breast. Marcel reminds her how he once said, as he watched her in the group with her baby at her breast, that he had initially been attracted to her sexually. It wasn’t until he saw and appreciated her goodness as a mother that he knew that what he most longed for was to be her baby, not her lover. We know

232  II  The group-analytic model

only too well that she is the kind of mother he’d never had. Anita’s sense of validation is passed back to him with appreciation of what he’d given her down the years, and her tears of gratitude fill the room. In time he will take the good sense of himself she confers and call on it to help him better understand the chronic conflicts he has suffered down the years with what the group call his ‘long line of disappointing ladies’. For the moment, unexpectedly and from what might have been the side-lines of this exchange, Maria is overwhelmed in a way that surprises everyone. She is now in tears, and she tells people that her history is populated with so many un-mourned losses. She can see that this is what she’s come here for help with.

Commentary The conductor concludes with an interpretation. She goes on to say that she thought different people staged so called ‘unavoidable’ absences, creating a kind of ‘leak’ in the group that reduced its pressure, in order to avoid the pain of these tears. And now that loss was finally being worked with, it was clear each one was dealing with active sorrow that belonged in the room, as well as with the hidden sorrow that lived on from their histories. By unpacking this, the group could allow James and Anita to go out on constructive terms that would in due course allow space for newcomers.

The group-analytic model is at work here. It introduces the scope of this section and its conceptual framework that will be made visible in key dynamics mapped out in the chapters that follow. They are given an overview in Table 1.2, where the visible and invisible elements of a group’s dynamic life are first introduced. The visible and invisible group The visible elements of the group’s dynamic life devolve first upon the conductor’s understanding and careful but discrete work with the dimensions of structure, process and content. Relying on her own understanding of these dimensions she is able to equip the group to locate the sources of its own disturbance and then translate the unconscious communication of anxiety into a language that all can understand in the common zone of shared experience. This brings the invisible elements into relief. Tables 8.1 and 8.2 describe the visible and invisible elements in the dynamic life of a group and the use of location, translation and interpretation to foster a three-dimensional model that brings the invisible elements to light.

8  A group’s three dimensions  233 Table 8.1  Visible elements in the dynamic life of a group 1 The movement of free-floating discussion fluctuates between monologue, dialogue and discourse. 2 The conductor takes up her role as convenor, therapist and group member. But she also gives scope for: 3 The exercise of a leadership role asserted from within the group by its members. 4 The acculturation of a recently arrived member is helped into a participating role in the group, synchronous with other dynamics that include 6 and 7 in this table. 5 The language of the group arising spontaneously is taken up in phrases used to help locate and illuminate the sources of a current disturbance. 6 Anxieties about impending loss in the group are found to lie behind its recent poor attendance. 7 Unconscious group behaviour takes a visible form that is translated from the language of descriptive behaviour into a psychological language that captures what denial has been serving to hide.

Table 8.2  Invisible elements and the emergence of a three-dimensional model 1

Location, translation and interpretation are key contributions to the life of the group, which are offered by the conductor and members alike.

2

Structural problems in poor attendance, unusual in the life of this group, are seen as boundary events that require analysis.

3

Process dynamics, released by the conductor’s analysis of the group’s boundary events, involve turbulence and conflict in the group and allow leadership functions to be taken up from within its membership.

4

Troubled process dynamics, in which members amplify and act out hidden anxieties, are discovered to be deflections from an avoided source of anxiety in the group, about impending loss.

5

Content: The sources of anxiety, now traced back to their origins in an impending loss, are found in the thematic content of the group’s discourse, which is used first to locate the disturbance and then to translate it into understandable terms which are given an interpretation.

What looks like a simple progression through this session is guided by the conductor’s use of these dimensions as each one illuminates the others. She holds to the convening role by maintaining the group’s structure as it works towards the departure of two cherished members, and she will go on to create space for the arrival of newcomers. Process dynamics that amplify hidden anxieties about loss are illuminated by the content of the group’s exchange, in particular by the way the group’s language is called on to illuminate what might otherwise be a hidden process. And the content of the emerging discourse comes to focus on the very issues that gave rise to it – the painful issues associated with loss.

234  II  The group-analytic model

Notes 1 The terms ‘structure’, ‘process’ and ‘content’ were first put to use in this way by Foulkes and Anthony in 1957. They dropped the section of their book in which these terms were used from the revised edition when it came out in 1965. The omission was passed on to the 1984 edition. The terms are also used to describe small group psychotherapy by de Maré in his book published in 1972. Subsequent writers have misattributed authorship of these terms to de Maré, who makes fine use of them in his analogy that compares a small group with a river and its waterflow and banks (de Maré 1972:131). The terms originate with Foulkes and Anthony, as this chapter makes clear. 2 The term boundary event is introduced in Chapter 2.

Bibliography Agazarian, Y., and Peters, R. (1981). The Visible and Invisible Group. London, Routledge. Anthony, E. J. (1978). The Group-Analytic Circle and Its Ambient Network: 2nd Foulkes Lecture. Group Analysis 11 (Supplement 1): 1–18. Reissued in M. Pines (Ed.), (1983, 2000), The Evolution of Group Analysis. London, Jessica Kingsley, pp. 29–53. Cox, M., and Theilgaard, A. (1987). Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley. De Maré, P. (1972). Perspectives in Group Psychotherapy: A Theoretical Background. London, George, Allen and Unwin. Foulkes, S. H. (1964; reissued 1986). Therapeutic Group Analysis. London, Karnac. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Garland, C. (1982). Taking the Non-Problem Seriously. Group Analysis 15 (1): 4–14. Zinkin, L. (1994; reissued 2000). Exchange as a Therapeutic Factor in Group Analysis. In D. Brown and L. Zinkin (Eds.). (2000), The Psyche and the Social World. London, Jessica Kingsley, pp. 99–117.

Acknowledgements: Figures ii.1 and 8.1 reproduced with permission from Malcolm Pines and Oxford University Press; extracts from Foulkes and Anthony (1957; reissued 1965, 1984), Group Psychotherapy: The Psychoanalytic Approach, with permission from E. J. Anthony.

Chapter 9

Structure Dynamic administration, composition, selection

In speculating about numbers one could say the following: 1  person is alone 2  form a pair 3  are in a sense the beginning of a group situation. I have called this the model of three. The point is that any one of the three can look not only upon another one but upon the relationship between the other two, or between all three of them. With 5 it is for the first time possible for one to be isolated, or in opposition to a compact majority constellation. It is also possible to be in a minority without being isolated, namely in the constellation 3 to 2. Beyond 8, say 9 or 12 or even 15 members, may be a suitable number for task groups, who already have a function to fulfil and are treated as a group in view of their function as a team. Anything much over 15 up to say 70 or 80 is a large group. Anything above that, from 100 onwards to several thousand is thought of as a ‘mass’. (Foulkes 1975/1986:85–86)

Structure is addressed in this chapter in different ways. It opens by looking at dynamic administration, the conductor’s overall responsibility in (a) the construction of the group, using an architecture involving principles of composition and selection, and then in (b) their responsibility for managing the group’s setting and boundaries. It looks next at the conductor’s work inside the group with structural dynamics focussed on the relationship between each individual, the conductor and the group as a whole. This is what Foulkes termed ‘the model of three’, first introduced in Chapters 3 and 4. The group matrix is built of these triangulated dynamics that link each individual with the conductor on the one hand and with all the other members – the group as a whole – on the other. Triangulation principles are called on and applied to the group matrix along the lines described by Marteen in Chapter 3. The diagram illustrating the group-analytic model of three, Figure 7.4 on page 210, is brought in again. Here it is adapted to illustrate the new clinical situation described in Vignette 9.1, the story of the wooden spoon – where it is called on to guide the work undertaken with structural dynamics illustrated by Figure 9.1.

236  II  The group-analytic model Table 9.1  Basic organising principles for group psychotherapy*  1

Members will have been chosen by the conductor(s)

 2

They in turn will have chosen to join and participate

 3

They will be expected to justify their place in the group by reliable attendance and participation

 4

The work will be governed by a psychotherapeutic contract

 5

The contract will include definitions of confidentiality and other professional boundaries

 6

The conductor will establish a therapeutic alliance with individual members, either prior to their joining or during the early stages of their attendance in the group, and this may take the form of a baseline therapeutic agreement or contract

 7

Agreed parameters will include the duration and time boundaries of the group as well as its membership and composition

 8

Groups can be homogeneous or heterogeneous

 9

Groups may have a fixed time limit or continue on a slow-open basis for many years

10 Groups may have a stable and fixed or a rotating membership in which empty places are taken by new members * Table 9.1 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Table 6.3.6.1, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1353. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my co-author Malcolm Pines for his consent to its re-use here.

Table 9.1 provides an overview of the organising principles used across the range of different kinds of groups that this chapter deals with. It takes in experiential and process groups which are therapeutic, though key elements of Table 9.1 apply only to therapy groups. The most basic terms of reference for joining a group are described in Table 9.1. The group’s underlying structure will need to be grounded by a therapeutic alliance that might take a contractual form to emphasise each individual’s voluntary presence, their freedom to come or go in line with the agreed arrangements for notice on departure and the conductor’s duties as the clinician ultimately responsible for each individual’s progress. The key significance of choice and agreement is central to the outcome of psychotherapy. This is as true in the different applications of group therapy, even where a group meets in a closed or custodial setting. Therapy and experiential or process groups There are key differences between therapeutic groups and experiential groups offered in training programmes, short courses and conferences, which are referred to in North American practice as process groups. Experiential/process groups are therapeutic in nature and intention, though they are not governed by the same individualized therapeutic alliance or treatment contract with each of their individual

9 Structure  237

members found in a clinical setting. Between experiential/process groups and those in a clinical setting or private practice with defined therapeutic purpose, there is a wide area of common ground. Much of what this book covers will be relevant to the conduct of both kinds of groups. The two categories are differentiated principally by the centrality of an individualized contract in the setting of a clinic or private practice based on a therapeutic alliance that might also be turned into a contract – described in items 4, 5 and 6 in Table 9.1 – and this is absent in experiential/process groups. In these groups the conductor or the event’s convening agency establishes terms with the group as a whole and not with each separate individual. The other core difference is that principles of selection and composition are unlikely to give the conductor the widest range of options in experiential/ process groups composed from the membership attending what might be a course or a conference. These groups use only the most elementary of the criteria below to ensure they are balanced for age, gender and experience, and to help avoid combining in the same group, people whose outside associations are likely to pose problems for one another when it comes to confidentiality and boundary issues.

The construction of the group and dynamic administration Dynamic administration in principles and practice The term ‘dynamic administration’ is attributed to Foulkes but is not found in any of his written work. Its earliest use is in tapes of his teaching sessions given between the founding of the Institute of Group Analysis in London in 1973, and his death in 1975 (Foulkes 1972). The term was first put to publication by Pines, Behr and Hearst in Gazda (1982:151), in which they define the conductor as a ‘dynamic administrator’ for the role they play in supplying, creating and maintaining the group setting throughout its life. They guard the group’s boundaries and negotiate between the group and the wider social environment, paying attention to its physical and psychological boundaries, both within the group and around it in the setting. Their ideas, drawn from Behr and Hearst’s later text in which dynamic administration receives its clearest account, are set out in Table 9.2 (Behr and Hearst 2005:42, 54).

Table 9.2  Twelve principles and practices of dynamic administration: Behr and Hearst*  1

Dynamic administration is the means by which the conductor creates and maintains the setting of the group The conductor:

 2

Provides structures for the group in time and place

 3

Mediates communication between the group and the outside world

 4

Guards the group’s boundaries and manages its times

238  II  The group-analytic model Table 9.2 continued  5

Gives definition to boundary events like late arrivals or premature departures so they can be explored therapeutically

 6

Helps ensure all actions are woven into the texture of the group’s dynamics

 7

Takes responsibility for furniture and furbishment of the room including its circle of chairs

 8

Handles notices about absences and provides messages to the group from absentees

 9

Provides out-group contact with relatives on the one hand and with fellow professionals on the other

10 Maintains correspondence with other clinicians concerned with the well-being of group members 11 Maintains a memory for the group in terms of its dynamic history and the dynamic history of its members 12 Fee-payment issues for groups in private practice are an integral part of dynamic administration * Table 9.2 is adapted from pages 42–54 in Behr and Hearst (2005). Grateful acknowledgements are made to the authors and publisher.

General principles of construction and selection Size and numbers Although homogeneous and mixed groups will be studied separately there are some general questions about a group’s size and membership that can be summarised for both kinds of group. A group will have optimal working resources with a membership range of five to nine members. Within this range a group will gain in intimacy as its numbers go down but will lose in its therapeutic momentum as its powers of amplification are reduced with the drop in numbers, as described in Chapter 10. As numbers go up its therapeutic momentum will be enhanced with the increased capacity to amplify the process dynamics of the experience, and this is likely to happen at the expense of its more intimate features. Between a working minimum of five members and a maximum of nine, numbers will vary according to the conditions of the setting, the kind of group and the preferences of the conductor. I choose to work with an optimal size of six, seven or eight members for stranger groups that, including myself, gives a composition of seven to nine. For couples’ groups I prefer to work with a number of three or four patient couples and a co-therapy partnership giving a membership of eight or ten. The sense of an optimal size is determined by the number of people who can be addressed in a single statement, taken in at a glance and remembered in detail at once, name by name. In my own experience if numbers go much above ten the climate can become depersonalised and this can lead to a sense of anonymity in the room. If numbers go below five the added likelihood of a member absent

9 Structure  239

due to illness for a session or late for unavoidable reasons can bring numbers down to only three or four, which can lead to feelings of depletion and anxieties about viability. Under good conditions sub-optimal groups can provide valuable therapy. Many conductors conduct sub-optimal groups with an opening enrolment of sometimes no more than three or four as they wait for others to join. Low and irregular attendance is often associated with a problematic composition, particularly if there is a high proportion of members with character disorders or borderline features. The inner sense of deprivation and loss can make the group seem unreliable and threatening, which can be reinforced if the conductor is seen to be in difficulty. Conductors who can maintain an understanding attitude and positive commitment to the group’s future will usually find the situation settles into a working nucleus of members that can be built upon. The literature on suboptimal groups gives encouragement to viability based on the conductor’s sense of assurance rather than on anything ‘magical’ about a defining number. Over time a sub-optimal group that engenders confidence amongst its members can be easily built upon with the intake of further numbers as it progresses (Zelakowski 1998). Principles of similarity and difference in group composition Under ideal conditions of composition, principles of similarity among prospective members will be combined with principles of difference amongst them. An active service and a busy practice stand the best chance of ensuring that the conductor has a large pool of prospective people to call on for the successful construction of a group. A group conducted in an out-patient psychiatric service or general practice will offer scope for a wide range of membership in terms of demographic, ethnic and cultural factors and in terms of presenting problems and diagnostic issues. In a slow-open group the phases and cycles of its development will mean that it can accommodate a new member at one point in its life who – at another point – could not be accommodated. In a closed group established with a fixed membership, its composition will determine its outlook. Melnick and Woods (1976) suggest that group composition should be guided by an optimal balance between conditions ensuring group maintenance or homogeneity and those maximizing interpersonal learning or heterogeneity. A group that shares one strong characteristic in a diagnosis like an eating disorder or a personal attribute like intelligence can accommodate a diversity of presenting problems or social backgrounds. If, on the other hand, the members are similar in social background, then diversity can be incorporated on another basis, such as diagnosis. Thygesen (1992) found that diversity enabled group members to recognise and work with differences in mental and emotional attitudes, life histories and developmental problems. Recognising and working with difference develops emotional resources and promotes flexibility and the tolerance of emotional tension. It also encourages the group to move from cohesion, in which security is based on identification, to coherence, in which relationships are based on differentiation. It is also useful to identify members likely to be isolated from the rest of the group by age, ethnicity, gender, personality or problems or a history that no one else shares, for

240  II  The group-analytic model

they are likely to find the group experience threatening. It is important to try and avoid isolation by virtue of identity – what might be called structural isolation. A simple ‘rule of thumb’ that lends itself to the widest range of applications is to ensure that if the problem focus is similar in – say – a group for people with drink and other addictive disorders, then the demographics and cultures should ideally be different. And if the group is conducted for people from within a narrow age, demographic or cultural range, then principles of difference can be built into its structure by ensuring that people’s presentation or diagnosis is different. Principles of similarity will engender identification within a group, allowing it to most easily become cohesive and thus create an arena for resonance. Principles of difference ensure that the emerging coherence has scope for mirroring and outsight, so it does not turn into a defensive association and pre-empt the changes that individuation can lead to. Principles of similarity can only be combined with principles of difference where membership prospects allow for thoughtful selection. As the issues for which a group is established become more problematic and complex – in a group for female survivors of child sexual abuse, one for male survivors of torture or for people convicted for sexual transgressions – then the more important it becomes to offer people an initial course of therapy in a group that works with a ‘pure’ culture that is built on their similarity of experience. Homogeneous groups like those described in the studies of Chapter 6, for well-defined populations like these above, including groups for people with psychiatric disorders in a hospital setting or for men with dangerous and severe personality disorders in a secure unit, can still allow for the sensible and selective inclusion of those most likely to be able to help one another. Composing groups by selecting for difference in a homogeneous population can still generate tensions of a differentiating kind that make for therapeutic progress. The virtues of these working principles can be seen in some of the vignettes. In couples’ group therapy described in Vignette 1.3, the combination of principles of similarity with principles of difference is honoured by ensuring that where there is a predominance of attendance round a single symptom picture – like depression or anorexia – the couples have variation in their backgrounds, cultures and identities. In groups for refugee survivors of organised violence described in Vignettes 2.1 and 10.8, where the focal issues draw from men’s experience of massive psychic trauma and complex PTSD, then their wide range of nationalities, religions and ethnicities proves essential for the movement described in the progression from relational to reflective and then to reparative experience. As Chapter 6 describes, an appropriate membership can be composed for slow-open groups by introducing commonalities leading to cohesion through one set of principles like people’s presenting difficulty or diagnosis. Variations that introduce difference can be introduced by another such set of principles like culture, demography or age. The most significant principles of similarity and difference are in people’s demographics including gender and age, occupation and education, culture, social class and intelligence and in the range of presenting difficulty or need. These ideas – about blending principles of similarity with principles of difference to optimise a group’s composition – are not set out in Foulkes’s writing on such defined terms. But they underlie many of his recommendations and serve as an identifiable range of group-analytic principles summarised in Table 9.3.

9 Structure  241 Table 9.3  Principles for group composition 1

Draw up principles of similarity grounded in some of the group’s selection criteria. These might include, for example, a group for people with character problems, for the elderly, for young adults, for men and/or women who live in or after abusive relationships, for people with psychiatric symptoms, for adolescents with family problems, for women who have a life-threatening diagnosis like metastatic breast cancer.

2

Draw up principles of difference grounded in a set of considerations that are well differentiated from 1 above, that can include presenting problems and all the factors in 1 above, plus demographic factors like age and gender, cultural, social and ethnic factors, occupation and social class.

3

Try to ensure your group’s membership includes those who come in on principles of similarity, as well as those who come in on principles of difference.

4

Try to ensure principles of difference are evenly distributed round the group’s membership and safeguard against any one member feeling so different that they are separated from the others by factors that will always keep them apart. A group made up of seven women and one man, or of six people in their 20s and one in their 60s, will have structural problems built into its future.

5

Prospective membership from a small pool of candidates will not always or readily allow for optimal membership along the lines set out in 1–4. But a slow-open group can be started with a sub-optimal membership and can be worked with on constructive terms as a wider membership is recruited over time.

6

Try to ensure that each individual goes through a uniform joining process that has consistency across the membership and over time.

Working with structural dynamics in the group Vignette 9.1  The story of the wooden spoon

Molly, a committed mother of two, takes advantage of unexpectedly low attendance in a group one day to shed her reticence and speak of her fears about an approaching interview for her counsellor’s training. The older of her daughters was learning an instrument and, though making progress in her playing, was struggling to read music because of dyslexia similar in form to Molly’s own. The younger daughter had just begun at school and – to her parents’ relief – showed no signs of a learning disorder. As we knew in the group, Molly was working hard to help the older one overcome difficulties that she herself had not yet resolved. She was learning to take account of a double dimension to her problems, the specific learning difficulty that still interfered with her writing and the controlling mother of her childhood by whom she was ‘occupied’. On the outside her confidence had been undermined by her mother’s harshness and now, more seriously, by her own self-denigration on the inside that restricted her scope to venture out and extend her capabilities. During her

242  II  The group-analytic model

two years in the group she gained the confidence to embark on a counselling training in which her husband was supporting her, but, though the work was not impeded by dyslexia, she struggled at every challenge. With only three others in the group and myself, Molly’s narrative gave new and key perspective to her mother’s punitive disposition that she now projected onto people she would be facing at the interview in the coming weeks. The story unfolded of how, during her first years at school, Mother would make her recite her tables, keeping time as she did so by beating a wooden spoon on the kitchen counter. When she got her figures wrong Mother would beat her hands instead of the counter. We could see that the story hurt her in the telling but she had the benefit of warmth and encouragement. The active narrative was doing her good until Cynthia, a woman her mother’s age who carried similar and worse childhood injuries, became indignant on her behalf. Cynthia’s indignation took the story away from Molly – a familiar enough pattern we had learnt to expect from Cynthia – but we didn’t let her derail Molly. The two other members and myself took an active interest in her faltering narrative, providing patience and encouragement as the truly troubled picture of Molly’s early years came into the room. Cynthia was furious with Molly’s mother, denounced her loudly and wanted to know where her father was through those cruel events. She wanted to know, she told us, because when her own mother used to slap her, her own father was useless. Of the five in the room I had been the most active and vocal in helping Molly tell her story. Turning to Cynthia I asked her again if she could – for the time being – leave the story for Molly to tell us more. She did so for little more than a few minutes, during which we learnt that Molly’s mother was convinced she was ‘thick’ (stupid). This proved too much for Cynthia, whose outburst on Molly’s behalf not only failed to protect Molly but extruded Molly from her own story. Cynthia had on many occasions driven me – and other members of the group – to distraction by her overwhelming and caustic humour and self-absorbed preoccupations. On this occasion I was able to keep a temperate disposition and asked her, in a quiet and restrained way, if she realized that she was now wielding the wooden spoon. There was a long silence that was concluded when Cynthia asked me if I realized what I had said to her. When I said that I found it a strange question because I wouldn’t have said anything I didn’t realize, she said, well if it’s your view that I’m beating Molly with a wooden spoon, I’d better go! We were close to the conclusion of the session, and in that moment she was persuaded by the others not to leave the room. But she was able to take little account of Molly’s feelings in the moment, nor indeed of any thing except her own injured emotions. At the following session when the three missing members returned, Molly returned to

9 Structure  243

her reticence, and what became known as the story of the wooden spoon was related by Cynthia and one of the only other two people present. We struggled with it for a long time. The story of the wooden spoon and Cynthia’s conviction that I had conducted myself unacceptably in making this challenge took up most of Cynthia’s time in the group for the weeks that followed and much of the group’s time, too. Cynthia was only held back from leaving precipitously at the time by the quiet, solicitous and helpful presence of the others who came forward to ensure she felt befriended and could see the challenge in context. And when I was later, some weeks on, able to acknowledge that in my dealings with her, I had ended up wielding the wooden spoon against her and apologised for hurting her with it, the tears in the room – including my own – brought healing to us all. In the long period of reparative review that ensued, a new degree of trust was built between myself and both the others who had been active in the episode of the wooden spoon – Molly and Cynthia – that was extended to the group and stood us in good stead for the years of patient and sometimes painful therapy that followed. Molly went forward with her application, was accepted by the training centre and went on to become a capable and accomplished counsellor who could hold her own and speak for herself, first in the context of her own group therapy and then in her own consulting room at work. Cynthia eventually grew out of her domineering ways and defensive victimhood, and she emerged to become an esteemed member of the group with gifts of reciprocity that were an asset to all. She could not bear to see in herself the figure who her children took flight from at home, but she found a turning point when she came to see in me – from the way I had once protected Molly from her – a father figure who stood between both these hurt women and their bad mothers. She eventually allowed me to ‘become’ the good father she had always longed for.

Commentary The conductor at work here addresses the individual as well as the whole group and considers the more conscious and individual dynamics as well as the unconscious and potentially destructive whole-group dynamics. The approach is guided by an integrated set of concepts relating structure, process and content to one another in which the group conductor works both as therapist and as group member to cultivate the ordinary language of shared conversational experience. The conductor at times takes up the convenor’s position using

244  II  The group-analytic model

principles of dynamic administration to address boundary events that arise here first in the matter of dominance and then in the subject of fairness as to the equitable distribution of the group’s time. At other times he speaks personally as one of the group’s members, especially when the group later enters a reparative phase when he can acknowledge that he himself ended up wielding the wooden spoon and apologises for doing so. Groups may begin with a relatively high level of leadership activity that is flexibly reduced with a decrescendo of responsibility as the group becomes the therapist and the leadership function is devolved upon its members, who become active co-therapists in each other’s treatment. At one key moment in the group its theme can focus on structural dynamics that link one member both to the conductor and to the group as a whole. The web of interconnecting dynamics between any one member and all the others is summarised by ‘the group as a whole’ – the matrix – which is called on to represent the inter-connecting latticework of relationships that includes all the members and the conductor.

Figure 9.1 reproduces the elements of a group-analytic group shown earlier as Figure 7.4 on page 210. This is now adapted to explore work with the new structural dynamics described here in Vignette 9.1. The matrix of the group is given in a schematic series of triangles that link each member with the conductor on the one hand and on the other with the group as a whole. In the figuration mapped out here, members one and two, who are un-named and whose identities and triangles are given in black, are – along with the missing others – the group’s ‘ground’. Molly and Cynthia become the ‘figures’, their names are given and their triangles, T1 and T3, are emphasized. Molly begins speaking of anxiety about an impending interview and, in triangle T1, her narrative describes the work she is doing to help her daughter. She relates this to conflicts she has within herself that are rooted in historical issues between herself and her own persecutory mother. The work here is being done in the relational dimension of the group and is steadily constructive. The conductor, guided by his understanding of this history (based on preparatory therapy with her prior to her joining the group) helps focus the group’s enquiry to explore the history and uncover its focal issues. He might have expected but could not have foreseen that the history would come to life in the circle of the group as, in triangle T3, Cynthia recoils from Molly’s narrative. This is the disturbance located in the process, which now becomes figural. Molly’s narrative holds an unbearable mirror to the history of Cynthia’s relationship with her own mother. With the conscious intention of establishing an alliance with Molly she is driven by her own repetitive compulsions to ‘become’ Molly’s

9 Structure  245 Boundary of the group as a whole

T1 MOLLY CONDUCTOR T2

T3 CYNTHIA

MEMBER 1

Group is represented by a series of triangles between each member, the conductor and group as a whole. Members 1 & 2 in black comprise, with the missing others, the group’s 'ground'. Molly & Cynthia become figural and are 'triangulated' with emphasis in triangles T1 & T3. The intensity of the emerging exchange between them is captured by an addional triangle drawn between them, T2.

MEMBER 2

Figure 9.1  Structural dynamics at work Source: Figure 9.1 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Figure 6.3.6.6, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1358. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my coauthor Malcolm Pines for his consent to their re-use here.

persecuting mother. The conductor, along with the others, knows only too well, just how impervious Cynthia can be and, using the group’s own language – Molly’s account of her mother’s wooden spoon – he gives Cynthia a picture of herself she once again finds unbearable. Like Cynthia, his own intention was to protect Molly, but in doing so he ‘becomes’ Cynthia’s own persecutory mother in triangle T3. The shifting reflective imagery generates pressure that feels almost unbearable, and Cynthia, unable to face the image of herself that has been generated, looks to take flight. The group is living through a de-constructive cycle as members one and two, along with Molly, now become figural in addressing Cynthia’s distress, and together they help contain her and re-create conditions of safety. The group as a whole ‘becomes’ the good mother that is missing in both Cynthia and Molly’s experience. The work proceeds in this figuration for weeks, along with different thematic issues generated by others in the group as Cynthia re-builds her own composure. When the conductor later apologises to her for injuring her with a wooden spoon – an apology held back until the climate in the room would allow

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for reparation – the group becomes reparative and the work becomes reconstructive. By then the conductor has emerged as an available ‘father’ who, coupled with the ‘good mother’ represented by the group, can be called on reflectively to protect both these troubled women from the injurious mothers they each carry within. One year later when something else happens in the group that is relevant to the work of this figuration, a truly cathartic moment arises when both women weep together in shared frustration over their fruitless efforts to build bridges with their mothers. By that point in their shared distress they can each become – for one another – the good mothers they never had. These references to mothers and fathers are not an explicit part of the process of working through but are called on here to anticipate further exploration of transference and countertransference in Chapter 14.

Bibliography Behr, H., and Hearst, L. (2005). Group Analytic Psychotherapy: A Meeting of Minds. London, Whurr. Foulkes, S. H. (1972). Group Analytic Psychotherapy: The Group Analyst and His Training. Behavioural Sciences Tape Library, Sigma Information, Inc., Tape 3, side 1. Foulkes, S. H. (1975; reissued 1986). Group Analytic Psychotherapy: Method and Principles. London, Karnac. Gazda, G. (Ed.). (1982). Basic Approaches to Group Psychotherapy and Group Counselling. Springfield, IL, Charles C. Thomas. Melnick, J., and Woods, M. (1976). Analysis of Group Composition: Research and Theory for Psychotherapeutic and Growth-oriented Groups. Journal of Applied Behavioural Science, 12: 493–512. Pines, M., Hearst, L., and Behr, H. (1982). Group Analysis (Group Analytic Psychotherapy). In G. Gazda (Ed.), Basic Approaches to Group Psychotherapy and Group Counselling. Springfield, IL, Charles C. Thomas, pp. 132–178. Schlapobersky, J., and Pines, M. (2009). Group Methods in Adult Psychiatry. In M. Gelder et al. (Eds.), The New Oxford Textbook of Psychiatry. Oxford, Oxford University Press, pp. 1350–1369. Thygesen, B. (1992). Diversity as a Group-Specific Factor. Group Analysis, 25: 75–86. Zelakowski, P. (1998). The Sub-Optimal Group. Group Analysis, 31: 491–504.

Acknowledgements:  Table 9.1 and Figure 9.1 reproduced with permission from Malcolm Pines and Oxford University Press; Table 9.2 reproduced with permission from Harold Behr and Liesel Hearst; extract from Foulkes (1975; reissued 1986), Group Analytic Psychotherapy: Method and Principles, reproduced with permission from the Group Analytic Society.

Chapter 10

Process Concepts and applications

All participants speak and understand this language . . . according to (their own) particular ‘resonance’. . . The conductor must know this language . . . should have learned it from his own experience and . . . continue to use it (in) a neverending process of learning. (Foulkes 1975, 1986:132) Mirror reactions are . . . brought out when a number of persons meet and interact. A person sees himself, or part of himself . . . reflected in the interactions of other group members. He sees them reacting in the way he does himself, or in contrast to his own behaviour. He also gets to know himself – . . . a fundamental process in ego development – by the effect he has upon others and the picture they form of him. (Foulkes 1964:110)

Process is explored in this chapter to generate therapeutic principles.1 The groupanalytic approach is a non-directive form of therapy that relies on free-floating discussion described in Chapters 1 and 4. The group’s language and non-verbal communication can be cultivated and explored so process becomes the hub or axis on which structure and content can turn. The conductor can shape a group’s experience by working directly with what happens, turning questions of structure and content into process dynamics. The conductor’s therapeutic role emphasises process but does not seek to dominate it. Foulkes and Anthony originally described these process dynamics as group-­ specific factors. This chapter sources the early definitions in the literature of these pioneers and their immediate followers like Pines, Brown and Zinkin. Today we know the elements of process are hardly group specific, so they can now be re-cast in the contemporary language of process dynamics. In this chapter I provide an account of the key dynamics of resonance, mirroring, reciprocity (exchange), amplification and condensation drawn from Foulkes and Anthony. I have set this out in a way that is comprehensive, integrated and related to contemporary work outside the group-analytic field. Bion’s concept of interpersonal valency is added to complete the picture. Thanks to the work of Pines, mirroring has been studied comprehensively (1982/1998). The conductor can harvest these reactions to promote ­self-development

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through subjective interaction, a formulation we owe to Brown’s own study of resonance and reciprocity (2000/2006). This chapter will look at mirroring in the context of the other key process dynamics. After this overview it provides defining terms for each of the process dynamics, followed by basic illustrations. It then goes on to a series of explorations and applications illustrated with tables and diagrams. Table 10.4 explores therapeutic applications in seven of the most common forms of mirroring found in group psychotherapy. The chapter is concluded with an extended clinical vignette in which process dynamics are seen working ‘in the round’, followed by a discussion focussed on practical learning points for conductors. What does it mean to be given the assurance on joining a new group that you need only participate to be assured of ‘results’? Participation is an elemental condition of our sociability – a feature of social groups in families, schools, clubs, congregations and every aspect of society. How does participation become therapeutic in a group? The question is addressed by removing the two outside factors from Foulkes’s original portfolio – socialisation and exchange – to show how the conductor can work with the five inside factors – resonance, valency, mirroring, amplification and condensation – to make good conditions for socialisation and exchange as therapy progresses from relational through reflective to reparative experience. Some of the process dynamics explored here have received sound treatment in the literature. Development has been piecemeal, however, and for these and other reasons, it has not attracted the attention of those working with the same issues outside the group-analytic tradition. I have set out to create a portfolio of working ‘tools’ to allow practitioners from a range of different orientations to gain from the group-analytic model’s key process dynamics. For example, in Vignette 1.3 on page 36, a group is talking about sausages. For a time sausages furnish the content of the narrative exchange. The conductors’ intervention, posed as an open question between them across the group, introduces a seemingly inane question. One co-therapist says to the other – in the group’s presence – ‘John, why are we talking about sausages?’ It seems to be an enquiry about content – sausages – but leads elsewhere. The question itself then becomes figural, and the subject matter of the content – sausages – falls into the background as the question is investigated through a play with words and associations that brings the group’s process to life. This dimension of content – sausages – is studied in Chapter 11. The purpose of its reference here is to emphasise how interconnected are the three dimensions – structure, process and content – with process at their core. The six key questions of Chapter 11 that are raised about content can be reviewed here to see how closely they also govern process. First, who is talking? And second, who is listening? In this group the men and women are talking to each other. Third, what are they talking about? Well, sausages and then bananas. The sexually suggestive phallic references create a lot of humour. And fourth, what is not being said? Using process to explore these questions we discover that what is really under review is the cholesterol content of the sausages in a symbolic reference to the poisonous projections that are recognised to be passing between the men and women. The process-based enquiries in which all participate lead through conscious and unconscious resistances to a new understanding of self-harm, a subject

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hidden from view in the group’s opening play with associations, but it is a key to their continuing therapeutic progress.

The terms, their history and current use Foulkes’s introduction of group-specific factors was central to his claim that group analysis would provide a radical new understanding of the interpersonal domain. He gives no account of these factors in his first text in 1948 but then identified four such factors with the first edition of the book with Anthony in 1957. In his own second book in 1964 a different set of four factors are described in Table 10.1a. In the second edition of his book with Anthony their original set of four factors is extended to include resonance, as described in Table 10.1b. There are other key factors in group-analytic psychotherapy that emerged in the course of his writing that are not organised in this original frame of reference. Those three not included in his own original portfolio are free-floating discussion, amplification and resonance. So their portfolio was developed ‘piecemeal’ and without systematic exposition. Foulkes evidently came to attach such importance to resonance that it formed the basis of his last paper published in 1977 and written shortly before his death. It is quoted from on page 252 (Foulkes 1977/1990:298–299). This list was extended in the second edition of Foulkes and Anthony’s text. The piecemeal collation of some discrete factors and extrusion of others is replaced by the following, more comprehensive list, but it now leaves out exchange. According to Pines, Foulkes named these ‘group-specific factors’ to emphasise that they were ‘not concepts derived from psychoanalysis . . . (but) from the field of observation of the small group, the new therapeutic context that he had established’ Table 10.1a  Foulkes’s original list of group-specific factors* 1

The group situation fosters social integration and relieves isolation

2

‘Mirror reaction’

3

Activation of the collective unconscious: condenser phenomena

4

Exchange

* Foulkes 1964: 34

Table 10.1b  Foulkes and Anthony’s revised list of group-specific factors* 1

Socialisation through the group

2

Mirror phenomena

3

Condenser phenomena

4

Chain phenomena including free association

5

Resonance

* Foulkes and Anthony 1965: 149–152

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(Pines 1998:18). Their use has largely been confined to a small number of practitioners in group analysis, but thanks to the development of attachment and relational theories the field has matured around us, as Chapter 2 makes clear. The originality of these pioneering insights is explored here to enhance our clinical practice and the reworking of these key issues has two broad objectives. First it offers an account that is comprehensive and integrated. Group analysts have tended not to utilise the full repertoire of clinical tools available from our literature. Instead we approach these factors piecemeal with isolated endeavours that study one such factor or another, like mirroring – for example – or resonance. Such fragmenting tendencies continue, despite the recognition by many clinicians outside our own frame that the Foulksian approach has much to commend it. And second, it seeks to bring the group-analytic portfolio into an active relationship with other related contemporary developments to try and rectify the inward-­looking and sometimes archaic frame of reference in our field. Foulkes and Anthony’s work anticipated much that is now emerging in relational psychoanalysis, neuropsychoanalysis and intersubjective theory, and we could be making much more active use of their constructs. The first and last items from their original list, socialization and exchange, are of generic relevance to all human life. Zinkin examines their relevance to group-analytic practice (Zinkin 1994/2000:99–117), and they feature amongst Yalom’s therapeutic factors. But socialization and exchange are so broad and generic that they feature whenever people meet to relate, work or play together. They encompass therapy, but they go beyond it to embrace everything our social life entails. When socialisation and exchange are applied as therapeutic principles, a group can turn the relief of isolation into social integration through the process of exchange. But how does a group do this? The middle two factors in the list above, mirroring and condenser phenomena, are key elements in what is needed for answers to this question, as are two other equally important clinical principles, resonance and amplification, which were introduced through the range of Foulkes’s writing but which – for puzzling reasons – were not always incorporated in the original lists. Anthony’s contribution in the second edition of their book brought these into the panel. The further concept of valency is drawn from Bion’s writing and a new working list of process dynamics in small group psychotherapy is presented in Table 10.2. Figure 10.1 that follows gives a picture of how we might see the dynamic relationship between these processes. I propose we rename these process dynamics and that we adopt resonance as their key. It is the most fundamental of these dynamics, the ‘carrier’ of the group’s process, and in the account given here it is understood and used together with the four others selected for study. This approach follows Agazarian’s early recognition that Foulkes was the first to formally transpose resonance from the language of acoustics into psychology and that: The resonance orientation of Foulkes and his followers . . . justifies their use of psychoanalytic (and other) concepts to build their model, and their great awareness and skilful treatment of the middle-level or resonance and amplification group phenomena. (Agazarian and Peters 1981:20).

10 Process  251 Table 10.2  A new working list of process dynamics in small group psychotherapy 1

Resonance

2

Reciprocity

3

Valency

4

Mirroring

5

Amplification

6

Condensation

Mirroring

Resonance

Valency Amplifica on and Condensa on

Reciprocity

Figure 10.1  Process dynamics in small group psychotherapy Source: Figure 10.1 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Figure 6.3.6.7, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1359. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my coauthor Malcolm Pines for his consent to their re-use here.

Definitions: Resonance, valency, reciprocity (exchange), mirroring, amplification, condensation This section offers defining terms and illustrations for the five concepts that govern process dynamics. Resonance Like a number of those terms in this list, resonance is transposed from one modality of investigation to another (like the term ‘trauma’, which is not studied here). These are ‘analogical terms derived from the physical sciences’ (Foulkes and Anthony 1957/1965:152), providing us with a conceptual frame of direct relevance to the relational field and found invaluable in all forms of group analysis.

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Definitions Advances in neuropsychoanalysis suggest that resonance is the key to this group, along with its conceptual partner, interpersonal valency (Lewis, Amini and Lannon 2000; Harwood, Stone and Pines 2012). Laplanche and Pontalis describe how resonance came to be used in psychoanalysis as ‘the unconscious communication of affect’ (1973:93). They describe it as ‘a mode of knowing that operates at the unconscious level and is perhaps acting outside of language’ (1973:93). However, it had no comprehensive definition there or anywhere else amongst the many who put it to clinical use until Foulkes provided this in his last paper, published in 1977: . . . Each individual member picks out of the common pool what is relevant to him . . . (and) responds according to his individual disposition . . .This unconscious, highly specific reaction . . . is roughly what I have called resonance . . . the individual resonates in the key to which he is attuned, in which his specific personality structure is set . . . The ‘stimulating’ event can take any conceivable form or manifestation . . . the ‘response’ – in our context the resonance – always takes into account the unconscious meaning and the ‘wavelength’ of the stimulating event, faithfully and correctly . . . communication (may) take place without any particular message . . . In a group . . . individuals not only resonate on a large scale to each other, simultaneously and reciprocally, but also to the group as a whole and particularly to the group conductor, who in turn is influenced by his own resonance. (Foulkes 1977, 1990:298–299) Agazarian and Peters give another definition in 1981: We define resonance in group psychotherapy as . . . a form of communication between group members which takes place primarily at an unconscious level, and is a function of the inter-dependent, affective responses of members to particular shared conflicts, as stimulated (by) the group’s work. (Agazarian and Peters 1981:19) They note the derivation of this concept from psychoanalysis, cite its origins in Laplanche and Pontalis and explain that ‘credit for extending this notion to groups probably belongs to Foulkes’ (Agazarian and Peters 1981:19). Resonance as the elementary conveyor of emotions We can extend these definitions to now define resonance as an element basic to all emotions in the relational world and one of their key constituents, and it can best be defined as the elementary conveyor of emotions. The process by which love and hate, discord, disillusionment and friendship are expressed, received, transposed and transformed all rely on this elementary conveyor. The transmission process

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relies on its partnered concept – interpersonal valency – for the conductivity of a resonant emotion relies on the valency of those who stand close to it. So, to be understood and used as a clinical term, resonance requires valency and, as illustrated by Figure 10.1, these process dynamics mirror one another. But for all its importance, resonance has a meagre literature even in group analysis. It received its first account in Foulkes and Anthony (1965, 1973:152); further attention in Agazarian and Peters (1981:20) and again in the work of Brown (1994/2006). The only further discussions are in student dissertations on the Qualifying Course of the London IGA (Levens 2011), in the relational field by Mitchell (2000:61) and a recent, excellent overview by Berman (2013:187–196). Acoustic resonance In physics resonance is the oscillation found in solid bodies that produces higher amplitude at optimised frequencies. Oscillation in sympathy between bodies creates sympathetic resonance. Modern physics involves the study of atomic, planetary, mechanical, electrical and magnetic resonance and in particular – for the purposes of this chapter – acoustic resonance, which Foulkes applied to group situations in the quotation above to capture by analogy with music, the patterning form taken by a resonance of feeling or identity between or amongst people. Limbic resonance This form of resonance is now at the centre of a new body of emerging work in which – amongst many others – Lewis, Amini and Lannon (2000) describe limbic resonance as a biologically given capacity for empathy and non-verbal connection that forms the basis of all social attachments. Communication through resonance can affect people’s neurophysiology by entry to and a purchase on fundamental areas of the mind, bypassing other sensorimotor receptors to penetrate all the defences of the conscious mind and gain access to the unconscious in sometimes extraordinary ways. These ideas have been extended to psychiatric work in which problems of empathic resonance are seen to lie behind a wide range of psychopathologies (Farrow and Woodruff 2012). They have been widely applied in trauma studies, where they shed new light on the psychoneurology of flashbacks and re-traumatisation amongst those individuals in whose psychological makeup the limbic region is not subject to ‘normative’ regulators and can be easily ‘flooded’ by seemingly innocent stimulators (Harwood, Stone and Pines 2012). They have also been applied to management studies in which mood or emotional contagion is seen to be critical to the work and malfunctioning of organizations (Barsade 2002) and in which the organizational mirror has been used by Nitsun (1998). Resonance is also used in mental health consultation and supervision where the concept of parallel process – that relies entirely on resonance – is now widely used.

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Valency Bion defined valency as: The individual’s readiness to enter into combination with the group in making and acting on the basic assumptions; if his capacity for combination is great, I shall speak of a high valency, if small, of a low valency; he can have . . . no valency only by ceasing to be, as far as mental function is concerned, human. (Bion 1961:116) Bion introduced this concept through the framework of basic assumptions, but there is no reason to so confine its use. The grounds of integration and parsimony give every reason to link Bion’s understanding of valency with Foulkes’s understanding of resonance, so the two concepts complement and reflect one another’s use and allow us to work with them in tandem. Valency to others’ affect and the resonating consequences of this valency – that induces corresponding, parallel or opposing emotions in others – can be understood as a basic set of human attributes. We will find these basic process dynamics underlying the more familiar psychoanalytic constructs of transference, projection and identification in Section III. Exchange or reciprocity For puzzling reasons the term ‘reciprocity’ is hardly found in group analysis. Brown introduces us to it from the title of his collected papers (Brown 1994/2006), and it corresponds most closely to what Foulkes and Zinkin describe as exchange (Zinkin 1994, 2000). Von Fraunhofer makes use of the concept more recently (von Fraunhofer 2008:288). In its broadest definition reciprocity is the practice of exchange between people for mutual benefit. It takes different forms according to the disciplines in which it is described. In structural anthropology reciprocity is the general principal used by Lévi-Strauss in his foundation text, Elementary Structures of Kinship (1949), where he argues it governs three spheres of exchange – language (exchange of words), kinship (exchange of women and offspring) and economics (exchange of things). In cultural anthropology, reciprocity refers to the non-market exchange of goods or labour ranging from direct barter to forms of gift exchange, where a return is eventually expected, as in the exchange of birthday gifts. In social psychology it refers to the response that a positive action creates by eliciting another rewarding and positive action as a reply. As a social construct, positive reciprocity means that in response to friendly actions people are frequently more cooperative than predicted by the self-interest model. And conversely, negative reciprocity means that in response to hostile actions people are frequently much more aggressive. Mirroring Mirroring can now be re-cast in the more contemporary language of process dynamics. It can be defined as a complex form of resonance through which affect,

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understanding or intuition, seen in or associated with others, can reveal truths about the self that may be welcomed, opposed, taken flight from or attacked. The challenge of harvesting these reactions to promote self-­development is one of the central purposes of group therapy giving mirroring a context amongst the other key process dynamics. Therapeutic applications are guided below by a study of seven of the most common forms of mirroring found in therapeutic groups. Mirroring has been given a systematic and expository account. It was central to Foulkes’s original portfolio of group-specific factors. His own definition of mirroring is given in the quotation that opens this chapter on page 247, which emphasises how ‘a person gets to know himself . . . by the effect he has upon others and the picture they form of him’ (Foulkes 1964:110). The concept was then taken up by Pines, first in his Foulkes Lecture (Pines 1982, 1998:17–39) and then in a number of other notable papers (Pines 2015). The mirror reaction is a concept based upon a self-and-other psychology, of persons becoming aware that their selves are incomplete and who can recognise aspects of themselves, ‘in particular a repressed part’, in other persons. Foulkes noted that by observing fellow group members, patients could often more easily recognise how conflicts and problems are translated into neurotic behaviour. (Pines 1982, 1998:18) Berger provides a good review of the literature (2012:197–216). I am taking the concept beyond its familiar usage by linking it with resonance and valency and by introducing the term ‘outsight’ to identify its therapeutic agency. The concept of mirroring stands between resonance and valency and this process dynamic can be amplified or condensed in a group, as Figure 10.1 illustrates. It has been developed as a widely used clinical tool and is one of the most frequently discussed topics in the literature. It leads us to the inevitable recognition that insight as a source of change drawn from psychoanalysis needs to be complemented by the notion of outsight developed in this book. ‘Outsight’ was first used by de Maré and then Pines as described in Chapter 2 but has not been previously defined. In this book it is put to use as a concept that, though novel, describes everyday practice in group therapy focussed on the therapeutic use of mirroring. It is described in this book’s Introduction on page 4 and in note 2 on page 21. It is defined in Chapter 2 page 61 and illustrated in Vignettes 8.1, 8.2, 9.1 and 10.2; related to mirroring in Chapter 10 page 255 and Vignette 10.2; and to longing and belonging in Vignette 15.2. Condenser Foulkes drew this concept from psychoanalysis where Freud had used it to describe how dream imagery can hold a wide breadth of meaning or association and condense it in a single symbol. It is used here to capture symbolic compression in groups but is not confined to symbols. Foulkes and Anthony define condenser as:

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The sudden discharge of deep and primitive material following the pooling of associated ideas in the group . . . There is an accumulative activation at the deepest levels . . . the ‘collective unconscious’ acts as a condenser covertly storing up emotional charges generated by the group and discharging them under the stimulus of some shared group event . . . group dreams, fears, or phantasies (containing) an element of surprise, because of the absence of conscious causal relations . . . (it) bears some relations to Bion’s ‘emergence of the basic assumptions’ and to Ezriel’s ‘common group tension’. (Foulkes and Anthony 1965:151) Amplification This is another term that has its origins in musicology. It is widely used in group analysis and psychodrama and was brought into the field by Jung to address the manner by which the range, recognition or intensity of an emotion – or its appreciation – is extended or reinforced. I have brought condenser and amplification together on discovering through student supervision that they can be fruitfully applied as a pair of terms to capture the emotional range involved in all the other process dynamics. Condenser governs the intensity of emotional association, and amplification describes the range of spread. The most relevant study of amplification is given by Hobson (1971).

Basic illustrations: Resonance, exchange, valency, mirroring, amplification, condensation The following illustrations are intended to help define these process dynamics by illustrating the way they can be used in group psychotherapy. Resonance and valency Vignette 10.1  Resonance and valency: The isolate and the avoidant

In a long-standing group, resonance to one member’s poignant story about troubles with her difficult mother brought most of its members to tears. However, two group members were unaffected, one an isolate – Frank – and the other an avoidant – Martha. Frank, sitting in the corner of the group, had no evident reactions because of his limited reactive valency, which meant that most emotion passed him by and continued to do so over a period of time. His presentation in the group corresponded to the way he led his life outside. Isolation affected most of his emotional makeup. The depth of his childhood deprivation affected all aspects of his personality. His passage through the group freed him from the most restricting aspects of his disordered developmental history through a growth

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of understanding rather than a challenge to his missing affects. In the group he grew through ‘left-brain’ functioning in his rational and analytical makeup and came to have real gifts of insight and outsight that were valued by the others. But they were expressed with a limited affective range and with little attunement to others’ emotions. Only much later in his therapeutic progress did other aspects of the group’s life – mirroring in particular – begin to gain access to his defensive makeup, allowing him to see a significant discrepancy between his own restricted range of emotional reactions and ‘the full Monty’ (as the group came to call it), ‘the full range’ of emotion in the lives of the others. Over time the group served him well as a pro-social therapy that socialized him through a mirroring process in which he learnt through the lives of others. When he finally left the group after many years he gave us a gift to express his thanks with a well-known pop art sign that said ‘Love’ that touched everyone profoundly. It stands in the group room to this day. In the meantime, though, Martha responded in that earlier session to only some of the group’s feeling. She had a dissociative disorder that had traumatic origins in the experience of being deeply hurt by her mother, but it did not affect her whole personality. She had enjoyed nurture and intimacy through the relationship with her father that continued to protect her from the injurious mother that she still carried within. Her avoidant rather than isolated makeup meant that in the range of emotion close to where she was defended, in areas to do with mothers – good ones, bad mothers and indifferent mothers – the group’s resonance left her strangely unaffected. Her countervalent and avoidant dissociation ‘neutralized’ the resonance.

Commentary So the two people who both seemed unable to respond to the emotions of a third, despite a group-wide resonance of feeling, were out of touch for very different sorts of reasons that had to be taken into account by the conductor’s different approaches to clinical management in each of these cases. For Frank the isolate, analytic work and interpretation were of little value in the group. What he needed was holding, containment and a psycho-educational approach towards his own distinctive make-up that led him gently to a reflective understanding and acceptance of his ‘deficits’. The group needed guidance from the conductor as to how they could best relate to him, and the emotional growth that followed (Continued)

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(Continued) allowed him to emerge from this isolation at work. But this kind of growth was to be a life-long challenge for which his time in the group made only a beginning. On the other hand Martha – the avoidant – gained profoundly from an interpretive understanding of her aversion to and avoidance of associations to do with mothering. Her countervalence to the resonance that affected most of the others when associations had to do with mothers had to be accepted for a long time to maintain a steadily constructive place for her in the group. This later gave way to her anger about her own mother and envy of the mothers brought into the group through others’ narratives. Once she was engaged at this reflective level in deconstructive work, which took a matter of years rather than months, her defences gave way to anger, then to grief and mourning and then – finally – to a reconstructive process out of which sadness gave way to reparation. Her position amongst us was seen to be established when she no longer ‘left the room’ to others when mothers came onto the agenda, as she put it herself. This chapter sets out to provide a differentiated vocabulary by which to address a group’s process dynamics in order to be able to deal with these different clinical challenges.

Mirroring Vignette 10.2  Mirroring and resonance: One person’s tears as a votive offering to another’s hidden grief

In a long-term group one of the men, Jeremy, who worked with children in his career, had recently split up with his wife in the aftermath of a miscarriage she had suffered. People were discussing their identities as parents, relations with their children and with the parents of the previous generation. Jeremy tried without success to convey his sorrow to the group first for their loss of the baby and then for his forfeiture of his wife’s love. People knew him well and tried to compensate for just how lost for words he seemed to be. There were no signs of sorrow on his own account. It was through his narrative alone that others found themselves affected. It was because of this very inability to express open feeling of any kind – for anyone – that he had joined the group in the first place, and he had a deeply dissociative makeup. One of the women, Gail, was just coming to terms with the fact that she would probably never have children of her own, now that she was over 40 and single. She described how she had read a newspaper article about the way the Japanese mourn the unlived lives of miscarried and aborted babies.

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It caught her attention after she had an abortion some years ago. Their Buddhist temples have shrines where people can bring votive offerings to honour the dead. She gave us a picture of the rituals that gave form to hidden feeling that had no counterpart in her life in London. As the man’s narrative of loss and suffering unfolded, she became deeply distressed and wept bitterly, leaving him disconcerted and then concerned for her. A third member of the group – Alice – saw Jeremy’s suffering in Gail’s face and, in a reflective moment of unforgettable consequence, said to both of them that Gail’s tears provided the votive offering to Jeremy’s lost baby and partner. It was not offered as an interpretation but a passing comment. The conductor ‘stopped’ the group’s process to take account of what Alice had said, framed her observation and then called on it to help frame the encounter. The construction heightened Gail’s sorrow, but this only seemed to deepen Jeremy’s sense of puzzlement. His concern for her had no apparent resonance when it came to his own losses. Gail later described how she took his matter-of-factness and surface calm as the only way Jeremy knew of dealing with his own grief and his fear of his partner’s grief overwhelming him. Although the interest in the Japanese rituals came from her own experience at the time of his telling the story, she felt some kind of short circuit that made her acutely and hideously aware of his pain, as she put it later. She felt that what happened in the room could allow him entitlement to his own grief about the baby and the end of his relationship with his partner, and she wished he were not so calm. Though her feelings did not seem to reach any part of him at the time, slowly and in painfully small increments, we were to witness to his steady development of previously unavailable feeling.

Commentary The exchange described here relies on mirroring for the hidden detail of the resonant emotions projected between Jeremy and Gail and then described for the rest of the group by Alice. Lost sources of feeling that were hidden but corrosive in both Jeremy and Gail emerged in a form that the group could pick up on, address and explore. Thanks to both the process and content of this exchange, framed by the conductor as a moment of consequence, we came to see emerging changes in their new availability for emotional exchange. Gail received Jeremy’s dissociated grief through identification with his story because of her own. Projective identification is at the core of the experience in this kind of mirroring, but use of the term ‘mirroring’ keeps the narrative and drama in the group’s own vernacular language.

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Condensation Vignette 10.3  Desire as a conscious condenser of accessible emotion

There was a cumulative cycle of developing exchange related to the subject of sexual frustration in a group in which two of the seven members had active sex lives whilst the others had either occasional sex or none at all. Some had partners and others were single. We were at work on the subject of what people could do to meet partners. Members had this cycle condensed sharply and brought to a point of review that was startling in its intensity when one of the women – alone now for some time after ending a sexually abusive relationship with her former partner – turned to one of the men in the group. He had worked most actively with her in the group over some time to help her extricate herself from her previously troubled bond and equip her to protect her own boundaries. She interrupted the exchange about something else by saying to him directly, ‘In my mind I take you home with me sometimes and I have a good time by myself whilst imagining what you and I might be doing together’. The group was stopped in its outside associations at the moment of condensation as the pairing exchange between these two brought sexuality into the room, and desire became a real and vivid force that was acknowledged amongst us across the group. The man she addressed was touched, and he blushed, responding tenderly and in turn offering her a picture of herself as a woman he could long for but could not allow himself to imagine having until now when she gave him permission. She in turn was deeply moved and was to later report how fundamental he was to her in her own recovery.

Commentary For a time afterwards these two continued their sexualised exchange, and it opened the subject out for the others. From the time of this condensation it gave a place in the group to pleasure and validation that the conductor tracked, monitored and enforced. These developments altered the group’s climate permanently and were to be a precursor for the later confidence, gained at different times and for different reasons by these two, that allowed them to leave the group. Later still they both went on to satisfying and balanced relationships with other life partners in the years that followed.

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Vignette 10.4  Unconscious condenser: He’s not a fucking professor, he’s my father!

In a group working through free association on issues to do with good and ‘bad’ – unavailable – fathers, an older man – Gerald – who had joined us to work through problems associated with his retirement, was going out of his way to offer a younger man, Michael, kindness. It was intended to offset Michael’s acute sense of historical neglect in his family of origin. There was an additional level of identification between them in their shared and active Christian faith. Gerald had his own issues to contend with in the challenges mounted against him by his wife and children over their long-standing neglect at his own hands and their hope that his retirement might change things for the better. But true to their misgivings he was already filling his outside time with other activities that looked likely to take him away from them through other legitimised forms of avoidance at home. Michael had compensated for the absence of his own famous father in his upbringing through a religious involvement in the life of his church where he found ‘an always-present Father’. This had the unfortunate side effect of turning his hidden grievances against his actual father into a litany of forgiving concessions to those who had hurt him, including a previous partner. These forgiving concessions were part of a character pattern in which he was always, and often inappropriately, obliging. They impaired the strength of his character and seemed to limit his potency. Through free-floating discussion in one session not focussed on either of these men’s issues, we came to talk about members’ family life as one of the other men reported a catalogue of incidents in which he had been overlooked and neglected by both his busy parents. Michael reported that he would be giving the lesson as a lay preacher in a religious service that his father had been invited to attend. But the father would not be present because he would – once again – be abroad himself giving a lecture. Gerald commented in his customary, offhand and casual way that ‘They’re always travelling somewhere else, these professors’. Michael responded with a challenge of outrage and shouted at him in fury, ‘He’s not a fucking professor, he’s my father, he’s my father’, and he burst into tears we had never seen before. We had known him as a man who could hardly raise his voice. Now he went on through his tears to shout at Gerald, saying, ‘He’s meant to be my father and I wish he was, but he’s just like fucking you!’ We were all shaken by the drama, especially its two protagonists. Michael had never before challenged anyone in this way, and Gerald had never been so challenged. The group comforted Michael as he cried, and Gerald, equally shaken and also lost for words, needed a lot of tissues also.

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Commentary Condenser phenomena cannot be planned for or predicted. They take us by surprise and, when they do, they can carry the compressed emotion of the group as a whole into the heart of everyone present. In the sessions that followed this one, the group struggled in the reparative dimension with the corrective recapitulation of early family life. The space was specially charged with the emotion generated between these men. The others, especially the man described above who had led such a neglected childhood, and all the women helped to bring them face to face with the emotional presence of an available man – in the person of the conductor – whose presence provided the figure of a father that neither of them had enjoyed. Michael found a voice for his own sense of aggrieved authority and gained in stature and presence. Gerald began to find his feet as an available male figure for others in the group that was in due course generalised and extended to his family life at home. When he was later negotiating his departure from the group people described how Gerald had ‘filled out’ emotionally, like a piece of dried fruit fills out to regain its truthful shape when soaked in water. There was a striking match between their description and the one offered by Foulkes of how people placed successfully in productive groups unfold like Japanese dried flowers when placed in water (Foulkes 1964:100). At the time people related this picture of growth and attainment to the characters of both these men, dating the beginning of this restoration to the awful truth they were confronted with by Michael’s challenge. Michael left the group some time earlier with his diffidence and deference so resolved that he was able to take up religious training successfully, secure ordination in his church, resolve the unhappy association with his previous partner and marry the woman he had been courting for some time.

Amplification Vignette 10.5  Amplification and condensation after exposure In a mixed group of men and women that met early in the morning, people were at work on issues about gender when one of the women came in with an account of a man exposing himself on the train she had just travelled

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on. She left the train at the next station and caught another, but her feelings of alarm and then of revulsion were amplified in the group as people joined her sense of violation, and she found this a relief. It affected our exchange with one another for weeks. The figuration of the group’s work at this time was marked by a struggle to differentiate predation from male sexuality – a recurrent preoccupation amongst both its men and women The amplification of these gender-based anxieties accentuated a sense of shame about their maleness amongst the men and of defensive anxiety amongst the women. This continued until one of the women was later able to talk about the pleasure and excitement she gained from her husband’s erect penis inside her in the months after she became pregnant. She talked with both arousal and gratitude about how her baby had come from his penis. This frankness and detail had a startling effect on the group at this point of disclosure and – from this moment of condensation – people enjoyed the shared discovery that sexuality had became a restorative subject once it was linked to fertility.

Commentary These discoveries moved us from a figuration centred on erotic experience to reflective curiosity about the grounds for its absence in previous months. The kind of exchange that circulated in the group was focussed by questions about the content of its resonance. Members raised acute and amusing questions as to why no-one seemed to have any genitals until someone was expecting a baby!

Explorations and applications Resonance and valency: Signal resonance 2 Resonance and valency are governing dynamics in the signalling process amongst people and animals. Even simple forms of resonance are of governing importance in small groups.

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Vignette 10.6  Signal (simple) resonance 1: Where fear and opportunity crawl the streets Filming on the South Shore of Chicago where we wouldn’t have known the risks without special guidance, we met the gangbanger teens popping drugs for breakfast. The survival instinct is definitely different in this ‘hood’, eyes darting about and not even their own ‘cribs’ provide a safe haven for these youngsters with few prospects beyond protecting their Corner. Fear and opportunity are crawling in the streets.

(Josh Beattie, personal communication)

This description of a filmmaker at work relies on the only data he can read. The visual detail that leads to his conclusion – that ‘fear and opportunity are crawling in the streets’ – is engendered by the resonant detail of what he sees of ‘eyes darting about and not even their own cribs a safe haven . . .’

Vignette 10.7  Signal resonance 2: Where sheep may safely graze On a walk with my dog on a Welsh hillside in the spring we find it covered with sheep browsing quietly in the evening light. The adults are grazing across the field and lambs are playing together like children in a nearby corner. My dog is safely beside me and poses no threat. But as we approach from another field we are seen by some of the adult sheep who bleat alarm signals. In a second all the mothers are calling to their lambs who scatter and – guided only by their mothers’ voices – the lambs find places of safety beside them. And then all the adults find safety in numbers, congregating in a tight knot at the farthest end of the field.

Commentary In the first account above, the urban landscape knows no safety. Fear, panic and the lure of money are conveyed by the resonant detail of visual information. In the second account of attachment behaviour amongst sheep, resonance is,

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again, the key signalling system. The resonance of an alarm signal breaks up the playful gathering of lambs, who find their way to their mothers’ sides guided by their resonant voices. Amongst the sheep, alarm and the search for security are conveyed by the resonant detail of vocal signals in a rural setting where lambs find safety beside their mothers and the mothers find safety in numbers. The word ‘resonance’ captures the detail and evocative qualities of the processes at work here in both settings, where they take a relatively simple form to provide signalling systems about alarm and security.

Resonance and valency: Complex resonance We can differentiate signal or simple resonance from its more complex form and differentiate descriptive from unconscious resonance. The vignette that follows describes ‘the wounds of injured experience that speak without words’.

Vignette 10.8  Complex resonance: The wounds of injured experience that speak without words In a new, time-limited group of refugee survivors – all of whom had different mother tongues but where we did all our talking in English – we were having a discussion about language difficulties. There was concern in the room as to whether we would be able to understand one another. One of the members said, ‘There is no problem about language. People who have been injured have our own language. We communicate with each other like deaf people do, without words or hearing. Our experiences speak to each other. The wounds have words. If you’ve been wounded then you don’t need ears to hear. We speak with our own signs’.

Commentary This group is a powerfully resonant arena thanks to the principles of similarity that have helped cultivate identifying associations and make for cohesion. The form taken in these patterns of resonance is much more complex than the (Continued)

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(Continued) simpler signalling systems described above. We can call this complex resonance and see that it can take a visible and descriptive form. The group will cohere through these resonant associations as people bear witness to one another’s stories. But it may also later take an unconscious form as a scapegoat is unconsciously ‘created’ in the group by a resonant pattern of blame, rejection and withdrawal. The scapegoat himself makes a key but equally unconscious contribution. Much of the work involved in the journey from relational through reflective to reparative experience involves the location of those resonant patterns that are unconsciously disturbing and their translation into descriptive forms that are amenable to conscious and reflective review that are described below.

Resonance and valency: Descriptive and unconscious resonance These terms are used to differentiate forms of resonance. Some of its forms are immediately available, open to observation and amenable to description. There are other forms which startle us by their immediacy, but they are invisible and can rarely be predicted because they work at unconscious levels that are often deeply hidden. I have devised a basic set of distinctions between simple forms of resonance – described as signal resonance – and the more complex, fully-formed emotional gestalts that bring people into relation with one another. Table 10.3 differentiates between these two different kinds of resonance both of which can arise unconsciously or consciously in terms openly amenable to descriptive observation. Table 10.3  Resonance: Simple, complex, descriptive and unconscious Descriptive

Unconscious

Signal or Descriptive forms of simple resonance include direct signalling systems and open simple forms of communication about single subjects like threats, alarm and safety.

Unconscious forms of signal or simple resonance include single subjects like alarm, safety or sexuality, in which the communication is neither open nor direct but often immediate and surprising.

Complex Descriptive forms of complex resonance include emotional gestalts that are often fully formed and global, bringing people into open and apparent relation with one another and their emotions, including likes/dislikes, acceptance/rejection, desire/hatred.

Unconscious forms of complex resonance include all that is stated on the left, but these forms of resonance pass between or amongst people through channels that are hidden, covert, unstated or invisible.

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During group therapy, containment in the setting creates conditions of safety in which regression can be tolerated and drawn upon for its resolving and productive benefits. Vignette 10.9 explores the unfolding events of a group in which a sequence of unforeseen events generated by a breach in the predictable containment of its boundaries led to an alarming and not reassuring resonance that had a deeply disturbing condenser in the moment. It was later put to good therapeutic account. One of its participants had a background in South Africa and, in the aftermath of the disturbance, when members were busy with associative reconstructions in the spirit of reparation, she gave a touching commentary to the group on just how appalled she had been at the time by the rupture and by how much she still had to learn from her deep-seated need for constancy. She quoted from a book now long out of print in her homeland, whose title lent significance to the reconstructive spirit in which the group went on to do its work: Familiarity Is the Kingdom of the Lost.

Vignette 10.9  ‘Familiarity is the kingdom of the lost’: The woman who found a newcomer in her group: Resonance, condenser and amplification at work in therapy During her supervision a psychotherapist reported an account of a slowopen group she was conducting in which an existing member entered the group a little late for one session to find a new member who she was not yet expecting. Though the group was on notice for the new arrival, the person arriving late had been absent the previous session and missed the reminder. On coming into the group now and finding a stranger, she fell into a panic, became distraught and attacked the conductor by saying ‘How could you hurt me so?’ and she prepared to leave in flight. The conductor talked to her directly in soothing terms, spoke to her by name, explained what had happened and assured her that her own place in the group was safe. The anxiety subsided, and the conductor, sitting close to the woman in panic, engaged with the rest of the group as the woman continued to cry. The group was contained, containment gave some assurance to the silent but equally troubled newcomer and the session came to a conclusion. Only in the weeks that followed did they come to explore a range of associations to do with helplessness and violation. The supervisee later reported on an exchange in the group when they came round to consider this more closely, helping each other find comfort and safety in the words from Goldilocks and the Three Bears – ‘Who has been sleeping in my bed?’ Several of the women were survivors of sexual violation that included rape and incest and, though the catalyst was a boundary event that should never have arisen, it was turned to productive therapeutic account.

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Commentary When the supervisee was invited to talk about what guided her through the successful negotiation of a crisis she said nothing helped her except her own instincts as a mother, based on experience years ago when she gained the capacity to hold a frightened child. In that moment, she reported, not even Winnicott was anywhere near her, and what guided her through the work so ably was a simple form of unconscious resonance carried over from her role as the family’s mother. The existing member came in to something unexpected, and the visual information alarmed her. As her anxiety level rose, alarm and panic were communicated in the direction of the group and its conductor. The conductor abandoned any effort at therapeutic discourse with the group and went into therapeutic dialogue with the woman in panic, offering her soothing behaviour, naming her repeatedly and, through the use of words to do with safety, conveyed containment in the other direction. Only then did the conductor re-orientate herself to re-establish a groupbased discourse to include the newcomer whilst maintaining a continuing place of safety for the most visibly troubled member, who was still sitting closely beside her.

All these exchanges are governed by resonance as the conductor of emotion. Much of the resonance at work here is visible and open to description. We might call it descriptive resonance. It takes place in our groups all the time and works through members’ verbal and non-verbal communication. But resonance also takes another form not amenable to descriptive portrayal that can be named as unconscious resonance. This is what overwhelmed the latecomer to the group – an arresting exposure to something that evoked deep and primordial emotions – and it is also what equipped the conductor to respond in a containing way. Unconscious resonance is also at work amongst us all the time, and it can become visible. Progress in making the invisible group transparent through location and translation is explored in Chapter 17. Outside the therapeutic setting we can see it at work when people pick each other out with unerring accuracy in group situations of many kinds through positive or negative valency, often before there is anything spoken to guide them. Resonance and valency will be used here as complementary concepts to identify the hold that individuals come to have on one another in these interpersonal situations. Exploring mirroring The contemporary literature is called on to produce Table 10.4, which gives an outline of different forms of mirroring.

Table 10.4  Mirroring in seven forms and ensuing group dynamics* A

B

C

D

E

F

Form of mirroring

Quality of mirroring

Subjective state of the mirroring person

Perception of other

Effects on interpersonal process & process dynamics of group

1

Imitative or Modelling

Adhesive

Idealising

Attractive Constructive Validated

Engagement Intimacy Affection

2

Empathic

Bonding/ Attachment

Befriending Enriching

Engaging Constructive Attractive

Attunement Recognition Identification

3

Contrasting

Puzzling

Disorientated, Disconcertingly puzzled or different confused

Enhances curiosity; arouses reflection

4

Confrontative Challenging

Anger, frustration

Antipathy – pressure for the other to change

Distress, alarm, motivation to change; opposition or acceptance

5

Oppositional

Hostile

Opposing

Counterpositional Conflict

6

Projective

Distorting

Denial/ Dissociation

Non-reflective (unable to see)

7

Malignant

Destructive

Overwhelmed Hate towards by other what is seen in other

Scapegoating of an unaccepted other who is alarmingly close to the self Outright attack on an unaccepted other who is renounced because so much like the self who is hated

* Table 10.4 is an adapted and extended form of Table 1.2 in Pines’ Reflections On Mirroring, his Foulkes Lecture of 1982 published in Circular Reflections (Pines 1982/1998: 31). Grateful acknowledgements are made to the author and publisher.

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Table 10.4 sets out the seven forms of mirroring I have most frequently found in my own groups and which readers are most likely to find in theirs. These are each set out on a different and numbered line from one to seven, and they are named in column B as follows: imitative mirroring – which takes the form of modelling in adults – and then empathic, contrasting, confrontative, oppositional, projective and malignant mirroring. Each form of mirroring is given a distinctive quality in column C which ranges from adhesive in the first to bonding, then unsettling, challenging, hostile, distorting and destructive. For each quality of mirroring, there is a distinctive subjective state in the affective world of the mirroring person given in column D that ranges from idealising in the first and then to befriending, disorientating, unsettling, opposing, denying and being overwhelmed with negative feeling. And for each form of mirroring there is a distinctive perception of the other, given in column E, that ranges from attraction in the first to engagement, disconcerting, antipathy, counterposing, blindness and hatred. And finally there is a set of contingencies in their effects for the interpersonal process that are given in column F, which will characterise a figuration in the life of a group at any point in time. Different figurations will be at work complementing, frustrating or replacing each other in the fluid dynamic of a group’s process. Reading down column F will give a picture of what a group’s life might be like at any one point in time, with one, several or all of these figurations emerging progressively or even at the same time.

Working with process dynamics in the round: Concluding illustration This is an account of a group that generates a resonant arena. The interchange of experience generates a common zone described in Chapter 4. Free-floating discussion brings out individual members’ immediate associations about discrepancies of need in close relationships, the session’s first subject or figuration.

Vignette 10.10  The story of four fingers linked to describe partnership – process dynamics at work in the round during therapy Sam: describes a dilemma with his new girlfriend – he doesn’t know whether it belongs between them or inside him. He ‘makes the running’ for their relationship, sets its pace and is more attentive to her than she is to him. On their return from a week-end abroad three days ago, he hoped she would spend the night at his home. She knew he couldn’t come to hers because of his dog that had to be collected from his neighbour. Her decision to go to her own home meant they would be separated on their return, and his fear was she wanted it this way. He was now reassured that she wanted to see him this evening but, even so, she would be coming over much later than was good for either of them as she had other things to do first.

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Commentary The dilemma, based on what is already known about Sam in the group, casts him in the role of his previous girlfriends and her in the role he would have previously occupied – of being less available. Using the language of musicology we can see this as the group’s first subject or, in the language of Elias, our figuration. People are activated to not only explore these issues with Sam, taking up constructive positions of concerned enquiry as they do so, but also disclose issues of their own that have bearing on this first subject – discrepancies of need in intimate relationships that can distort mutuality. This is how resonance works. Sam arrived amongst us in a deteriorating spiral of difficulty with a former partner 18 months ago that saw no resolution. He settled with us, but the relationship finally ended in separation, leaving his former girlfriend bereaved and Sam lost and bewildered in the group. Since then he has had a sense of the remote about him. More recently people have been delighted for him with the development of this new relationship. The terms of the first subject lead to corresponding narratives from the others with emerging though differentiated subjects: Who wants how much intimacy? Who wants how much less or more than their partner? And how should an intimate bond be negotiated? The common zone embraces the group’s first subject, a current figuration that is then differentiated into a range of other related subjects in which each has a story of a related but different kind. Resonance generates the common zone that is, on this occasion, to do with intimacy. People’s narratives are interposed one with another and are not developed in the way they are described here as ‘single-item’ speeches. There is a rich interchange of experience in which one says something that another picks up on and a third then relates it to themselves or to a fourth member. The narrative is not linear but interposed and interactive – discussion generates a resonant arena that builds a common zone.

Vignette 10.10  continued

Grace: tells us of her ‘cavernous’ neediness. She was recently on her way back from a work assignment abroad and, stuck at an intermediary airport awaiting connection, anticipated coming home to a partner whom she knew she would find half drunk. The work she had done in the group allowed her to stop drinking and she was even off cigarettes

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at last, but she couldn’t stop herself from buying a packet. By the time she got home a few hours later she was ‘back on the weed’ in a big way. Trish: tells us of her visit to her boyfriend in Cardiff when she met his family for the first time and she felt held, cared for and respected. After they returned to London he invited her to travel down there for the next week-end but, needing time at home, she had to say no. She is worried his disappointment is behind his lack of communication since then. She turns her concern over to Sam and invites him to look at his own neediness in relation to his girlfriend’s own more pressing need to be alone at home. Sam: won’t be helped by this mirroring connection. He doesn’t look at it and stays in his own narrative of frustrated need – and is overwhelmed by fear that it is going to destroy his new relationship. Trish begins to cry and says she just feels sad for him. Gwen: says to him that Trish’s tears could be a mirror in which he might see the answer to the question he gave us earlier. Is the dilemma inside him or between them? She says it’s obvious now that it’s inside him. Now that he’s finally with someone who, unlike his previous partners, can arouse and deserve his love surely now he can finally look inside and see what’s missing in him. Sam’s tears: tells us she is close to the mark, and he takes his story back to his own needy mother who got him to feed her whilst making out that she was exhausted feeding him. It was what he calls her ‘propaganda’, but it has left him unable to trust need in either direction – his need of a woman or a woman’s need of him. Gwen: tells us on her own account that she was out with her own two little ones the other day, a daughter of seven and a son of five, and she thought about how much she was in love with them as she watched them play. As she looked at them and saw their vitality and playfulness with each other, two kids who just wanted to go out into the world, she knew they would never be in love with her in the same way that she loved them. She worried about the selfishness of her need for their love. Joanna: says if only Gwen’s husband met her halfway she wouldn’t need her own children to meet her at her halfway house. Joanna has been silent until now but comes forward to say that she worries that if Sam pursues his girlfriend with his neediness when they’re just getting to know each other, he will drive her away. She remembers this only too well from her time with her own lost partner. She invites Sam to bring us his neediness and give his strength to his girlfriend – and then things might grow well between them.

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Michael: says yes, that’s all very well, but is she going to go home with him and look after him on the many nights when his girlfriend won’t? There’s a lot of laughter, and through the humour we can see Sam and Trish both in tears. Conductor: I ask what the tears are about. Trish: says her sadness is for what looks almost inevitable – that he will mess it up again. Sam: says he remembers the story I recounted in the group a few weeks ago, taken from a psychotherapy text that describes internalisation. The author describes how, if a baby can enjoy nurture and nourishment with its mother, and if she can give of herself deeply to the baby, then the child who was once inside the mother can find the good mother inside him. He says he has no such ‘good mother’ inside. Sam: goes on to say that, with his own needy and pining mother, he never had anything like this. His insecurities down the years have either kept him away from prospective partners altogether or led him to people much more insecure than himself. For the first time he’s now with someone he’s fallen head over heels in love with. He’s frightened he’s already fucked it up and she’s going to go. Grace: asks Sam if he’s going to be able to tell her tonight, something – anything at all – about the work we’re doing together on these issues in the group. He’d like to tell her, he replies, but she’ll get in so late that they’ll only have time to go to bed together, and then – he hopes – they’ll have more important things to do together. There is more touching laughter, and both Sam and Trish go out with tears in their eyes.

Commentary In this figuration mirroring takes place in the relational and not the reflective dimension. Sam is so overcome by anxiety that he cannot see the mirroring potential in Trish’s story – he cannot see that Trish has goodwill about her boyfriend’s greater need for her; she can tolerate his greater need and reassure him. He cannot see that Trish’s ‘legitimate’ need for time out of the relationship is a mirror to his own girlfriend’s likely goodwill towards him, despite prompting from all of us. His own reflectiveness takes the reflective enquiry (Continued)

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(Continued) back to his own history by reviewing the process of an earlier session that becomes the group’s second subject or figuration – the recognition of early injury. The culture of the matrix is mature, robust and nurturant. No one is excluded, intrusive or exhausting of others’ time, nor of the group’s resource base. The group is modelling a state of balanced mutuality in which insight and outsight are both at work. A number of the group’s members are striving for this in their own outside relationships. We come back a week later to the next session.

Vignette 10.10  continued

Trish: tells us she has been thinking about Sam and asks the group if people ever saw a film, Children of a Lesser God, about the relationship between a hearing-impaired young woman who has grown up in a residential facility and is now one of its junior staff and an older instructor with whom she develops a relationship. She tells us it put her in mind of Sam and his issues and of her own. In the film neither of them has mastered the balanced mutuality we had in the group the other night, she says, and which you need in order to have a real relationship. She’s beginning to learn about these things now and had been worried that she and her own new boyfriend had fallen into the same kind of trap that was bothering Sam. But they are now going from strength to strength and, she says, it comes from the benefits she has been getting in the group and from other activities in her life where she has been learning about open systems. People want to know what an open system is, but she can’t find a definition. She came across it in something she read, and then she tells us what it looks like. She illustrates the symbol used in sign language amongst deaf people that she saw in the film. Partnership is signed by holding the thumb and index finger in one hand in a closed ring with the same two fingers in the other. She holds the sign up so we can all see the open system at work – neither hand has possession of the other. The bond that one hand has depends on the bond that the other hand has. It’s a symbol, she says, of a voluntary hold, not an anxious one, and she longs to be able to have a link like this with her new partner. It begins to look like a possibility.

10 Process  275

Commentary Process dynamics begin to work therapeutically through the conductor’s stance. He will need to react and respond to these dynamics personally in the relational dimension and then extend himself to a reflective enquiry that can – over time – generate reparation. Process dynamics can allow for the play and interplay of experience to provide the energising factors to drive the progression through the different domains of which it is comprised. The exchange begins at the current level reported on in the outside world of people’s relationships. The progression to the transference domain in the group and then to the projective and primordial domains is driven by process dynamics. The conductor’s own attunement keeps the dynamics of the group’s different domains open to one another. Principles of location and translation – studied further in Chapter 17 – help establish references in the group that frame what is problematic about life outside it and help turn identification into understanding. In a mature group cohesion can be built into coherence and longing can be transformed into belonging. Section III takes the subject through key areas that each have a chapter of their own. It opens with a study of the four domains or levels of the group, then goes on to transference and countertransference and then to the progression from longing to belonging. Process needs to be maintained as a fluid and fluctuating passage that keeps the common zone open to include all the members in the shared experience of the subject. This allows movement between the different domains so the current level can be looked through into the deeper areas of transference. Below this, the projective dynamics can lead the analysis on to the primordial or archaic domain as the symbolic register comes to provide mutative metaphors – in the signing for partnership – that can work for change.

Notes 1 This paper was presented for the first time at the Intensive Learning Event of the Institute of Group Analysis, London, April 2014. Grateful acknowledgements are made to Sarah Tucker, Linde Wotton and the other staff and students for their comments that have helped shape its current form. 2 The term ‘signal resonance’ introduced here is based on Freud’s introduction of ‘signal anxiety’ to the field in 1926 and is intended to serve a related purpose – to differentiate this simple form of resonance from its more complex forms found in mirroring and condensation (Freud 1926).

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Bibliography Agazarian, Y., and Peters, R. (1981). The Visible and Invisible Group. London, Routledge. Barsade, S. (2002). The Ripple Effect: Emotional Contagion and Its Influence on Group Behavior. Administrative Science Quarterly 47 (4): 644–675. Berger, M. (2012). The Dynamics of Mirror Reactions and Their Effects on the Analytic Group. In J. Kleinberg (Ed.), The Wiley-Blackwell Handbook of Group Psychotherapy. Chichester, Wiley-Blackwell, pp. 97–216. Berman, A. (2013). Resonance Among Members and Its Therapeutic Value in Group Psychotherapy. In J. Kleinberg (Ed.), The Wiley-Blackwell Handbook of Group Psychotherapy. Chichester, Wiley-Blackwell, pp. 187–196. Bion, W. (1961; reissued 2000). Experiences in Groups. London, Routledge. Brown, D. (1994; 2000). Self-Development Through Subjective Interaction: A Fresh Look at Ego Training in Action. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. Routledge, London. Reissued 2000, Jessica Kingsley, London. Republished in J. Maratos (Ed.). (2006). Resonance and Reciprocity: Collected Papers of Denis Brown. London, Routledge, pp. 107–123. Farrow, T., and Woodruff, P. (2012). Empathy in Mental Illness. Cambridge, Cambridge University Press. Foulkes, S. H. (1948; reissued 1983). Introduction to Group-Analytic Psychotherapy. London, Karnac Classics. Foulkes, S. H. (1964; reissued 1986). Therapeutic Group Analysis. London, Karnac. Foulkes, S. H. (1975; reissued 1986). Group Analytic Psychotherapy: Method and Principles. London, Karnac. Foulkes, S. H. (1977; reissued 1990). On the Concept of Resonance. In L. Wolberg and M. Aaronson (Eds.), Group Therapy: An Overview. New York, Stratton Intercontinental Books, pp. 52–58, and E. Foulkes (Ed.), Selected Papers: Psychoanalysis and Group Analysis. London, Karnac, pp. 297–305. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Freud, S. (1926). Inhibitions, Symptoms and Anxiety. SE, 20: 87–172. Harwood, I., Stone, W., and Pines, M. (Eds.). (2012). Self-Experiences in Group Revisited: Affective Attachments, Intersubjective Regulations and Human Understanding. New York and London, Taylor & Francis. Hobson, R. F. (1971). Imagination and Amplification in Psychotherapy. Journal of Analytical Psychology 16 (1): 79–105. Laplanche, J., and Pontalis, J.-B. (1983). The Language of Psycho-Analysis. London, Hogarth Press. Levens, M. (2011). Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation. MSc dissertation. London, Institute of Group Analysis/ Birkbeck College, University of London. Lévi-Strauss, C. (1949; reissued 1977). Elementary Structures of Kinship. Boston, MA, Beacon Press. Lewis, T., Amini, F., and Lannon, R. (2000). A General Theory of Love. New York, Vintage. Mitchell, S. (2000). Relationality: From Attachment to Intersubjectivity. Harvard, Academic Press. Nitsun, M. (1998). The Organizational Mirror: A Group-Analytic Approach to Organizational Consultancy. Group Analysis 31 (3): 245–267.

10 Process  277 Pines, M. (1982, 1998). Reflections on Mirroring: Sixth Annual Foulkes Lecture. Group Analysis 15, Supplement; and in Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London, Jessica Kingsley, pp. 17–39. Pines, M. (2015). Collected Papers. London, Routledge. von Fraunhofer, N. (2008). What’s in It for Me? The Development From Immature to Mature Dependence in Groups. Group Analysis 41 (3): 278–290. Zinkin, L. (1994; reissued 2000). Exchange as a Therapeutic Factor in Group Analysis. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. London, Jessica Kingsley, pp. 99–117.

Acknowledgements:  Table 10.1A and extracts from Foulkes (1948), Introduction to Group-Analytic Psychotherapy, Foulkes (1964), Therapeutic Group Analysis and Foulkes (1975; reissued 1986), Group Analytic Psychotherapy: Method and Principles; Foulkes (1977), On the Concept of Resonance in Wolberg and Aaronson (1977), Group Therapy: An Overview; reissued Foulkes (1990), Selected Papers: Psychoanalysis and Group Analysis, reproduced with permission from the Group Analytic Society; Table 10.1B and extracts from Foulkes and Anthony (1957, 1965, 1984), Group Psychotherapy: The Psychoanalytic Approach, reproduced with permission from E. J. Anthony; Table 10.5 reproduced with permission from Malcolm Pines and Jessica Kingsley Publishers; Figure 10.1 reproduced with permission from Malcolm Pines and Oxford University Press; extract from Pines (1982, 1998), Reflections on Mirroring: Sixth Annual Foulkes Lecture. Group Analysis 15, Supplement; and in Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis, reproduced with permission from Malcolm Pines.

Chapter 11

Content Key questions about narrative, discourse and the voice of the symbol

Worlds are made by words and not only by hammers and wires . . . Therapy is one way to revivify the imagination and exercise it. The entire therapeutic business is this sort of imaginative exercise. It picks up again the oral tradition of telling stories, therapy re-stories life. (Hillman 1983:46–47) it is not enough to be free of the whips, principalities and powers where is your kingdom of the Word?. . . I must be given words to refashion futures like a healer’s hand.

(Brathwaite 1988:65, 67)

The conductor should be ahead of his patients . . . in hearing (what Grotjahn calls) ‘the voice of the symbol’ . . . patiently waiting for them to catch up, cautiously helping . . . but most concerned with what is in the way, blocking the group’s own understanding. (Foulkes 1975, 1986:132) Bachelard writes that: ‘The image has touched the depths before it stirs the surface’. He encapsulated (what) . . . we had slowly come to learn from . . . psychotherapeutic attempts with the psychotic, borderline, and psychopathic patient . . . the significance of associative sensitivity is not confined to the clinical field . . . It enhances all deep human encounters . . . An image could safely hold experience . . . too painful, too brittle, or too broken to be firm enough to tolerate analysis . . . the image, activated by metaphor, could be the location of exploration or the fabric of support. (Cox and Theilgaard 1987, 2003 xiii)

This chapter provides therapeutic principles for working systematically in groups with the content of people’s stories in their narrative, drama and interaction.1 The Table of Vignettes on pages xv–xvii illustrates the challenges a conductor faces in making the most of what is always provided by people’s words of engagement.

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People’s language can convey so much about their therapeutic experience in both its inner meaning and shared significance. They may be talking about the past, the present or the future, their problems in the outside world or their relations with one another. The group may be rich in words with an active and vocal exchange. Or it may be governed by strange and seemingly unwelcome silence – they may not be talking at all! One person may be talking, or there may be sub-groups of exchange between – say – the newcomers and those long established in the group or between the men and the women. There may be a prolonged monologue by one troubled person or dialogue between individuals or sub-groups, or there may be discourse of a free-floating and undirected kind. The exchange may be kind, confrontative, exploratory or explosive. The mood may be consoling, desultory or desperate. The matter under discussion may be loss, sexuality, loneliness, recovery or friendship or all of these in association. The subject matter of exchange may begin with reports of people’s troubled lives in the world outside the group, undiscovered grief, recent experience of friction in the group, reports of a troubled or relieving dream or a recurrent daydream or fantasy. What is significant outside is worked on to become part of a significant interior. If the process is to be therapeutic the group’s attention will need to shift from what is troublesome – reported on in people’s homes and offices, their city or the world at large – to what is troublesome about the world within the room and the person in the group. It is here that resolutions may be found as the group progresses through its spiral of growth and development to reveal the hidden but active group at work inside each person in the room. The arising moments of reflection and reparation can put people in touch with the world revealed in the group and the group revealed within the self. Therapeutic direction seeks the locus of members’ own agency through which they can come to own the responsibilities that they themselves carry for what is unfolding in the room. This may be an argument, an evasion, a conflict, a storm, a flood of tears or an encounter with something lifegiving and renewing with its origins located in the person who is talking or not. As a group’s discourse unfolds its language and imagery are self-generated and, as Cox advises in the quotation above, the ‘image can safely hold experience . . . too painful, too brittle, or too broken to be firm enough to tolerate analysis’.

The dimension of content in the literature: Its history and relation to discourse theory Work with a group’s narrative and dramatic content, often regarded as the hallmark of the group-analytic approach, has a modest literature, despite its importance, with some exceptions. The work of Cox provided landmark publications over many years. My own paper, The Language of the Group: Monologue, Dialogue and Discourse in Group Analysis, is re-published here in its original form as Chapter 4. It introduces the study of free-floating discussion and explores basic questions about the place, role and significance of language described in three

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primary forms – monologue, dialogue and discourse. It draws on relational theory to differentiate between one-person, two-person and three-person psychologies, each of which is then related to one of a group’s three language forms. Other early contributions to this focus included Wojciechowska (1993), and the field today is opened to the wider study of language in our groups. As well as the forms of speech first introduced – monologue, dialogue and discourse – other enquiries in the group-analytic field include von Fraunhofer (2008), Brooks (2009), Wotton (2012), Verebes-Weiss (2011), Levens (2011), Rayfield (2013), Tyerman (2012), Wainstein (2013) and Peleg (2012) and others, only some of whose papers have been published. Beyond group analysis there are promising, wider enquiries into field theory, language and metaphor in psychotherapy, with a valuable contribution by Montana Katz (2013) in an edited collection in which Modell (2013) brings forward perspectives from Winnicott on transitional process. We remain in the early stages of a framework by which to analyse and explore the content of an exchange and relate it systematically through its figurations to structure and process. Differentiation between the dimensions of structure, process and content is notional. A group’s content will not be therapeutically productive unless it is set in context by productive work in the other two dimensions. Metaphors only become therapeutically mutative when the warp and the weave – the structure and the process – are in place. Free-floating discussion develops through interplay between narrative and drama, story and exchange, reconstruction and encounter. Discourse describes the communication of thought by speech, the exchange between someone speaking, someone listening, and something listened to, the relationship between narrator, listener and story. The language of a group is a form of behaviour in the group, a way of referring to experience in and beyond the group and a way of transforming experience in and beyond the group. The use of discourse theory to explore free-floating discussion can give clinical depth by focusing on a series of six simple questions set out in Figure 11.1. They were first introduced in Chapter 4. As the conductor reviews the group’s dynamics, they will gain purchase on the process by asking themselves the following questions: Who is speaking? To whom are they speaking? What are they speaking about – what is the message? What is not being said? The two additional questions introduced here are: Should the conductor intervene in any of these areas? If so, then on what terms?

Basic questions about language and non-verbal communication Tyerman has extended the enquiry by applying these questions to the non-verbal communication of a group and her four questions about non-verbal communication are set out in Table 11.1. She invites us to extend the questions as follows: As part of the understanding of the translation process in group therapy, I want to propose that the conductor helps the group think about non-verbal and somatic expression through a variation of the questions suggested by Schlapobersky:

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3 What’s the message? What are they talking about?

1 Who is talking?

2 Who are they talking to? 4 What is not being said?

5 Should the conductor intervene in any of these four areas? YES

NO

6 If they should, what is their op€mal interven€on?

Figure 11.1  Six questions about the language of the group Table 11.1  Tyerman’s four questions about non-verbal communication* 1

Who is communicating through the body or by some other non-verbal form?

2

Who is watching?

3

What is being conveyed?

4

What is being hidden?

* Table 11.1 is adapted from Tyerman, S. (2013: 14) Watching the Body in The Group: Theory Paper, Institute of Group Analysis, London, p. 14. Grateful acknowledgements are made to the author.

These dynamic questions can be used for guidance as the work develops through the therapeutic challenges described below.

Therapeutic challenges for the conductor The conductor faces primary challenges turning thematic and narrative analysis into therapy, and these are set out in Table 11.2. First the conductor needs to promote narrative and narrative encounter so people can find their own voices, gain confidence in self-expression and then discover their positions in relation to one another as their stories interact and intersect. Second, the spirit of enquiry planted in the group by the conductor can grow

282  II  The group-analytic model Table 11.2  Working with content: Five therapeutic challenges for the conductor Conductor’s challenge

Therapeutic purpose

1

Promote narrative and narrative encounter.

Foster interaction and intersection between people’s stories (1) so people can find their own voices and (2) so they can discover their positions in relation to one another.

2

Develop a sense of enquiry into the group’s narrative and thematic development.

The spirit of enquiry planted in the group by the conductor needs to grow amongst its members. Thematic and narrative analysis will come to be undertaken by all the group’s members.

3

Crystallise thematic development with group-as-a-whole observations.

Bridge different people’s contributions with linking observations, especially when this does not happen by itself.

4

Work with the modalities of time and place generated by group and bring them round to the dynamic present.

Foster systematic exploration of members’ past and present, inside and beyond the group, and then bring this into the dynamic present.

5

Listen to the voice of the symbol and educate the group’s members in how they too can hear it.

The group’s process is explored for the metaphors it generates, and this in turn allows its metaphors to have purchase on the process. What is looked for in the movement between content and process is the discovery of meaning in the implicate order of experience.

and mature into the shared task of analysis so members can develop a sense of enquiry into the group’s narrative and thematic development. Third, the conductor needs to help crystallise thematic development, often by bridging people’s different contributions through linking, especially when this does not happen by itself, and this becomes the subject for group-as-a-whole observations. Fourth, the conductor needs to give the group latitude to roam freely across the modalities of time and place between the past, the present and the outside world, and he can then draw the experience steadily into the dynamic present where it can take on a sense of immediacy in the dynamics of change. And fifth, the conductor needs to listen to the voice of the symbol and educate the group’s members in how they too can hear it. The group can be cultivated so its process generates metaphors and its metaphors can then have purchase on the process. In the flux between process and content meaning will emerge in the implicate order of experience like the emerging form of an artist working on an image. A group working in this way will have open dynamics of interchange among its four different domains – the current, transference, projective and

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primordial – as described in Chapter 13. And so, when its membership is sensitised to and curious about the symbolic meaning of their experience, the primordial level can create fluency and depth for the transformative impact of the work done in all the other three domains. When the life of a group can grow so the dimensions of process and content can work on one another in a reciprocal way, then its figurations can allow dynamic moments of great intensity. In what follows the chapter traces the enquiry through these five different challenges to help explore what we mean by figurations as they evolve and bring change to people’s lives. Promote narrative and narrative encounter Vignette 11.1  People’s voices come alongside one another, followed by their stories One of the women in a new group – Catherine – emerges as a relatively silent member. She is attuned to what happens but does not have much to say. Some sessions into the group, as events in her life outside bring her forward to talk, she does so with new urgency for the first time. The content of what she says leads naturally into David’s narrative. They are discussing their homes. She cannot manage hers and is overwhelmed by its clutter. David talked last time about his refurbishment, and she – by reflection – is talking about her clutter. He comes forward to talk alongside her and 10 minutes later is doing all the talking as Catherine encourages him to clarify what he is trying to tell us. The rest of us are witnesses to their exchange and remain in the background. David tries to go further without success, and Catherine follows in the gap to talk alongside him for some time as we all pay close attention, especially as her voice is so new. Then she stops herself, turns to David, apologises for interrupting him and encourages him to take up from where he last left off five minutes ago. There is laughter round the room on her behalf that she does not seem to understand. David says, ‘That’s how it works here; your voice then my voice then your voice then mine. And any one else’s voice too’. And he looks around. One of the others – Lisa – says to Catherine, ‘You were doing the talking and he came alongside you. Then he was doing the talking and you came alongside him. And now you apologise for interrupting him! Can you not see how shy you are of speaking for yourself ? Your voice has a place amongst us. Don’t stop . . . we want to hear from you!’

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Commentary Catherine does not yet believe that her voice has a place in the group. She seems ‘threatened’ by the space in the room and the attention she receives first from David, then from Lisa and then from the rest of the group. But in small, steady increments she finds her place amongst us and discovers the sound of her own voice. In the flux between the group’s three forms of speech – monologue, dialogue and discourse – people interact through their voices and then their stories interact. It would be tempting here to consider the process dynamics as they unfold, but the subject matter of this chapter is in its content.

Six key questions applied to the promotion of narrative encounter We can now apply the six basic questions about the language of the group described in Figure 11.1 on page 281 to the first of the conductor’s five therapeutic challenges. QUESTION 1: WHO IS TALKING?

Catherine and David are talking about their respective homes. Catherine has been profoundly depressed for a long time, and the mess in her home is understood to indicate her own depressed mood and messy sense of self. David longs for a partner to share his home with, but none of his attempted relationships work, and he remains lonely. QUESTION 2: TO WHOM ARE THEY TALKING?

Catherine and David are talking to the group – including the conductor – through one another. QUESTION 3: WHAT ARE THEY SAYING?

If I’ll help you with your home, and if you’ll help me with mine, will the group help us with what we cannot speak about? QUESTION 4: WHAT IS NOT BEING SAID, WHAT IS UNSPOKEN?

This fourth question – what they cannot speak about – can be opened up by using the four domains of communication introduced in Chapter 13.

11 Content  285 QUESTION 5: SHOULD THE CONDUCTOR MAKE AN INTERVENTION IN RESPONSE TO ANY OF THESE FOUR ISSUES?

QUESTION 6: IF THEY SHOULD, WHAT IS THEIR OPTIMAL INTERVENTION?

These six key questions are built out of an earlier construction in Chapter 4 where they open the Clinical Illustrations. A repertoire for interventions using Foulkes’s four domains of meaning The repertoire of possible interventions is now explored using the original Foulksian concept of the group’s four levels in Chapter 13. There the four levels are re-named domains. This new terminology is used here to provide a framework for considering the conductor’s options when dealing with content. IN THE CURRENT DOMAIN

David and the others are, first, helping a faltering member find her voice and, second, David and Catherine are supporting each other in their efforts at home improvement. IN THE TRANSFERENCE DOMAIN

David and Catherine, who both live alone and do not have partners or close siblings, ‘offer’ themselves as ‘significant others’ for one another – they take on an emerging identity as one another’s ‘surrogate’ partners. IN THE PROJECTIVE DOMAIN

Like a nest-building bird or squirrel, David is making space in his home life with refurbishment, and in an unconscious construction or fantasy he imagines Catherine coming to fill it with him. There is no expressed desire between them and no indication of romantic interest, but they ‘borrow’ each other, becoming figures serving as fantasies for ‘the real thing’. His home is otherwise so empty of humanity and her home is kept so cluttered that its emptiness does not have to be registered. She is allowing David – in particular – to help her de-clutter it. She might be doing so with the reciprocal fantasy that he will also help her live in it. IN THE PRIMORDIAL DOMAIN

We come to discover that the other home ‘under construction’ is the group itself. The unspoken – what is not being said – is that we are building a place of safety for a group of strangers. We hope to create a new sense of being at home together

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and will want to occupy it in security. The new-found, self-created sense of security will become the fulcrum on which people can rest the levers with which to re-build their lives in the outside world. Foster narrative and thematic analysis in the group by the group The group described above is a new one and has the resources to work and understand itself at the current level – so the work is mostly in the relational dimension. Constructions put later at the transference level engendered reactions of tolerant amusement and disbelief and had the effect of stifling the exchange between Catherine and David, so the conductor stopped talking about surrogacy and pairing and discontinued this focus. Reflective observations about what is called empathic mirroring in Chapters 1 and 11 and horizontal transference in Chapter 14 were offered again later as opportunity allowed in a spirit that was tentative and enquiring. At this later point they helped everyone appreciate how the emerging bond between these two served the group as a whole. The conductor then allowed the group time to find its own way forward through the reflective dimension to reparative experience, working always within the limits of its own as yet tentative understanding and looking to extend this. What proved to be most useful in developing the group’s capacities was the responsiveness engendered amongst them in taking up the challenge of narrative and thematic analysis. Once achieved then thematic development described in 3 and 4 above could be crystallised. But if the developing bond between Catherine and David had been made the subject of an interpretation it would have evoked disbelief and protest. Had the conductor put to the group prematurely his own a group-as-a-whole constructions, offered as ‘leading’ or ‘plunging’ interpretations about building a home together, this interpretation might have more closely addressed the conductor’s own projected hopes than the needs of the group. People were only just beginning to create a psychological ‘home’ with him, and he may have imposed on their associations an unwarranted burden in terms of his own need to do well by them. All this emerged as described in 4 – the primordial domain above – at a meeting point between the group’s readiness and the conductor’s intuitive judgement. Vignette 2.2 on page 70 describes another new group for those recovering from acute mental illness and describes how, from the hospital: We looked out at the ‘normal’ world that included the traffic of human society outside . . . participants decided . . . that the world outside was comprised of aliens whilst we alone lived in a ‘space capsule’ called ‘the Normals’ . . . a yellow submarine . . . a refuge and sanctuary as people slowly rebuilt their lives. In these relational moments the creation or discovery of a bond is also a source of illumination through which the group becomes an auxiliary ego. The conductor’s role in fostering narrative and thematic analysis works first through phatic

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speech – as described in Chapter 15 – with the kind of intervention by which someone says ‘thank you’ to express gratitude or uses ‘please’ to convey politeness. The emotion of gratitude or politeness is not separate from but located in the use of the word by which it is expressed. In the buildup of communication in a new group that creates the ‘space capsule’ of the ‘normals’, the conductor picks out phrases, gives them emphasis, uses phatic connotation to allow its members to appreciate the relevance of their own words and experience and then – without any further notice or forewarning – members of the group begin to describe themselves living in a space capsule called ‘the Normals’ – a yellow submarine. We move – through the group’s own agency – from the relational to the reflective dimension working at the primordial level to include everyone in a new-found sense of security. The voice of the symbol is in the song about the yellow submarine. In Vignette 2.4, The image of the jangling keys is called on first by one of the group members and then by the conductor as a figural image, a figuration that captures nuances of relational meaning. It then becomes a symbol of the intersubjective, capturing something that belongs amongst us about the way in which aggression intrudes into relations amongst us with a series of ruptures that cut people off from one another (page 76). Crystallise thematic development In Vignette 5.6 the group has an emerging vocabulary that the conductor calls on to focus on a key phrase that it generated – ‘springing the trap’. This phrase came to speak for its members’ struggles with their self-created states of neurotic confinement. It describes how: the privacy of self-declared need was found during an unexpected period of silence. The metaphor of springing the trap plunged us into a long, deep reverie . . . the image of ‘springing the trap’ is itself a piece of poetry that provides us with a relatively pure form of the imagination at work (page 154–5). The metaphor of a trap being ‘sprung’ to release someone who has been a hostage to a history of neurotic difficulty serves to help crystallise the thematic development of the discourse. The conductor draws this image from the language of the group, and he then calls on it to frame the discourse and point the way forward for its members’ further engagement. Work with the group’s modalities of time and place and bring them round to the dynamic present In Vignette 11.2 on pages 290–291 we can see a mature group reacting to an outside event in the current life of one of its members that generates profound associative images from their different histories. During the historical discourse the conductor

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reminds the group he will be away for its next session. One of the members challenges him, saying, ‘How can you go away at a time like this? Here we are talking about all these terrible things and you just go sailing off’. The return of the repressed is expressed in the transference. The group is at work on the corrective recapitulation of early family life. Anger against the injurious others who populate people’s histories takes the conductor as its target and is given space to emerge and find understanding. Listen to the voice of the symbol and educate the group to hear it too Vignette 4.5 on page 128 shows a mature group calling on all four domains of communication – current, transference, projective and primordial – as it works its way through the individuals’ resistances to progress. The group is not dealing with one person’s manic flight, another’s depression, another’s disorder of sexual desire or the reaction of the group as a whole to the recent Christmas break. Nor is it dealing with the common relational problems they mirror to one another. It is dealing with all this simultaneously. As the relational matrix generates a semantic field this in turn helps transform their relationships inside the group and beyond. In this semantic field meaning is condensed by a number of key images that enter the word play of the discussion. A disorder of sexual desire is an empty house; passion can bring the roof down; desire can become its opposite; two whole hearts can produce an empty house. The group’s subject is not simply the series of static images by which it is reproduced here. A sense of profundity accrues as the process of discourse – now a chain reaction of associated images – develops a symbolic language by which the tension between hope and fear is brought out and resolved.

Language, imagery and thematic development further illustrations The two concluding vignettes of this chapter illustrate how content can be worked with ‘in the round’. They are both schematic. Vignette 11.2 is comprised of working content in a group that spans long periods of time into two single sessions separated by a gap of one year. Process dynamics amongst the individuals and between themselves and the conductor will be evident as they take their inception from a current dramatic event reported by one of the members which sets the stage for what follows. The group is studied for what it can reveal about the issue of content. Vignette 11.3 is comprised of working content generated in an experiential (or process) group at a conference for mental health professionals. The dynamics based on resonance and reciprocity are ‘greyed out’ to concentrate on the content of the discourse in its associative imagery, the patterning of its words and its key lines of thematic development. Both vignettes describe the promotion of narrative and the fostering of narrative and thematic analysis by the group. Thematic development is crystallised through key words and images as the group’s

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modalities of time and place are brought into the dynamic present where all can hear the voice of the symbol at work. The voice of the symbol at work 1: The clinical illustration describes a therapy group at work and compresses the progress of an extended period into two sessions situated months apart described in schematic form.

Vignette 11.2  Anger and its monsters: Language, imagery and thematic development in the content of a therapy group over time

The consulting room 1: Brendan: reports a recent, dramatic incident. He is an unemployed actor who drives minicabs. Yesterday he saw two men assaulting a third, and as their victim fell to the ground they began to kick him. Before he knew it – he told us – he was out of his car and he seized a spade from a workman digging a ditch and attacked the assailants, screaming and brandishing the spade like a sword. They both fled, and when he found himself under his own control again he was standing protectively over the bleeding body on the ground. Others came to his assistance, and an ambulance fetched the man he had saved. But by the time the police arrived to take a statement from him he was shaking so much he could hardly speak. He begins to shake in the group and others, with the encouragement of the conductor and knowing his history, provide helpful analytic questions taking him back to memories of his childhood in London amongst other poor Irish families. His father’s charm, lovely singing voice and endearing ways were offset by violent, drunken outbursts against the mother. The sight of a defenceless person beaten in the street took him straight back to forgotten but dreadful pictures of his mother’s distraught body under their father’s blows. As a boy, he tells us, he had been too little to protect her, but he tells us – with prompting and support from the others – that now as a big man himself, and armed with a spade, he could have finally brought his father down! Angela: tells us that ‘finally’ is a very final word. She recounts the incident with her father that finally brought her into therapy. She was visiting him with her teen-age children a few years ago when a terrible row broke out and her father struck her, right in front of the children. She hit him back with a huge blow to his face that came from herself and also, she says, from both her younger sisters. She

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left immediately with her children and has had little to do with him since then. Rena: notices gestures that Angela makes whenever she talks about these things, as if she could wave them away as if they were dirty. That’s how she feels whenever she talks about her parents’ relationship. Her father was devoted to her and she could do nothing wrong. But he despised her mother, and the cries her mother used to make when her father used to strike her! She feels dirty talking about it. And no one knew. She and her sister were the only ones who knew that her father was anything except a famous doctor – to this very day. Sarah: joins this chain of associations to tell us yet again the story of how her father came back from the war. She was only five and had hardly ever seen him. There he was on the day of his return standing in the narrow passage, not her father at all but just this strange man with an unshaven face stinking of cigarettes. He wore a uniform of rough khaki that scratched her when he picked her up. He was such a disappointment – she lost as much with his return as she had done with his earlier departure. She had longed for his return and dreamt of being able to tell him how frightened she was of her mother’s rage. Once home he never protected her. Geoffrey: tells us that in his family it was his father who was the victim. We know some of this story but hear more of its detail for the first time. His father was tormented by a brother-in-law who forced him out of the family business. His wife – Geoffrey’s mother – sided with her brother rather than with her husband. One day his father got into his car – his only private space – and gassed himself with monoxide. Geoffrey is in a lot of pain, and we are all shaken by the intensity and detail of the descriptive content. People sit in silence amongst their memories and associations. Beneath the descriptive content is a dynamic process that allows the return of the repressed. The violence of the external world has ruptured into the containing space of the group and now acts like a catalyst to bring the range of early injury to the surface. The bad objects of childhood, frequently lost to conscious recollection, emerge in the group’s analytic climate. It allows the original injuries and their associated emotions to become sources of reflective enquiry as we move between the relational and reflective dimensions. The session is nearing its end, and I remind them that next week I shall be away. Sarah: turns on me with a hostile attack. The ambivalence in her relationship means that I am sometimes the benevolent father she never had and at other times the inadequate father in whose hands she suffered. ‘How can you go away at a time like this? Here we are talking about all these terrible things and you just go sailing off’. The return

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of the repressed is now expressed in the transference. She gets angrier still, and I interpret the transference suggesting that her rage is perhaps based on a fear that when I come back I will, like her father, be wearing a rough khaki uniform and smell of cigarettes. She says half in play, ‘I could murder you’; she snarls and chuckles at the same time, and there is affection towards me evident in the tears in her eyes. ‘Perhaps you’d like Brendan’s spade’, I reply. ‘Then you could really bring me down, just as Brendan dreams of doing with his father’. She doesn’t say anything but it is clear she is struggling within herself, and the struggle shows on her face. We have now moved into the reparative dimension of therapy and are working on the corrective recapitulation of early family life. Some of it is replayed in the dynamic present of the group’s transference with me. Anger against the injurious others who populate their histories takes me as its target and is given space to emerge and find understanding. Before we conclude the group falls into a brief discussion about how angry they sometimes get with me. It is important that this anger is acknowledged and contained and that I am not provoked into retaliatory behaviour or self-justification. As we prepare to leave Brendan – who has been deeply but silently absorbed in the process dynamics – gets a generous dose of affectionate concern from the others as they make sure that he’ll be all right driving away.

The same consulting room 2: One year later the same group with a slightly different composition is meeting with the subject of despondency on its agenda. Brendan: tells us that he’s actually feeling worse. It’s nearly three years since he joined us, and it feels worse than ever. His level of despondency is palpable. What good is all this therapy if he still feels so much hurt, he says. Angela: thinks that he’s very different. She has been able to follow and understand the emotions of his recent relationship and its breakdown. She has felt very much for him – there’s a ‘him’ here now for whom she can feel, and she contrasts this with his personality when she met him two years ago when she arrived and first met him. He used to say virtually nothing and, when he did talk, spoke only about his succession of one-night stands. Brendan denies this but: Rena: who has been in the group throughout Brendan’s time, reinforces Angela’s position and reminds him of just how little he used to

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say, week after week. When he joined the group he was so withdrawn. Then he had a woman – she struggles to remember her name and is reminded that she was called Sally. Yes, Sally, Rena remembers, and says: You fell in love with her so quickly and she gave you the boot and then you collapsed. And then you found another and another. And all of it was invisible – we knew nothing about any of it until you were in that dreadful state. Now we’ve been able to share things with you and you don’t seem depressed even though you’re hurt – we’ve been able to share it with you and you do at least have us. Brendan: makes a joke of it to invite one of the women home with him tonight as he looks in turn at each of the three in the group. There is warmth and laughter. Conductor: I remind him of the incident he shared with us two years ago when he intervened during a street fight and saved someone from being beaten on the ground. It seemed to mark a turning point in his development, and he has been using the group in a much more open way since then. Angela: reminds us of another of his violent incidents, something he was able to share with us soon after the one described above. There was an angry encounter in the street between himself and his car and two people in another vehicle. When they threatened him he became so aggressive and made such a noise that they were intimidated and backed away. He put himself at unnecessary risk, just as her son had done recently in another incident. None of this is necessary. It’s all just testosterone, she says. Where’s the intelligence? For a man with your gifts and words, to live like a street fighter, what a waste! I wish you had a woman in your life – I’m sure she’d calm you down! Paul: reminds us that in the six short months since he joined us he’s heard about none of this, and Brendan is persuaded to recount both incidents. Paul himself is a successful journalist, and his stories have included interviews with people in prison for violence. It’s no joke, he says. Brendan: tells us in some detail of the two worst instances, responding to Paul’s further enquiries with an account of people he knows serving time in prison for crimes of violence. Rena: says to Brendan that he seems to be coming out of a different kind of prison. For the years in which he was invisible with us, he was numb. We didn’t see or hear any of what was really going on inside. Now we can see the trouble, and although it troubles her to see him hurting so much, she’s relieved it’s coming out. There is a long period of silent reflection. Adele: tells us that her life is beginning to change. She doesn’t know what it’s due to or even whether the group is playing any part in the changes, but over the last year she is beginning to feel differently about herself – it’s a question of confidence, she says. In the short time

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she’s known Brendan, she’s seen him change. When he challenges the group for not helping enough, he’s getting us to take him seriously. She doesn’t like what she can see coming out of him, but he’s got to get it out. He speaks with such depth about the very issues that bother her – fear of futility and feelings of despair. Paul: thinks back to his days at school when they used to beat each other up. He’s still got some kind of double-headed monster raging inside him. Looking around he thinks we all have. It reminds him of the movie his own kids love to watch called Shrek. It’s a monster who is redeemed by love, but when it finally meets its princess their kiss changes her into a monster so she can join him.

Commentary There is an identification amongst us that allows each person to own their own hidden anger monsters. It takes place through bonding, disclosure, mutual acceptance and humour. These anger monsters are the mutative metaphors that speak with the voice of the symbol. Brendan’s involvement with the women in the group becomes a topic that we move on to from the attention we have so far given to the history of his relationship with his father, and we explore further what he needed and did not get from his mother. His inability to tolerate frustration and the speed by which difficulty makes things feel impossible suggests that absence must once have meant abandonment.

The same consulting room 2:  continued Paul: then tells us more about his history of adoption. We know he was given up for adoption by his mother, but this is the first time we hear his true emotions about this history of abandonment and rescue. For the first six months of his life he had no-one except the care staff in the home. His adoptive mother had him from six months. He knows that somewhere inside him there are frozen wastes. He’s got a Siberia somewhere in his heart and knows this stands behind the history of difficulty in his relationships. That’s where the anger monster lives. We are beginning to discover that behind the anger there is desolation – a bleak and empty inner world blighted by neglect and absence.

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Commentary The uncovering dynamics of the group lead us from depression to numbness. They go behind the numbness to identify rage.   And then they go behind the rage to locate despondency found to have its origins in the earliest experiences of uncertain and insecure attachment. If we begin our analysis with the basics we can see that the emotions of early insecurity are encapsulated in defensive character structures that seal off the psychic states of despondency and abandonment. These states are withheld from conscious experience because they are too painful. Their consequences emerge instead as rage. External events act as triggers or targets onto which early affronts are projected, and the ensuing rage attacks the early injurious other – whether this be mother or father – who is represented by the person responsible for a current provocation. This is the world inhabited by each of this group’s members. In their repetition compulsions, fate neuroses and ongoing difficulties in life, the originating traumata remain invisible. The group provides a containing resource by which, through mutual acceptance and then identification, we find the anger monsters in each of us, and these are the reparative discoveries. The matrix of experience that conditions the social unconscious of deeply injured people can also provide the vehicle for its repair. Their own anti-group propensities, if harnessed to self-examination, can yield insights that can begin to melt the defences represented by Siberian desolation. The group opens with an account by Brendan that locates its discourse in the external present – the attack he witnessed and his own reactions. As he shares his story he has a post-traumatic reaction that locates us very dramatically in the dynamic present as he shakes in the group. The direction of our therapeutic enquiry takes Brendan back ‘there and then’ to his childhood, the external past that we discover is not remote at all.   Angela, Rena, Sarah and Geoffrey join the associative chain with recollections of injury, abuse, confrontation and tragedy that keep us in the external past. The conductor brings them to the group’s present by reminding them he will be away next week. One of the members, Sarah, attacks him on behalf of the others for abandoning them at a critical point. The conductor explores her anger with him in the dynamic present by offering a construction in the transference that takes up Brendan’s account of how, armed now with the weapon he found in his hands, he could finally have brought his father down – as she would like to do with the conductor in her rage about abandonment. She is moved to tears and says, only half in jest and with deep affection, ‘I could murder you!’ The conductor brings out the evidence of aggression against him, survives the ‘notional’ attack without retaliation, and the therapy is picked up and progressed two weeks later in the next meeting.

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The study in Figure 11.2 of the modalities of time and place follows a demarcation introduced to the field first by Strachey (1934), who took the view that for an interpretation to be mutative it would have to address the past, the present – in the transferential moments of the session – and the world outside the analysis in the person’s actual life. It is always a challenge to frame an interpretation that serves to be accurate and encompassing at the same time, especially in the heat of the moment in a group. Figure 11.3 provides a perspective on further advances in group-analytic thinking and practice in which the conductor’s interventions are guided not so much by Strachey’s original ‘architecture’ of interpretation but by a different focus. This is the consistent endeavour to guide the dynamics from the other three quadrants of time and place and locate disturbances that arise in the dynamic present where they can focus their resources on attunement to the current dynamics and emotional communication in the moment. A discussion of Strachey’s original contribution and an overview of how work with transference has been modified over time is provided in Chapter 14. The resolving dynamics of the group’s process moves the energy from the external present through external past, then through the group past and finally into the dynamic present where it is addressed by the conductor in the transference.

1 2 3

4

Figure 11.2  Content analysis and the modalities of time and place Source: Figure 11.2 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Figure 6.3.6.9, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1364. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my coauthor Malcolm Pines for his consent to their re-use here.

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Experience in group

3

4 Experience in present

Experience in past

1

2

Experience in outside world

Figure 11.3 Progression of group discourse towards resolution and change

Stories, narration and reparative symbols The voice of the symbol at work 2: Vignette 11.3 is drawn from an experiential group at a conference in Germany held in the early 1990s. For many of its members this was a ‘first time since the War’ event. The significance of the content is carried in the vignette not so much by the imagery or language of the group as by the narrative of its stories and the reparative meaning of its symbols. Its fruitful working process relies on good relational experience, but it goes beyond this to the other two dimensions of psychotherapy to provide reflection and reparation.

Vignette 11.3  The woman whose birth saved her mother: Content and thematic development in a short experiential group

There were 10 of us in the group, and many came from countries that had been attacked or over-run by Germany during World War II including Czechoslovakia, Denmark, Greece, Israel, Norway, Poland, United Kingdom and Yugoslavia. As the group’s convenor I did not make any disclosures in the group about myself, though my own Jewish identity, the loss of our family in the Holocaust in Lithuania and my father’s role as a soldier in the liberation of Italy during World War II were all relevant. Some of us knew one another vaguely from previous such events, but we were mostly strangers and through the four days of the conference we met early each morning for an hour and a half. There

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were two German women in the group, and it is the interaction between these two women – Susanna and Sabina – and the rest of the group and especially the content of their disclosures at its conclusion that illustrates the progression of a group’s life to reach the reparative dimension. All the group’s members had been born in the post-war period. There was an additional sense of acute locational awareness based on the fact that many were here in Germany for the first time. People were preoccupied with stories of wartime events learnt originally from their parents’ generation that were now brought to the surface by their visit. As they shared their associations they would sometimes look through the windows onto the wide streets and imagine the town dominated by swastikas and military parades only one generation earlier. Each had a different and equally poignant story to tell of events that befell the previous generation during their country’s occupation. There were accounts of wartime brutality, sacrifice, heroism and betrayal. In each case we traced the events of the 1940s through to their many consequences in people’s own life histories. We were taken up by the social unconscious of the group rather than by the unconscious dynamics of its individual members. Susanna and Sabina remained subdued through this exchange. One of the reasons people gave for coming to the conference included their wish to make contact here with their generational counterparts from other countries, and there were similar feelings expressed by these two German women. But despite befriending overtures, they remained unforthcoming. Only after a warm alliance had been forged did one of them – Susanna – share her immediate history. She was still coming to painful terms with an earlier decision not to have children and used the group to help her with her grief about this. She had fallen pregnant two years earlier and after a short but heavy period of doubt – because she wanted to have the baby – decided against it. She felt it was too late in her life to have children and at the time had no stable relationship in which a baby could grow. Her exchanges with different members, including Sabina, helped her see that her often unhappy relationships with men had something to do with the complicated history of her early childhood and then a later crisis with her otherwise beloved parents. Whilst she was a young adult she had fallen in love with a man from the Near East. Her parents’ rejecting reactions gave her – what she called – ‘a very intensive course in everyday racism’. Although they never broke completely, the rupture with her parents damaged

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their relationship and left her with a kind of political and moral confusion that she now brought to the group. Her parents had been very ‘normal’ mainstream people of their time, but the link between their racism and the fascism of the country’s past left her unable to find a clear way for herself. By the time she did so – now – it was too late for children. We found the story distressing in the group and were witness for the first time to the burden of history carried by the next generation on the other side. We tried to get behind this and do what we could do to help Susanna free herself from culpability that preceded her birth but which she was now acting on through a masochistic protest against her parents’ generation. In the group she initially found that accounts of brutality at German hands confirmed her own sense of guilt. As the discussion progressed she found that people’s efforts to make contact with her allowed her to see herself – like them – as a victim of history. Sabina remained silent, and she sat through the first sessions in a tearful and withdrawn state. She would not be drawn out about her tears but eventually spoke in our concluding session one day later when she told us how much of a burden her mother had been to her. She was still carrying the weight of her mother’s depression. We explored what part this had played in her own decision to become a therapist, and the story unfolded in an unforeseen direction. She was born in a small town in the east of Germany close to the Polish border on a day in July 1945 when there was still fighting in the area, which was then invaded by the Russians. People were in a state of terror knowing that the invading soldiers came to rape and pillage. When the Russians banged on the door of their home her grandmother called out that a baby was being born at that very moment. A Russian officer came in to inspect and, on seeing her mother in labour, was so moved he marked the door of the house with a cross and wrote beneath it in Cyrillic so it enjoyed security throughout the occupation despite the soldiers’ despoiling activity elsewhere. Later her mother fled with her to West Germany where she had been raised. The picture formed by the non-Germans in our group of the full extent of suffering amongst Germans – suffering of which they had no former picture  – created a new figuration that had farreaching consequences for all of us. The story took on new meaning when the group’s membership was able to construe this as an account of how the innocence of new life in a baby’s birth had saved its mother and her family.

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Commentary The story had powerful symbolic meaning for each of us. Its reparative significance, expressed through the symbolic voice of a baby’s innocence, provided a sense of absolution brought by the newborn with benefits of redemption for her mother and the household. The decisive impact of a birth at a critical moment and the continuing presence of a baby’s vulnerability had halted the blood craze of vengeful soldiers. In front of us now there was a grown woman, but the baby was still there inside her, and it brought out in everybody the recognition of a new generation’s innocence.

The group discovered a poignant sense of grace with consequences for both women that was extended to touch all of us. As we talked those many years ago we began to see how the innocence of those born after the Holocaust – witnessed in the group in both German women – could work back to soften the burden that lay on the generation of those who had been responsible for it. The parents of Susanna and Sabina had not played any direct part in Nazi activity, but when their daughters could see historical meaning in the hurts of their own upbringing, and when they could share this meaning with people from ‘the other side’ who had similar biographies, they could begin to see how to carry the circumstances of their lives with a new grace that would always be with them.

Note 1 Sections of this chapter were presented as keynotes to the Israeli Association for Group Psychotherapy, Haifa, 2001, and Deutsche Gesellschaft fur Gruppenanalyse und Gruppenpsychotherapie (D3G), Dresden, 2014. Grateful acknowledgements are made to Haim Weinberg in Israel, to Marita Bartel-Rosing in Germany and to members of the different audiences for their contributions in helping shape the material into its current form.

Bibliography Bohm, D. (2002). Wholeness and the Implicate Order. London, Routledge. Brathwaite, E. D. (1988). Rites of Passage. In E. Braithwaite, The Arrivants: A New World Trilogy. Oxford, Oxford University Press. Brooks, F. (2009). The Othering of Silence in Groups. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Cox, M., and Theilgaard, A. (1987). Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley.

300  II  The group-analytic model Foulkes, S. H. (1975; reissued 1986). Group Analytic Psychotherapy: Method and Principles. London, Karnac. Hillman, J. (1983). Healing Fiction. Putnam, CT, Spring Publications. Levens, M. (2011). Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation. MSc dissertation. Institute of Group Analysis, London/ Birkbeck College, University of London. Modell, A. (2013). Metaphor, Meaning and the Mind. In S. Montana Katz (Ed.), Metaphors and Fields: Common Ground, Common Language and the Future of Psychoanalysis. London, Routledge, pp. 59–66. Montana Katz, S. Ed. (2013). Metaphors and Fields: Common Ground, Common Language and the Future of Psychoanalysis. London, Routledge. Peleg, I. (2012). Oppression, Freedom, and Recognition in an Analytic Therapy Group: Group and Therapist Interactions from Relational and Group Analytic Perspectives. International Journal of Group Psychotherapy 62 (3): 436–458. Rayfield, E. (2013). Weathering, Shifting Perspectives and the Space In Between. M.Sc Dissertation. Institute of Group Analysis, London/Birkbeck College, University of London. Schlapobersky, J. (1994; 2000). The Language of the Group: Monologue, Dialogue and Discourse in Group Analysis. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. London, Routledge. Reissued Jessica Kingsley Press, pp. 211–231. Strachey, J. (1934). The Mutative Effects of Transference Interpretations. International Journal of Psychoanalysis 15: 127–159. Reissued in R. Langs (Ed.), (1990), Classics in Psychoanalytic Technique. New York, Jason Aaronson, pp. 321–338. Tyerman, S. (2012). Watching the Body in the Group. Theory Paper for Qualification. Institute of Group Analysis, London. Verebes-Weiss, J. (2011). Capacity to Be in a Group: Small-Group Psychotherapy in a Forensic Therapeutic Community for People With Dangerous and Severe Personality Disorder. Theory Paper for Qualification. Institute of Group Analysis, London. Von Fraunhofer, N. (2008). What’s in It for Me? The Development From Immature to Mature Dependence in Groups. Group Analysis 41 (3): 278–290. Wainstein, S. (2013). An Exploration of Intimacy in Group Analytic Psychotherapy. MSc Dissertation. Institute of Group Analysis, London/Birkbeck College, University of London. Wojciechowska, E. (1993). The Group as Transformational Object: Fusion, Transition, Transformation. Theory Paper, Institute of Group Analysis, London. Wotton, L. (2012). Between the Notes: A Musical Understanding of Change in Group Analysis. Group Analysis 46 (1): 48–60.

Acknowledgements:  Extract from Braithwaite (1973), Rites of Passage, in The Arrivants: A New World Trilogy, reproduced with permission from Oxford University Press; extract from Cox and Theilgaard (1987), Mutative Metaphors in Psychotherapy: The Aeolian Mode, reproduced with permission from Jessica Kings­ley Publishers; extract from Foulkes (1975; reissued 1986), Group Analytic Psychotherapy: Method and Principles, reproduced with permission from the Group Analytic Society; Figure 11.2 reproduced with permission from Malcolm Pines and Oxford University Press.

Chapter 12

The conductor Convenor, therapist and group member

Those who do not trust enough will not be trusted. When actions are performed Without unnecessary talk, People say, ‘We did it!’

(Lao Tsu 1972:17)

Group analysis rests on a paradox: the conductor is the only person in the group who carries the authority of a professional therapist, yet it is the group as a whole which carries the professional authority . . . (and so) to embrace both wings of this paradox, the conductor has to move adroitly between two positions: one which allows the group to determine the flow of the therapy, and one which enables the conductor to assert (their) own therapeutic authority when necessary, perhaps against the current of the group at the time. (Behr and Hearst 2005:102)

The group-analytic model has a unique term for therapeutic leadership, the conductor, first devised by Foulkes and then developed between himself and Anthony. The range of definitions for leadership across the different models of group therapy includes the terms ‘group leader’, ‘facilitator’, ‘convenor’ and ‘therapist’. They come together in the work of the conductor. The term embraces the leadership role in some of these other models and adds more distinctive features. The conductor both contains the group and has a place inside it. This paradox is part of what can make this leadership role fruitful. The conductor’s contribution will be critical to the process of turning a collection of suffering strangers into a working group that can advance the well-being of its members. Progress in moving from the relational to the reflective and then reparative dimensions of the work turns on the availability of the conductor as a person, their resources as a therapist and their capabilities as a convenor. I have put this three-fold designation forward as a variation on Foulkes’s own original outline of the conductor in which he used three slightly different headings that emphasise who the conductor is – as a person, what they do – their technique and what they represent – what they come to mean to the group and its members (Foulkes 1964:285–287).

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This chapter  provides a systematic account of the conductor’s different but concordant roles as convenor, therapist and group member. The same group will have different leadership requirements at different stages of its life and development. Different kinds of groups, varied by setting, membership or purpose, will call on the conductor for a more emphatic contribution in one or another of these roles. Each of these roles can be seen to have the other two embedded within it. This provides the rationale for a leadership style that is integrated, flexible and dynamic and equips the conductor to live through the flux of feeling and exchange, helping people turn the inevitable discords and reciprocities into the resolving experience of a productive therapy. The first half of this chapter is devoted to the different role functions considered separately. In the second half these differences are set aside to consider the leader as one whole person who is there to conduct the group. What the conductor finds in the group will be a reflection of what the group finds in the conductor. This chapter is addressed not only to the conductor in the group but also to the group in the conductor whose own undeclared dynamics will inevitably come to life and be reflected to them by the group. We need to be prepared for what we will inevitably find, whether it is an anti-group, a group that cannot cohere, one that cannot hold its members or one that over-invests in its members’ progress. It is for reasons of this vital kind that the training of a group analyst sets such store by their own experience of therapy. The conductor’s own makeup, history and especially the unconscious detail of their preoccupations, problems, strengths and liabilities will inevitably come to life amongst the members of any group they conduct. The use of countertransference as an active working principle is key to the group-analytic approach and, as was discovered in the originating discoveries of early psychoanalysts, it creates a framework by which to turn liabilities into assets. Countertransference can be used in ways that are both responsible and effective for which the conductor will need to be on terms with their own makeup, circumstances and history. They will need to be able to retain their composure when at close quarters with suffering and disturbance and will need to be available for intimacy without being directly transparent. The conductor needs to be able to expose themselves to the dynamics of those in therapy, remain closely attentive to their own responses and emotions and be able to pass this back to the group and its members as ­information about the whole process, in a careful and considered way. This chapter is devoted to challenges of this kind and, at the end, it is illustrated by Vignette 12.1. A musical conductor has an orchestrating role in relation to the voices of the singers or instruments to whose musicality they give a tempo as they set the beat and bring out the harmonies and discords. A conductor in group analysis has a related role but also one that calls for both more activity and more abstinence as the work is being done without a score and is more like improvisation than orchestration. Rutan, Stone and Shay introduce the startling recognition that the literature written for group therapists gives clarity to the protocols that advise on how to begin and end groups. For the ‘in-between’ – that is, most of the work – the

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therapist is left to find their own way. Their recognition is based on an account provided by Freud as follows: One of Freud’s more famous remarks was his comparison of psychotherapy to chess. Of the latter he observed, ‘Anyone who hopes to learn the noble game of chess from books will soon discover that only the opening and end games admit of an exhaustive systematic presentation and that the infinite variety of moves that develop after the opening defy any such descriptions. The gap in instruction can only be filled by a diligent study of the games fought out by masters’ (Freud, 1913:128). In other words, the beginning and end of therapy can be taught—less so, the middle. (Rutan, J.S., Stone, W. Shay, J. 2014:177) This chapter  follows those authors by looking to illuminate the conductor’s tasks throughout their time with a group.

Advice to aspiring group analysts The many pages of protocol that follow here will count for little in helping a new group analyst who wants guidance on how to do their job unless they first consider the seven cautions identified in Table 12.1. For someone who has never conducted a group before and is looking to do so now, these seven advisory points qualify what they might expect from this chapter. Table 12.1  Advice to aspiring group analysts: Seven cautionary points 1 After reading this chapter it might be most useful to forget about it. Try to do the job by working as spontaneously as you can to ‘plant a spirit of enquiry in the group and model a way of behaving’ (Behr and Hearst 2005:109). There is nothing mysterious about spontaneity. Table 17.1 shows how Foulkes addressed this topic – which hardly features in the group-analytic literature – as a function of the group but never of the conductor. Moreno, one of Foulkes’s earliest associates, gives us a useful account of its value in the conductor’s person, describing it as a way of thinking, communicating or acting authentically in the here and now to bring about positive change in the moment. It includes creativity, novelty and the capacity to find adequate responses to new situations or new responses to old ones (Gill and Sherbersky 2013:34–39). 2 Before ‘forgetting’ about this chapter there are two others you might read, and then you can ‘forget’ about all of them before you start. The most illuminating account of leadership is Foulkes’s own writing. On Leadership is Chapter 4 of his Therapeutic Group Analysis (1964:54–65). Behr and Hearst in The Start of a New Group set up a dialogue about the opening stance of a conductor. You will inevitably place yourself somewhere in the pictures they generate, and the more aware you are of your own predispositions, the easier it will be for you to work with instead of against them (Behr and Hearst 2005:81–91). (Continued)

304  II  The group-analytic model Table 12.1 (Continued) 3 If you have not been in group therapy yourself, make sure you find a group for yourself before you offer one to others. 4 You are most likely to be able to work with and from yourself on spontaneous terms if you can go back to your own experience of being in group therapy as a patient and remember what it felt like. 5 Ensure you have a sound and trustworthy supervisor on hand and good arrangements in place to meet with them regularly. 6 Ensure all the preparatory protocols are honoured in terms of the convening and therapeutic roles. The convening role covers the setting, composition and membership of the group, its duration and the frequency of meetings, all of which will need to be discussed with members in your opening session. The therapeutic role will cover the content of the assessment meetings and preparatory, individual sessions with each member if that is your mode of practice. You might be starting an experiential group in a training programme or conference, in which case you will have no foreknowledge of the members, and you will begin with them as they begin with one another. Between these two parameters is a whole variety of others including the process of taking a group over from a colleague, replacing a co-therapist who is leaving a group or working in an in-patient psychiatric service or therapeutic community with small groups, where you are likely to come into an on going group with a rotating membership and other colleagues you will staff it with. 7 The final point of advice is to sit down as a member of the group by giving close and silent attention to the extraordinary things that will inevitably unfold. Whilst it is true that you will conduct a group most successfully by listening rather than speaking, you will often need to speak in order to hear what is not otherwise spoken by others.

The conductor as convenor, therapist and group member Figure 12.1 shows the dynamic relationship between each of the three role functions which, taken together, comprise the work of the conductor. The group can be thought of as an undertaking that begins in the mind of the conductor as they set about constructing definitions for the group’s scope, membership and duration. So the diagram begins with dynamic administration – the convening function – it progresses to the therapeutic function and then to the place of the conductor as a personal member of any group they are conducting  – a member whose own humanity is one of its principal resources. The convenor’s management tasks in the practicalities of a new group begin with dynamic administration. This is another group-analytic contribution to the field that links the convening to the therapeutic function (Hutchinson 2009). In a new group, dynamic administration will require a much more active role of the conductor, referred to as crescendo, in which the convenor’s management establishes their authority for maintaining the group’s boundaries, membership, setting and stability. This activity is carried into a therapeutic role where the conductor

12  The conductor  305 Convenor – Dynamic Administrator

Group member

Therapist

Figure 12.1  The three role functions of the conductor

models a position that members can adopt towards one another. Over a period the group’s members can absorb some of the conductor’s leadership functions, which allows a decrescendo in the conductor’s own role. As the group gains authority the conductor can be freed from an exclusive role as the group’s source of authority, and members steadily find a voice and a language in which to address each others’ behaviour, including late-coming, non-attendance and other boundary events. The conductor can then take up a less prominent and central position as convenor and now contribute more actively as therapist and group member. As therapist the conductor is responsible for promoting discourse, for moving the group from relational through reflective to the reparative dimensions and for helping the group with the location of disturbance in this process. These disturbances that seemingly ‘get in the way’ of the group’s work can always be anticipated. The challenge of translating them from latent or invisible terms that arise from the unconscious into a descriptive language about observable group behaviour is the work itself. Transference is a critical part of this task, and the work of interpreting transference in group analysis is not so much to review or reconstruct the past as to investigate the dynamic present. In dramatic contrast to Freud’s account of the psychoanalyst at work behind the couch, Foulkes’s account gives us a picture of the conductor who: treats the group as adults on an equal level to his own and exerts an important influence by his own example . . . representing and promoting reality, reason, tolerance, understanding, insight, catharsis, independence, frankness, and an open mind for new experiences. (Foulkes 1964:57) On this account therapy takes place ‘by way of a living, corrective emotional experience’(Foulkes 1964:57).

306  II  The group-analytic model

As group member, the conductor contributes from an abstinent position with regard to their own needs but with regulated self-disclosure in the active use of countertransference, serving the group’s progress by commenting on the unspoken and sometimes unspeakable issues that arise in the exchange. In doing so it will be important for them to make active use of the first person plural – the word ‘we’ – to help to support the bonding process by which a collective identity is established. For example, when bringing a background issue into the foreground of the group’s attention, the conductor might use ‘we’ to say something like – ‘We don’t seem to want to pay much attention to Brenda and her withdrawal. She’s been sitting on the side-lines of the group for the last few sessions’. A group will inevitably respond to this kind of comment, as the conductor owns their own part in the shared avoidance of a member’s depression. Brenda may be relieved or embarrassed by the attention she now receives from the group, but whether or not she comes forward, the group will be prompted to address its own excluding process and will likely try to draw her in. The most illuminating account of leadership in group analysis is in Foulkes’s own writing On Leadership in Chapter  4 of his Therapeutic Group Analysis (1964/1986). He presented it first to the annual meeting of the American Group Psychotherapy Association in New York in 1959, and it was later incorporated in his third book in 1964. His emphasis in the chapter is on the subtle use of a humane and available presence in the room combined with a withholding of the authority function to engender this from within the group. The chapter is illuminating in its depth and imagination but fails to differentiate the management task – which no-one else in the group could conceivably assume and which is the sole responsibility of the conductor – from the therapeutic task in which he takes up a position as one amongst others in this ‘living, corrective emotional experience’. The qualified interest with which his paper was taken up in North America at the time probably arises from this critical absence of reference to the duality of role and function as between the convening and therapeutic functions. Anthony’s comments about this period and about Foulkes’s writing are included in the conclusion of this chapter on pages 322–323. There has been an encouraging development of dialogue in the field, including a productive controversy between those speaking for this ‘classical’ Foulksian position on leadership in which the conductor leads ‘from behind’ (Behr and Hearst 2005) and Hutchinson (2009) and those calling for a more direct stance on the conductor’s part, in particular in their responsibility for focussing on aggression and anti-group dynamics (Nitsun 1996, 2009). A good deal of this debate arises out of how poorly established were the executive functions of dynamic administration in Foulkes’s original accounts of the conductor at work. Part of this chapter’s purpose is to join this debate by emphasising the three roles as discrete functions of the conductor. Each of these requires the exercise of a different kind and degree of authority. So, in what follows, the chapter will first explore each of the three role functions as a separate set of leadership responsibilities. And second, it will explore the coherence of these functions in a single and integrated leadership role.

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The three role functions of the conductor taken separately The conductor as convenor: Dynamic administration In Figure 12.2, the dark grey circle demarcates the conductor’s on-going convening duties in the life of the group, with their continuing therapeutic functions represented by the mid-grey circle embedded within it, making clear that the management tasks and duties are all called on  – as they arise  – for therapeutic purposes. The light grey circle embedded within that, representing their member role function, makes clear they are always and inescapably a person amongst others in the group. One of the most probing challenges facing the conductor will involve the requirement that they should be available in personal terms without being transparent. Many of the tables and diagrams following in this chapter are addressed to the subtle and complex challenges required of this interface between personal availability and the conditions by which it is qualified to regulate personal transparency. The convening functions of the conductor and their responsibility for dynamic administration will vary dramatically between one setting and another and between different group populations. It begins with the definition of a group’s goals, the recruitment of its members and the establishment of its setting, venue and timetable. These duties of care remain with the conductor  – in this convening role  – for the maintenance of the group’s on-going life. This includes liaison in correspondence with referrers, the protection of the group’s external and internal boundaries and the management of people’s departures and arrivals, including – in on-going groups – the introduction of new members. Dynamic administration, studied in detail in Chapters 8 and 9, captures the centrality of the management task and the way it is incorporated as part and parcel of the

Convenor Therapist Group member

Figure 12.2  The conductor as convenor: With their therapeutic and member-role functions embedded

308  II  The group-analytic model

therapeutic process. Two of the most critical elements in dynamic administration are set out below. A  The convenor and the setting The conductor supplies, creates and maintains the setting throughout the group’s life. This will differ depending on the wider system in which the group is located, calling for one role from the convenor if, for example, it is an out-patient group where a secretary or receptionist is the only other important person on the boundary, and a much more active liaison role if it is located in a hospital or prison where negotiations with ward and custodial staff are an integral part of the conductor’s administrative task. This is a continuing and fundamental part of therapy and will involve protection of the group’s external boundaries such as meeting times, punctual beginnings and endings, the predictable frequency of its meetings and breaks and the general guarantee of a stable background against which the instability of individual members can become the foreground for the group’s attention. B  The convenor and boundary events in the life of a group Every aspect of the group’s life including absences, departures, late attendances and extra-group communication in terms of letters, phone-calls and messages, referred to generically as boundary events, are open for discussion and enquiry. Boundary events can be divided between those that arise on the group’s external boundaries and those that infringe internal boundaries. EXTERNAL BOUNDARY EVENTS

External boundary events can be interpreted for the meaning they might hold for the life of the group as a whole. This is a task initiated by but not confined to the convenor, and as the analytic frame and the events that break its boundaries become topics for discussion, the setting itself – to which each member is seen to contribute – acquires a capacity to hold its individual members and contain their anxieties and insecurities. For a forensic population, for example, the issue of containment is of great importance, as is the discovery – by people who may have no belief in themselves as responsible members – that they can take responsibility for themselves and expect responsibility from others like them. The group is thus responsible not only for the nurture, acceptance and security of its members – in a sense for their ‘mothering’ – but also for their containment, the setting of limits and the maintenance of consistent authority – for their ‘fathering’. The conductor will invariably have to lead the way in modelling both roles for the group’s members, but the evolution of a therapeutic culture will see individuals taking up these roles and the emergence of some capacity in the group as a whole to develop and maintain its norms from the standpoints of both ‘mothering’ and ‘fathering’. On the other hand, a population attending an outpatient group in private practice,

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like the groups described in the opening vignette of Chapter  2 and throughout Chapters 3 and 4, will not have the same reliance on the convening function of the conductor, whose contributions can be more closely attuned to the therapeutic needs of the moment. INTERNAL BOUNDARY EVENTS

Problems with the group’s internal boundaries, when members’ group behaviour is transgressive in their dealings with one another, will always need the convenor’s attention. The conductor is ultimately responsible for the equitable distribution of time and attention – for what Brown calls ‘Fair Shares and Mutual Concern’ (2006). Issues arising out of the conduct of people who monopolise, who earn the epithet ‘help-seeking complainer’, whose withdrawal or bullying behaviour is of consistent concern or who take up the compulsive position of every one else’s caretaker will need to be addressed. The attention might be required on therapeutic terms but authority is sometimes called for and, unless the conductor can exercise their own authority, others may find themselves helpless in meeting these challenges. ‘The Story of the Wooden Spoon’ in Vignette 9.1 provides an illustration of how the conductor’s response to internal boundary events was turned to productive therapeutic account. The conductor as therapist In Figure 12.3, the mid-grey circle  – which is here the primary one  – demarcates the conductor’s primary role function as therapist. Within this their on-going duties in the convening role are embedded in dark grey and within that, their continuing identity as one member amongst the others represented in light grey, will remain of continuing relevance and will be guiding the therapist. The therapist role function is summarised below under four different headings. It has already

Therapist Convenor Group member

Figure 12.3  The conductor as therapist: With their convening and member-role functions embedded

310  II  The group-analytic model

been studied in detail in this section’s preceding chapters. The summary below includes: the development of therapeutic, reflexive attitudes in the group; promoting discourse by building on monologue and dialogue; making progress from relational to reflective; and from reflective to reparative experience; and using countertransference to make transferential experience visible and comprehensible in the group. A  Therapeutic role and attitude The conductor’s functions evolve as a therapeutic role with their demonstrated responsibility for establishing a therapeutic attitude towards individual members, their intra-group relations and the life of the group as a whole. This will help to establish reflexive attitudes and a culture of enquiry about self and other for the whole membership. Powerful affects and attitudes will be directed towards the conductor that she will need to monitor and transform into verbal and non-verbal therapeutic responses. The development of the therapist role function will call on their own free-associative reactions to the atmosphere and events in the group and their readiness to speak about these things, which will also help model the development of free-floating discussion. B  Promoting discourse First, the conductor will need to demonstrate their own confident resources to work with these dynamics and model this ‘use of self’ in the here and now to promote discourse. Promoting discourse will begin by cultivating monologue as people begin using the group to talk about themselves and their issues. The therapist will need to help turn this into dialogue as bridges are found between different people’s experiences. The therapist’s own bridging role will often be a critically important one in the early life of a new group. Interventions aimed at this kind of bridging have received relatively little attention in group-analytic literature. Foulkes, in fact, sets himself against bridging interventions as Table 17.2 makes clear. But they stand at the heart of Modern Analysts’ work in North America amongst whom bridging interventions are often highly directive (Ormont 1992). In the group-analytic tradition discourse is more frequently promoted by the conductor’s readiness to engage on a sometimes personal basis as they ‘play’ with the group’s experience to allow discourse to emerge as a non-directed and spontaneous chain of associations and reactions. C Progressing from relational to reflective and reparative experience The therapist will need to be able to move from relational to reflective experience in the climate of the group’s exchange and then from reflective to reparative experience as the group matures. These three primary aspects of the conductor’s role function will arise in all applications of the group-analytic model.

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D  Working with transference As the group generates its own climate of exchange, the therapist will need to be able to explore the emotional impact of the moment by reflecting on its transferential implications. A key part of their work will involve making transference visible and comprehensible in the group. A vital source for the understanding of what is happening transferentially can be gained as the conductor monitors and explores their own countertransference reactions. They are first and last a person amongst others and, in the presence of troubled and painful emotions, their own containing resources will need to serve as an anchor that begins the process by which the group becomes a container for its members. The conductor as group member In Figure 12.4, the light grey circle that is here the primary one demarcates the conductor’s continuing human presence in the group. It is a presence that is governed first by their embedded convening function – given in dark grey – that regulates their responsibilities for the group’s life throughout. And it will be guided by their therapeutic function – given in mid-grey – that will furnish them with a therapeutic rationale to guide their interventions and focus their understanding as to what is going on in the group, how much or little they will say at any point in time and what therapeutic purposes their interventions will follow, even when they choose to speak most personally. As a group member, given in light grey, the conductor will need to be able to call on their countertransference reactions to monitor what is happening in the room. And then – without being transparent and without more self-disclosure than is necessary – they will need to metabolise their own personal reactions and turn them into contributions in the life of the group that will demonstrate their availability to the process and help it progress from relational to reflective and from reflective to reparative experience. In the earliest stages of a new group a narrative commentary from the conductor, offered from a subjective standpoint, is likely to be found Group member Therapist Convenor

Figure 12.4  The conductor as group member: With their convening and therapeutic role functions embedded

312  II  The group-analytic model

alarming amongst a group of strangers. But a conductor’s simply given first person observations about the setting, the room, the mix of people and their apparent ease or unease is likely to model for those new to therapy how to begin using the process. A conductor who could not tolerate silence in the group is likely to be more active than is wise and would likely intervene too frequently and thus foreclose on the group’s own free-associative process. But on the other hand a conductor who was too detached could come to be experienced as withholding and punitive in their silence and could draw counter-therapeutic attention towards themselves by their very detachment that might subvert the therapeutic process in some other way. The balance is, as ever, a complex one and is likely to be maintained by the conductor’s own personal experience of group therapy in the past or present and/ or by their own experience of clinical supervision. As the group settles and progresses, the conductor will be the recipient – as suggested above – of projections and other powerful affects from the members, their sub-groups and from the group as a whole. At later stages more extended countertransference observations and interpretations – provided in reflective and reparative terms – can become a key to help locate the group’s disturbance. At the same time the conductor can model a process-based activity to also help equip others work together in this way as the group’s enquiry deepens. Therapeutic use of the conductor’s member-role functions are studied in depth in the chapters of Section III.

The integrated responsibilities of the conductor Different clinical populations and the wide variety of settings in which groupanalytic psychotherapy is practised will call on the group analyst for different kinds and qualities of leadership. The picture is further complicated by the fact that the same group – in the early stages of its life, for example, or in a mature and creative phase much later on – will require different leadership roles of the same group analyst. But despite these divergences, the model has a sufficiently robust set of definitions that allows them to be set out in a series of general principles. The first integrated set of principles follows in Table 12.2 with an outline for the conductor’s prevailing identity in a developing group – in their role function as convenor, therapist and group member – and assigns phase-specific duties to each of these discrete functions. The developmental life cycle of a group is set out in this table in a notional way, progressing from the establishment phase through the consolidation and creative phases to the termination phase. We are not dealing with ‘an exact science’, and there are many other ways of describing the developing life of a group, as set out in Chapter 3. This cycle is an approximation to cover the broadest likely range. A long-standing slow-open group will work through a spiral of development that might include elements from these different phases occurring at progressively more evolved stages as people come and go. A shortterm closed group, like one that meets for experiential purposes in the course of a training event or conference, will likely have these different phasic elements inter-penetrating one another, calling for a wide variety of different interventions

Table 12.2  Phases in the cycle of a group’s development: Conductor’s prevailing identity and responsibilities Group phases

Prevailing identity of conductor in role function in group

Conductor’s responsibilities

1

Convenor (dynamic administration)

Definition of group. Selection and composition of membership. Management of attendance and participation. Maintenance of boundaries and protocols.

Therapist

Establish and maintain therapeutic attitude to individuals, sub-groups and group as a whole, promote discourse, progress from relational through reflective to reparative experience, work with transference.

Group member

Call on countertransference to guide transferential work. Model use of the group as a forum with occasional personal observations, including readiness to speak as a witness to people’s experience, making frequent and active use of the word ‘we’.

Establishment phase

2

Consolidation phase

Therapist

Containment, inclusion, integration, maintenance of a memory bank for the group by linking past, present and outside world. Development of trust. Promotion of discourse by building on monologue and dialogue. Progression from relational through reflective to reparative experience. Work with transference. Foster cohesion and coherence.

3

Creative phase

Therapist

Locate disturbance. Translate group experience from symptomatic language to the language of descriptive group behaviour and meaning. Interpret linkages between past, present and outside world.

Group member

Participation in group as a member with things to say that include the personal but excluding self-disclosure, making frequent and active use of the word ‘we’. (Continued)

314  II  The group-analytic model Table 12.2 (Continued) Group phases

Prevailing identity of conductor in role function in group

Conductor’s responsibilities

4

Convenor

Help departee with evaluation of their experience, their individuation in the group and anticipation of life after group.

Therapist

Generalisation from group to outside world. Address issues of loss and change; relate these to both departee(s) and to those remaining (in open group).

Group member

Speak for their own experience of impending termination and loss, conditioned by limits of being available without being transparent.

Termination phase (departing member or whole group)

on the part of the conductor – or none at all – within a very limited time-table. Developmental phases are already addressed in Chapter 3, so what follows here is focussed on leadership and the conductor’s role. Leadership principles for small and median group therapy and then for large groups are explored in Tables 12.3 and 12.4. Although large group leadership is outside the scope of this book, Table 12.4 addresses this to differentiate between the different leadership roles for these different kinds of undertaking. In the course of group-analytic psychotherapy people find themselves carrying each other’s stories and emotions around with them between sessions and having arguments or rapprochements with one another in their mind’s eye and during odd moments in the week. These can be returned to when brought back into the sessions, where the group’s past and people’s lives outside its sessions come to converge on the dynamic present. It is this ‘here and now’ that comes to carry an increasingly significant charge as the levels of intimacy are deepened in moments of profound exchange. Some of the distinctive attributes of small group leadership emerge when the approach is contrasted with large group leadership. In a large group, the unconscious life of an institution or meeting comes to life in the arena of the group, though it is not worked through by attending to individualised motives or need, which is the governing task of small group psychotherapy. In a large group people’s voices and exchanges are taken to represent thematic tensions, concerns or ‘hot topics’ that are relevant to the life of the whole, to its sub-groups and to the

Table 12.3  Leadership principles for small- and median-group therapy 1 Visual and auditory contact are important so everyone can see and be seen, can hear and be heard. These requirements of the setting are key responsibilities of the convenor. 2 Everyone enjoys an equality of presence, and the voices of all are welcomed. Safeguarding equality of presence is a key task for the convenor and, when the group’s alignment inevitably departs from this ideal, the new figuration will call for therapeutic interpretation. 3 The exchange develops spontaneously. It is not directed, has no set agenda or theme and grows through free-floating discussion. 4 The exchange evolves from monologue through dialogue to discourse. Neither of these earlier speech forms are disregarded, and the group’s process dynamics will move spontaneously between them in a spiral of developing exchange, based on the needs and pressures of its members. 5 The group’s early phases are dominated by the struggle to progress from strangeness to familiarity and then to community – described as cohesion – through which both regressive and progressive attributes of personality can be expressed and understood. People will struggle with deep and passionate emotions about each other that are sometimes close to love and hate. 6 Intimate conversations in a cohesive group can go on to cultivate coherence, a shared sense of meaning through which the reflective process of the group is internalised. 7 In a cohesive group members find a place for themselves in the intimate conversations that take place and the group becomes a witness to each individual’s story. 8 Later, in a coherent group, the intimate conversations find a place within each individual. The connections become transpersonal when people have a valent or counter-valent place in one another’s hearts, as they bear witness to each other’s struggles with resolution and reparation. 9 One or two conductors act as convenors who are responsible for managing the setting, for keeping the time and for providing a running commentary on the life of the group, speaking as its therapists. Outside the convening role, the conductor(s) are as abstinent as possible in their ‘use’ of authority. The search for leadership is a quest – a part of the group’s reflective enquiry. 10 The unconscious comes to life in the circle of exchange. It becomes visible through the emerging interactions, stories, metaphors and idiomatic language that are unique to each group. In this flux groups become cohesive. Cohesion leads to understanding that can yield coherence. The key shifts from cohesion to coherence are described in the move from points 5 to 6 and from 7 to 8 above. The table illustrates that there is a progression here from cohesion when members find a place for themselves in the intimate conversations of the group. And it matures to coherence when the intimate conversations also find a place for themselves within each individual. At such ‘third-level’ moments of disclosure and connection, linkages among the members take on a dimension construed as transpersonal in that they go beyond the group’s location of time and place.

316  II  The group-analytic model Table 12.4  Leadership principles for large groups 1

The large group is a kind of congress or assembly to provide a containing forum for all who attend the event/institution/course.

2

The protocol for exchange honours the voice of each person present in the setting of the whole. Each person’s right to be heard is based on what is due to a hearing for others. With the balance between rights and responsibility, the forum is a microcosm for citizenship.

3

The experience begins with the struggle to achieve a sense of community – described as cohesion – through which both positive and negative societal forces can be understood.

4

With the emerging cohesion/community, acceptance can embrace both positive and negative societal forces and can lead to coherence. In large groups, coherence is an aspiration or goal that is not always achievable.

5

When coherence is achieved, it takes a form based on fellowship rather than the intimacy of a small group.

6

The convenors model a process through which the assembly can witness itself at work in the arena of the group. The issues will include a struggle with membership, inclusiveness and sub-grouping and with the movement from cohesion to the coherence. This allows both benign and destructive forces to be worked through and be accepted in a collegiate spirit of fellowship.

wider struggle for coherence in the group and in society beyond. The leadership role is modified to take account of this in ways set out in Table 12.4. Adapting Foulkes’s ideas to clinical practice, Lipgar basing his account on that of Pines (Lipgar and Pines 2003), describes leadership as the performance of functions which enable the group to adapt to the requirements of changing internal and external realities; which promotes a sense of group cohesiveness and identity; which protects individuality while achieving group coherence and integrity; and which allows a range of achievements that can be shared. Not all psychodynamically trained psychotherapists will be comfortable with or competent in group-analytic psychotherapy. In some settings and populations the leadership role will have much more in common with the role of a family therapist engaged in systemic practice, using circular questioning. But there is likely to be a key difference between group and family therapy practice in the level of restraint and undirected leadership required in group therapy. A psychotherapist qualified to practice group-analytic psychotherapy will need to be fluent in the following competencies. The therapeutic rationale in point 5 of Table 12.5 points to the importance of a consistent and well-assimilated working model for practice, which is the purpose of this book. The conductor will need to be discriminating and consistent about interventions of various kinds during the life of the group, which Lorentzen addresses in Chapter 6.

12  The conductor  317 Table 12.5 Requirements for therapeutic competence in group-analytic psychotherapy* 1 The ability to follow complex interactions and processes. 2 The ability to discriminate between appropriate activity and a containing form of silence. 3 A reflective attitude and the capacity to consider and reflect upon the processes concerning both the individual members and the group as a whole. 4 An eye for both the visible and invisible group and a curiosity about the unconscious or otherwise hidden aspects of a group’s life. This will require the therapist’s access to their own internal process and a capacity to make use of it. 5 A therapeutic rationale for action related to the group tasks and leadership requirements, including the psychopathology of the individuals, their psychodynamics and group dynamics. * Table 12.5 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Table 6.3.6.2, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1354. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my co-author Malcolm Pines for his consent to its re-use here.

What follows in Table 12.6 ‘unpacks’ the group-analytic model providing an orientation to its applications based on the progression from cohesion to coherence in the move through constructive, reconstructive and deconstructive process. The aim is to foster the integration and integrity of the group and its members through the three dimensions of psychotherapy. The convening function of the conductor’s role is evident enough in the first of its points. In points 1 to 3b, process-based work is mapped out using the key group-analytic constructs of resonance, valency, mirroring, amplification and condensation which were set out in Chapter 10. The points that follow in numbers 4 to 10 form the basis of what is addressed in Section III. Table 12.6 is especially relevant to the therapeutic management of groups with more disturbed, narcissistic or borderline patients. They bring to the group their more primitive psychic structures and processes that can put strain on the resources of other group members. They can also create turmoil in which the conductor’s task is to maintain the responses of the group from a more mature level of psychic organisation. By responding to part–object relationships and processes on the level of whole–object relations, more benign containing responses can be established. Progressively, these help build up for the disturbed patient a more benign world of inner object relationships and processes. More disturbed patients desperately seek attention in ways that are inappropriate and disruptive. This search for attention arises because the patient cannot establish a sense of connection between herself and the processes of the group. Mirroring and resonance can steadily come to replace these isolated and fragmentary responses allowing the patient to attain – for the first time – a coherent sense of self and a capacity to recognise the identity of others. In groups that are new, young or otherwise fragile, members will need to be helped to speak, linking communications will be important and so will enquiries

318  II  The group-analytic model Table 12.6  The conductor’s interventions in time and place* 1

Foster the cohesion of the group and in most cases address process rather than content, building the group into a resonant arena (resonance).

2

Help members recognise aspects of themselves in others and accept the viewpoints of others on themselves so mirroring can become a safe and recognisable feature of the group’s life (mirroring).

3

Monitor the intensity of participation to allow an enabling pace so members can develop resources to deal with the intimacies of each other’s lives and cope with their discrepant tolerance of intimacy and disclosure.

3a

Work towards the group’s cohesion by exploring the amplification of affect (amplification).

3b

Work towards the group’s cohesion by exploring the condenser effect of the affects located in the group and its individual members (condensation).

4

Work towards the coherency of the group through the interventions that follow in 5–10.

5

Establish a sense of enquiry about the fluctuations of mood and outlook and a sense of curiosity about thematic movement between the different modalities of time and place.

6

Help the group recognise role configurations taken up by individuals (therapist’s assistant or rival, joker, complainer).

7

Hold in mind the gestalt of figure and ground. If someone stands out, what is the background against which they do so? If the ground changes the underlying pattern of the group, how might the figural person be affected?

8

Help the group recognise sequences and patterns and lead the way in exploring the group’s shifting thematic configurations.

9

Help the group decode and find meaning in the constructive, deconstructive and reconstructive elements of its exchange.

10

Foster the integration and integrity of its members.

* Table 12.6 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Table 6.3.6.8, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1363. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my co-author Malcolm Pines for his consent to its re-use here.

of a direct kind. If these are kind and thoughtful they will set the pace and the pattern for the form of exchange that the conductor will hope to foster amongst the group’s membership, including the readiness to challenge and confront its ­members. In such circumstances silence will have its place, and members will gain confidence steadily as they see the conductor taking up an enabling position, speaking only when necessary and speaking mainly to give words to experience for which others may not yet have a voice. On the other hand, a conductor who spoke too much in an established and long-standing group, who could not tolerate silence themselves and whose own activity pre-empted the group’s sometimes silent struggle with its own

12  The conductor  319

experience, would be interrupting and forestalling free-floating discussion. The group-analytic method calls on the conductor of a mature and well-established group for a balanced deployment of all 12 principles of leadership and analysis in the first set of headings in Table 12.7. As the group matures one will expect to see a progressive diminution of their own active leadership in favour of a more reflective and interpretive stance. From this position silence will almost always be ‘golden’, should rarely be interrupted by the conductor and where possible should be explored according to the principles of interpretation in the second set of headings set out in Table 12.7, which are addressed in detail in Section III. Table 12.8 recapitulates the scope of all the chapters in Section II to map the conductor’s therapeutic roles against the three dimensions of a group – structure, process and content – and against the work that will be required of them in the group’s four domains, anticipating the work of Section III. Table 12.7  Summary of therapeutic principles in group-analytic psychotherapy: Leadership, analysis and interpretation* A: Leadership and analysis 1

Model a capacity for open, direct communication

2

Maintain therapeutic neutrality

3

Attend to boundary events

4

Provide holding and containment

5

With-hold personal material but

6

Draw on countertransference for

7

Reflection on group events

8

Bring events from background to foreground or vice versa

9

Provide linking communications

10

Clarification and confrontation with individuals

11

Attention to omissions, avoidance, denial

12

Maintain silence

B: Interpretation 1

Locate group preoccupations

2

Translate from the language of unconscious (individual and group) behaviour

3

Interpret or provide metaphorical constructions for: i  Defences and resistances ii  Transference and projective process iii  Archaic and primordial experience

* Table 12.7 is adapted from an earlier form published in Group Methods in Adult Psychiatry as Table 6.3.6.4, by Schlapobersky, J., and Pines, M., in New Oxford Textbook of Psychiatry, ed. Gelder, M., et al., OUP 2009, p. 1359. Acknowledgements are made to Oxford University Press for permission to adapt and reissue this material, and to my co-author Malcolm Pines for his consent to its re-use here.

320  II  The group-analytic model Table 12.8  Conductor’s therapeutic role mapped against group’s three dimensions and four domains (refers to Figure ii.1) A: Dynamic administration: Structural dynamics Conductor working as convenor and therapist 1  Manage group selection and composition 2  Manage the setting 3  Manage boundaries, membership and time issues B: Process dynamics facilitate members’ participation and reflective analysis: Conductor working as convenor, therapist and group member 1  Allow and cultivate free-floating discussion 2  Work with resonance, valency, mirroring, amplification and condensation 3  Locate group preoccupations and focal conflicts 4 Translate from language of unconscious symptoms to conscious behaviour – ‘ego training in action’ C: Dynamics of content analysis and interpretation: Conductor working as therapist and group member 1  Therapist provides holding, containment and reflection:   CURRENT DOMAIN 2  Analysis of transference issues:   TRANSFERENCE DOMAIN 3  Interpretation and therapist’s use of countertransference:   PROJECTIVE DOMAIN 4  Mutative use of metaphor and allegory:   PRIMORDIAL DOMAIN

Vignette 12.1  Late-night vigil – waiting for parents to return: The conductor at work

Here is a vignette drawn from a long-standing group in the setting of an outpatient department of psychiatry: People were struggling through recovery from major mental illness and problems that included self-harm, abusive sexuality in which they were the agent or recipient of transgressive behaviour and deep-seated problems of dependency. The following took place: One of the members, a man who had been with us for some years longer than the others, gave notice of his departure. He carried a sense of adequacy and resolution and looked towards relocation with his wife and family to another part of the country which prompted the

12  The conductor  321

timetable for his departure. We were pleased for him and made our good-byes in his concluding session with validation and appreciation. There was then a break for some weeks, and when we re-convened everyone was present except our latest ‘graduate’. People wanted to know if I  had heard from him and, when I  answered in the negative, some agreed with each other that we would never hear from him again. ‘He’s now too well for us’, someone said. Someone else disagreed and reminded us that after the last ‘graduate’ left, we had a note from her sent on through the conductor that shared the good news of her progress and gave us a picture of her developing life. We were bound to get something like this from this man in due course. And then the group seemed to stop. No-one said anything for nearly five minutes, an uncharacteristically long silence for this group. As it extended into the next five minutes some of them fidgeted and others became restless in their chairs. We lost eye contact with one another, and everyone seemed to draw back into a hostile and passive withdrawal, right to the end. The following week the group’s atmosphere had the same stuck and impervious qualities. And the week after several people arrived late and we were – once again – facing a prolonged and passive withdrawal. On this third occasion I found myself getting drowsy 10 minutes into a silence punctuated once again by a range of interventions that seemed to get nowhere. It was a hot summer’s afternoon, and I must have drifted off to sleep briefly for, when I re-composed myself and looked around, people were sitting in the same withdrawn state, no-one seemed to have noticed my drowsiness and there was a dream image in my mind that came from my own childhood. I was the oldest of my siblings, and we lived on a farm. I found myself back in the living room as the only one awake late at night charged with the care of my siblings who were all asleep. I sat waiting with increasing anxiety for the return of our parents. The dream image was interrupted by the relief of their return, as I came to myself in the group. I waited a little and then said, ‘It feels like we’re a group of children here waiting for the adults who’ve left the house. We’re waiting for them to come back again. It’s as if we’re sitting waiting for trustworthy older people, as if – any moment – we’ll hear a car drive up and listen to a key in the door as he (the departed member) returns’. The construction attached to this figuration captured something essential in the recesses of the group’s unconscious, as they all seemed to come alive in their chairs once again. Their bodily positions changed, and the conversation was resumed on terms familiar to us from the period prior to the recent ‘graduate’s’ departure. People agreed that it would have been very nice if he could come back ‘from the other side’ and let us know life was up to living.

322  II  The group-analytic model

Commentary The intervention and its unforeseen, productive consequences illustrate all the 12 points of leadership and analysis in Table 12.7 and all three of the interpretive principles. The construction of the interpretation was based on my own unconscious resonating to the unstated sense of resignation that goodness and recovery had left us with the graduate’s departure. The dream construction, offered from an unstated countertransference position, seemed to bring back into the room a renewed sense of viability. A summary of the conductor’s varied and changing role, including the ‘crescendo/decrescendo’ of activity, is given in Table 12.8.

Concluding commentary by James Anthony Anthony’s commentary on ‘the leader who does not lead’ in this approach follows in his account below. . . .The therapeutic group is (not) an ordinary type of group, and . . . is governed by its own context. Foulkes insists that the group conductor does not assume active leadership and is not concerned with leading the group anywhere. He ‘defaults’ on the group’s expectations of his leadership, listens, observes, participates, and helps to make easier the translation from latent to manifest . . . Therapeutic leadership of the group is, at any one time, an amalgam of manifest and latent leadership tendencies . . . two wavelengths of listening, two levels of understanding, and two basic problems of leadership that gradually become comprehensible . . . The interaction between the manifest and latent life of the group resolves the crucial dilemma to which (it) . . . is exposed from its beginning. At the latent level, the group shows a craving for a father who is all-powerful and all-knowing, as the child does in the family . . . On the manifest level, the conductor receives this latent projection, but, as Foulkes puts it, his therapeutic aim is ‘to spoil it’. . . therapeutically, tactfully and gradually, allowing for  .  .  . an immense, immature need for his authority from the individual members. He accepts the position as leader ‘in order to be able to liquidate it later on’. . . . Any form of authoritarian utterance or behaviour would fixate the group on the level of its unconscious demands. A  conductor never ‘actively’ assumes the position of leadership, never acts upon it, but on the other hand, never denies it ‘by word or deed’. As Foulkes says, he behaves . . . as the psychoanalyst does in the transference situation. In weaning the group

12  The conductor  323

from its leadership wishes, two profound movements take place: a decrescendo whereby the group dethrones the conductor from his ‘authoritarian pedestal’  .  .  . and a crescendo which enables the group to replace the leader’s authority by its own. Infantile leader-centeredness gives place to group-centeredness. . . In Lewinian terms, the Foulkes group is essentially democratic (to) provide . . . not only a better way of life for the individual in the group but also for the individual in the world. For the group  .  .  . to accept the conductor deeply as a leader, there must be some qualities that facilitate such transference reactions. (He)  .  .  . will need to be democratically oriented in his ­everyday life, reasonably secure and reality-prone, and especially immune from any temptation to play God . . . (There) should be a resolution of the oedipal conflict which enables him not to abuse power. (His) aim is to create peers and it is not surprising to learn how many ex-patients have become active in the field of group-analytic psychotherapy. Foulkes was well aware that the manifest qualities of leadership by no means told the whole story, and that the profiles omitted the extraordinary underlying components related to charisma that seemed to be inherent or acquired very early in the life of the future therapist. This brought its own enchantments, and so . . . the group, even the most group-centred group, never quite surrenders its adoration of the therapist, and this was evident in the case of Foulkes . . . This point of view regards the need for leadership as a symptom of the group that is curable only by a therapist who does not lead. (Anthony 1991:85–86)

Bibliography Anthony, E. J. (1991). The Dilemma of Therapeutic Leadership: The Leader Who Does Not Lead. In S. Tuttman (Ed.), Psychoanalytic Group Theory and Therapy: Essays in Honour of Saul Scheidlinger. American Group Psychotherapy Association Monograph, pp. 71–86. Behr, H., and Hearst, L. (2005). Group Analytic Psychotherapy: A Meeting of Minds. London, Whurr. Brown, D. (2006). Fair Shares and Mutual Concern. In J. Maratos (Ed.), Resonance and Reciprocity: Selected Papers of Dennis Brown. London, Routledge, pp. 124–130. Foulkes, S. H. (1948; reissued 1983). Introduction to Group-Analytic Psychotherapy. London, Karnac Classics. Foulkes, S. H. (1964; reissued 1986). Therapeutic Group Analysis. London, Karnac. Freud, S. (1913) On Beginning the Treatment (Further Recommendations on the Technique of Psycho-analysis). Standard Edition 12. London, Hogarth Press. Gill, M., and Sherbersky, H. (2013). Rediscovering Spontaneity. The Magazine for Family Therapy and Systemic Practice 126: 34–39. Haddock, R. (1992). Silence in the Matrix in Group Psychotherapy. Theory Paper for Qualification. Institute of Group Analysis, London.

324  II  The group-analytic model Hutchinson, S. (2009). Foulkesian Authority: Another View. Response to Foulkes Lecture by Morris Nitsun. Group Analysis 42 (4): 354–360. Kennard, D. et  al. (1993; reissued 2001). A Workbook of Group-Analytic Interventions. London, Jessica Kingsley. Lao Tsu. (1972). Tao Te Ching. Translated Gia Fu-Feng and Jane English. New York, Vintage. Lipgar, R., and Pines, M. (2003). Building on Bion: Vol. 1: Roots; Vol. 2: Branches. London, Jessica Kingsley. Nitsun, M. (1996). The Anti-Group: Destructive Forces in the Group and Their Creative Potential. London, Routledge. Nitsun, M. (2006). The Group as an Object of Desire: Exploring Sexuality in Group Psychotherapy. London, Routledge. Nitsun, M. (2009).  Authority and Revolt: The Challenges of Group Leadership. 33rd Foulkes Lecture. Group Analysis 42 (4): 325–348. Ormont, L. (1992). The Group Therapy Experience: From Theory to Practice. London, Vintage; New York, St. Martin’s Press. Ormont, L., and Furgeri, L. B. (2001). The Technique of Group Treatment: The Collected Papers of Louis Ormont. New York, Psychosocial Press. Pines, M. (1982, 1998). Reflections on Mirroring: Sixth Annual Foulkes Lecture. Group Analysis 15, Supplement; and in Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London, Jessica Kingsley, pp. 17–39. Rutan, J. S., Stone, W., and Shay, J. (2014). Psychodynamic Group Therapy (5th ed.) New York, Guilford Press. Schlapobersky, J., and Pines, M. (2009). Group Methods in Adult Psychiatry, Second Edition. In M. Gelder et  al. (Ed.). (2012), New Oxford Textbook of Psychiatry. Oxford, Oxford University Press, pp. 1350–1368.

Acknowledgements:  Extract Verse Seventeen from Tao Te Ching by Lao Tsu and translated by Gia-Fu Feng and Jane English, translation copyright © 1972 by Gia-fu Feng and Jane English, copyright renewed 2000 by Carol Wilson and Jane English. Used by permission of Alfred A. Knopf, an imprint of the Knopf Doubleday Publishing Group, a division of Penguin Random House LLC. All rights reserved; extract from Behr and Hearst (2005), Group Analytic Psychotherapy:  A Meeting of Minds, reproduced with permission from Harold Behr and Liesel Hearst; extract from Foulkes (1948), Introduction to Group-Analytic Psychotherapy reproduced with permission from the Group Analytic Society; Tables 12.5, 12.6 and 12.7 reproduced with permission from Malcolm Pines and Oxford University Press; extract from Anthony (1991), The Dilemma of Therapeutic Leadership: The Leader Who Does Not Lead, in S. Tuttman (ed.), Psychoanalytic Group Theory and Therapy: Essays in Honour of Saul Scheidlinger, American Group Psychotherapy Association Monograph, reproduced with the permission of James Anthony.

Section III

Dynamics of change

Section overview The five chapters in this section explore how the group-analytic model delivers the key challenges met by effective psychotherapy – understanding and change. The progression through this section uses the work of Pines to plumb the deepening movement of a group from the basic cohesion of relational life through the reflective dimension to reach coherence, where the reparative dimension becomes central. Pines originally drew the concept of coherence from self-psychology in the work of Kohut. It is now widely used in group analysis to describe transpersonal states in which people hold meaning with and for one another (Pines 1998:211–223). These connections can be deeper than the affects on which cohesion is based. Coherent bonds can be especially significant at times of reprieve when the moment that bridges rifts between people can – at the same time – forge internal bridges across the inner rifts of the divided self. A momentary glimpse of something new developing between people can be turned into a personal resolution providing nourishment that leads on to major life changes. These moments arise out of group experience that can be boring, aggravating or frustrating, but they can be portal moments of a transformative kind and are illustrated throughout the book. In the vignettes of this section they are given closer attention by using the figure–ground effect to put them in the foreground so the play of light and shadow can illuminate them. There is a constant interplay between the surface features of these dynamics – the work of cohesion in the relational dimension – and a group’s deepest and most unconscious resolutions involving coherence, reparation and new development.

Chapter summaries Chapter 13 introduces one of Foulkes and Anthony’s most original and useful contributions, their account of the layering of group experience represented by four significant levels that move from the surface to the most unconscious – the current, transference, projective and primordial levels – that are present in the

326  III  The dynamics of change

life of every group. There are shortcomings to their original conception, which gives a hierarchy and bounded differentiation to these levels  – as if the only way the current and primordial levels could influence each other was through the transference and projective levels. So I have introduced a new formulation here that re-describes them as domains that have an interdependent relationship with one another so each of them can be seen to work directly on each or all of the others. Chapter 14 traces the evolution of transference from its origins in Freud’s classical theory  – where it is the foundation of his one-body psychology  – to its central role decades later in both the developing two-body psychology of object relations and in Foulkes’s three-body psychology of the group. Both these relational paradigms emerged separately in London, and over the same period in time, but remained strangely unrelated. They are brought together here as the chapter  traces the evolution of the associated concepts of countertransference, projection, identification and projective identification that, together with transference, frame the psychodynamic approach. It goes on to review how this set of concepts is modified by and applied in group therapy, how they are related to the group-analytic model set out in Section II, how they inform a group’s structure, process and content and how they can be taken up to enrich the practice of its conductor. Chapter  15 explores how play generates mutative metaphors to generate the symbolic language of transformation. It deploys a conceptual framework drawn from the work of Cox, Bollas and other more recent contributors to a developing literature on the silence and musicality of groups. Chapter 16 considers the prevailing affects in a group under the headings of longing and belonging. They are derived from Winnicott’s concepts of object and environment mother applied to the figurations of holding-containment and exploration-play. The flux of movement between silence and activity and between narrative and drama allows the shifting focus to address existential anxieties by locating the emptiness in the circle of associations – the whole in the middle of the group – that can address each of its members’ individual fears about ‘touching the void’. This recurrent set of concerns, found so often in the life of groups, carries with it a defensiveness that can generate avoidance. Chapter 17 explores how the conductor can bring about a climate of change and resolution in a group that will stand to its members’ lasting benefit by using the principles of location, translation and interpretation. These principles are at the heart of the group-analytic model, and this chapter summarises the scope of Section III by looking into the work of translation and interpretation when dealing with the location of a group’s disturbance. Chapter 18 concludes the book with an overview of its title and scope, a summary of the model at work and a brief review of some of its key concerns like the Rosetta Stone of Chapter 14, on which the languages of group analysis and psychoanalysis can be read against one another in the study of transference and countertransference; an enquiry into professional motivation; and a review of the

III  The dynamics of change 327

methodology for the vignettes that discusses the difference between evidence and illustration. In conclusion, the last word is given to former group members.

Bibliography Pines, M. (1986; 1998). Coherency and Disruption in the Sense of Self. British Journal of Psychotherapy 2 (3): 180–185. Reprinted in M. Pines (1998). Circular Reflections: Selected Papers On Group Analysis And Psychoanalysis. London, Jessica Kingsley, pp. 211–223.

Chapter 13

Four domains of communication Current, transference, projective and primordial

The language of the symptom, although already a form of communication, is autistic. It mumbles to itself secretly, hoping to be overheard; its equivalent meaning conveyed in words is social. This process of communication is the medium of all other therapeutic agencies. It drives the therapeutic process forward  .  .  . (in) a move from symptom to problem, from dream to the conflict underlying the dream . . . (Foulkes and Anthony 1984:259–260)

The layering of experience in groups, one of Foulkes and Anthony’s most original contributions, is introduced and amended in this chapter. They described 12 different layers stratified by their level of conscious or unconscious experience, and they used this account to illustrate degrees of conscious and unconscious experience in the life of every group. The account is consistent through both editions of their book and is then simplified and reduced by Foulkes himself to four levels – the current, transference, projective and primordial levels – described in his 1964 text. Our students find this one of the most useful Foulksian contributions. We will explore the play and interplay between these levels and, to do so, I will re-describe them on new terms as a set of four domains, each of which can be directly in touch with each and any of the others – or with all of them at once – in any set of permutations. There are shortcomings to the original conception. The first problem is that the levels imply a hierarchy of importance or depth and the second is that if these are really layered then the only way the ‘top’ and ‘bottom’ – the current and primordial levels – could influence each other would be through the transference and projective levels. So a new formulation is introduced here that re-describes them as domains that have interdependent relationships with one another. In what follows, we will see how each of them can work directly on each or all of the others. This is illustrated in Table 13.2 and Figure 13.1. The chapter opens with an account of group life through vignettes that illustrate each of the domains by giving special reference to the conductor’s work. The concluding Vignette 13.7 describes the ‘The work of the crying group’ in which the shift of meaning between domains is

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put to work in an experiential group at a conference. The key to therapeutic work with these domains lies in the challenge faced by the conductor to keep open the channels of communication between the domains so that each is pervious to the influence of the others.

Four Levels The current domain The stories that circulate in a group include accounts of life in the world outside, which are interspersed with reference to people’s histories with one another in the room and with reference to their personal histories outside. As we progress to the point at which we are able to talk frankly about one another, it is clear some people have a situational awareness of themselves in context, a kind of sixth sense. Others appear to have no idea why people’s reactions take the form they do. There are pressing issues in the room, as members have joined this group to address severe problems in their lives. This is the current domain, and its ‘problem-solving’ focus is the backdrop to everything else.

Vignette 13.1  Learning containment: The current domain A sub-group ‘organises’ itself around one of its member’s recurrent issues focussed on the changes he is making in his life inside and outside the group. He is first described in Vignette 3.1 on page 103. Brian has had a long-standing pattern of chaotic mismanagement of self, affecting his job, finances and relationships. In the group his regular lateness has provoked frustration and resentment amongst the others. Now he is rarely late at all. People’s challenges progressed to the point of anger, to which he was at last able to respond. This is partly due to a process by which he has also been in receipt of a developing understanding contained within the group’s matrix, of underlying transferential issues. These include his newfound understanding of his own covert forms of aggression held against his father in particular, which are turned against the self to ‘protect’ the limited good father he holds in his mind. This has been played out between himself, the conductor and the group as a whole for some time. In consequence of developing progress, he explains, he is now hardly late anywhere. We know he is speaking authentically not so much because of what he reports about life at the workplace but because of his new found reliability here, combined with a present sincerity and new emotional availability to others.

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His team at work – a group of journalists – are pleased by his punctual presence at conference calls where he is present, available and productive. There is a developing sense of agency in the group that translates into Brian’s potency that equips him to make real changes in his life in the group and beyond.

Commentary Brian’s struggle to emerge from a basic maturational problem, for which the group provides a facilitating environment, brings all the levels into play. The group’s developing sense of agency – in the stabilisation of ordinary outside experience – belongs in the current domain. The conductor’s focus at the current level bridges the world of the group and the world beyond so people can appreciate how changes achieved in therapy can prefigure those taken to their outside lives. There the changes can be applied and generalised and then brought back into the group as a new source of validation.

The transference domain There is an emerging complexity of feeling and perception through which people take on an identity in the room generated by the associations of the group itself. The thoughts and feelings that dominate the current climate are drawn from people’s past emotional lives. They can be projected in the form of ‘whole-object’ transference that is addressed in this paragraph or ‘part-object’ transference that is addressed below in the paragraph on the projective domain. The description of the conductor’s special tasks at the current level above run alongside those that belong to the transferential one described here. In this domain the conductor will need to be emotionally available to recognise and to receive transferential projections, to hold and live with them and to be seen in the group looking to understand them so others may do so too.

Vignette 13.2  Fighting with the ‘wrong’ sister The antipathy of one man in the group – Alan – towards the makeup of a woman in the group, Elaine, who does her best to get on with him but

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whom he always wrong-foots, is discovered to have its origins in his unresolved conflict with his younger sister. We only realize how serious the transferential context is, lying behind an otherwise mysterious antagonism, when someone asks Alan, seemingly by chance, what his sister’s name is. ‘Oh, it’s Elaine’, he says, as if he has registered nothing significant. There is an amused chuckle of recognition round the circle as everyone looks at the group’s own Elaine, who finally says, ‘I might have guessed!’ He replies, ‘Guess what?’ Someone else says, ‘Ghosts in the room. You’re fighting with ghosts when you give this Elaine the hard time that belongs to the other one outside’. The penny drops, and he turns to her to say sorry with an amused sense of apology and chagrin.

Commentary The conductor’s focus at the transferential level equips its members to develop outsight, recognise themselves in the group’s mirroring and then look back from ‘the here and now’ to identify what took place ‘there and then’ in their childhoods so they can understand how it continues to inform and warp the present. In Alan’s early childhood the arrival of his baby sister Elaine brought on a sense of displacement that had no ‘legitimate’ outlet. For various reasons there was no room in their family’s life for ambivalence. If he did not show his love for his sister his parents threatened to withhold their demonstration of love towards him, and he suffered. The threat posed by this suffering drove his feelings of sibling rivalry into the deepest areas of his unconscious mind. Both children were probably cherished but the threat posed by Elaine, from the time of her arrival ‘there and then’, has interfered with ‘the here and now’ of his relations with all the women in his life. The arrival in this group of his new rival Elaine eventually provided the focus for this understanding of painful sibling rivalry. He hardly remembered he had a sister, and the dissocated detail of his family history was so repressed that it disguised the way it impaired his relationships in the present.

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The projective domain Beneath this experience of ‘whole-object’ transference is the ‘part-object’ world, which is the even more hidden domain of projected experience that remains fragmentary, fleeting and transient.

Vignette 13.3  Something new ‘cooking’ in the group: Projection and change Every time George looks at Carol she gets furious. ‘Don’t put your depressed eyes on me’, she says, ‘You fill me up with sadness just by looking at me’. People are finally able to convince Carol that it is her susceptibility to take up a depressed position under George’s sad eyes that gives them power over her. His projected feelings of wretchedness can only penetrate her because she is wretched in herself. Her valency for this resonant projection of depression now comes into focus and allows the group to recognise what hidden anxiety she lives with and how much vulnerability her protests conceal. Whilst this is taking place the figuration comes to include Ella, a different woman who has been going through a long period of initiation in the group. She has become known for just how much she has to cry about, first in her sad family history and then with the breakup of both her marriages. Developing changes become noticeable as she settles and starts talking about her new interest in cooking that includes her family’s traditional Polish recipes. An emerging narrative in the group about television chefs and their spice recommendations is seen to draw on her changes. The resonance to her new-found interest fills the room with stories of recipes and accounts of the things different people are learning to cook. The group has amplified her developing sense of nourishment, and it would seem to have happened all by itself, but the conductor has played a key role by identifying and enhancing the amplification without interpreting it. In another session there is an emerging and shared sense of sadness projected from one of its members and identified with by the others about a lost childhood in which parental encroachment, abuse and neglect has left people with little capacity to play and a poor sense of enjoyment in the moment. The shadows of their sad histories outside emerge in vivid contrast to the sense of something new that is ‘cooking’ in the group. We are living out a novel sense of playfulness in the group, and its new-found vitality allows its members to appreciate, during moments of much sadder reflection than any we have known, the shadows that kept their childhoods in darkness.

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Commentary The conductor’s focus at the projective level draws attention to the dynamics of movement from the one to the many and from the group to each individual. Individuals are equipped to take back their projections, and the group is equipped to own its figurations by paying attention to their progression and to the different sources of meaning they can yield.

The archaic or primordial domain Beneath this projective domain is the most extraordinary one of all. We are on its margins with the narrative about recipes, slow cookers and master chefs. The primordial level can emerge in the language of cooking, through monsters from the deep or with seagulls in the room, as the vignette below will illustrate. Whilst the group’s life is unfolding, something else dramatic takes place when Maeve, one of the group’s longest-standing members, is called abroad to go ‘home’ with news that her father’s terminal illness is reaching its concluding phase. She is away for two weeks.

Vignette 13.4  The living will not be buried with the dead Maeve underwent terrible misery through her father’s sexual molestation of her childhood. Over some years we have been her witnesses in the group and have been helping her come to terms with this history. For the first time in many years she goes ‘home’ to be with her father and family – it is a critical time for them all. On returning she tells us in the group that she had a priest attend for her father’s last rites when he asked her for forgiveness, which she was helped to give. She tells us that none of this would have been possible without the work of the group. She then goes on to tell us about the funeral. She is graphic about the seagulls flying around the cemetery during the burial. In her description she is helped to recall the freedom she felt when she looked up and saw the birds flying and saw that they were free to come and go. They represented something new for her about being able to go back to her childhood home and return to her home in London. She then tells us about a nightmare when, after two weeks away, she finally came back to her own home in London. She dreamt that she was back at her father’s graveside as he rose from beneath the earth, a large and terrible rotting corpse who approached to embrace her, calling out, ‘The living

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shall be buried with the dead’. The revulsion she felt, which was contagious in the group through the detail of her description, propelled her from his embrace, and she took flight from him in her dream but woke in a state of dread, as if he could still be after her. In the group people shuddered at the imagery of the dream and said so. We can see this as the condenser erupting into the group from the dark side of her unconscious. Touching on other members’ reactions she drew the affirmation that the message from her unconscious was calling on us to help her leave her father to lie in his grave. People recognised with her that the dream brought her close to a feared identification with his sexualised intrusion during the mourning process.

Commentary Maeve had been using the group to create emotional distance between herself and her family of origin and, by ensuring that her own personal life was happy and fulfilling, she was learning to stand aside from the abuse. The picture of the conductor in this group emerged as a guiding and benevolent male presence for her, a man whose fathering she could allow herself to receive without fear of violation. This transferential bond was seen, recognised and affirmed in the group but never made the subject of any extended interpretation that could be experienced as intrusion. Rather, the experience of safety in a positive transference was seen as the source or groundwork for the well-being of the other developments. Long after this dream and during the course of a subsequent course of individual psychotherapy with a woman, she went on to discover a happy sexuality of her own for the first time in her life and leave her father behind with both love and a sad sense of grievance. The conductor’s focus in the primordial domain is to equip the group as a whole to recognise ‘the voice of the symbol’ in a cry from the unconscious that says, ‘the living will not be buried with the dead!’ Members of the group decided they could be as free to find themselves as seagulls are free in flight.

Levels, domains or holograms: Different conceptual frames Each of the four paragraphs above describes the same group at work. This is a notional group and draws on related material from different groups at different points in their lives. No one therapeutic endeavour could provide illustrative material for all four domains in such a compressed form. It has been assembled here for

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illustrative purposes and, as we look into its life, the different emerging domains reveal different hidden depths. Our view of this group’s life is something like looking into a hologram. Our image of the group changes ‘as the position and orientation of the viewing system changes’.1 We can look into the work of the primordial level whilst still seeing the work of the other three levels, and, in fact, we look through one level to see into the others. This conception allows us to see the group through the four domains. In common with holography in other areas, this holographic picture is not a series of single images but a profile of one process at work – the group – seen through a prism that differentiates these domains and allows us to see into the deeper ones through those that are more apparent. Each domain bears an isomorphic relationship with the others so that changes forged in one domain have the inevitable consequence of bringing change about in the others. The named individuals in the vignettes above – Brian, Alan, Elaine, George, Carol, Ella and Maeve – comprise its membership of seven. Each of their characters is real, but their identities in this group, like their names, are a series of constructs that are drawn up to shed light on the dynamics and identify the conductor’s special tasks in each of the four domains.

Background and originating account of 12 group levels The ingenuity of the original table set out by Foulkes and Anthony first described a range of 12 levels that has yet to be explored by those with research interests in the subject. Foulkes went on to provide a simpler form of the analysis in several publications that emerged at just that point in time when – with Anthony – he brought out a second edition of their text in 1965. No one responsible for conducting a group is going to find it useful to remember 12 levels between the most deeply repressed and completely unconscious and the most evolved forms of conscious communication at ‘six degrees above zero’. When this table came out in its second form in the 1965 version of the Foulkes and Anthony text, they must have been mindful that it would have limited utility for practitioners. So Foulkes devised a simpler classification of four discrete levels that he described for the first time in Therapeutic Group Analysis (Foulkes 1964/1984:114–115). This is the one that most students of group analysis are familiar with that is described both in Foulkes’s own language and in the language of current practice in Table 13.1. The original account of 12 differentials describes the layering of experience in groups across a range between ‘what is normally conscious and . . . (what is fully) unconscious’ (Foulkes and Anthony 1965/1984:260) represented across ‘all the modes of communication’. Their original outline provided a schematic model and diagram that describes the ‘frontier’ between conscious and unconscious communication. It gives degrees of departure from the frontier in both directions, going up to the most fully conscious and down to the most unconscious. They give the value of zero to the baseline on the frontier between the conscious and the unconscious, and they then give ascending and descending values to different degrees of conscious and unconscious communication in groups based on their proximity

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to the frontier. They went down through six layers to ‘six degrees below zero’, where the most unconscious forms of communication in groups ‘correspond to bodily equivalents of emotions, organ language (somatic expressions of feeling), conversions and structural changes’ (Foulkes and Anthony 1965/1984:260). At ‘six degrees above zero’ they locate the fruits of the most advanced forms of consciousness in abstract symbolic languages that they suggest include mathematics and artistic communication. It includes the language used on this page as the writer reaches from his patients’ experience and seeks to convey it to his readers through their own experience as you reflect on what you are reading right now. Would it occur to anyone reading this book that, in order to make sense of this paragraph, you are reading it at six degrees above zero? The term ‘six degrees below zero’ is of immediate clinical use. Most psychotherapists have been confounded by enactments and somatisation at ‘six degrees below zero’ and by the accompanying bland or aggressive denial found in dissociation.

Vignette 13.5  The triumph of hateful failure in a masochistic protest

Michaela joined a group to get help with her inability to make relationships and her unmet longing for sexual intimacy. The many disappointments she encountered aggravated a real somatic disorder – fibromyalgia – that produced neuropathic pain in different body sites, mostly in her lower back. The rejection she lived through in needing to be held and finding herself hurt instead aggravated body sites where pain was familiar. This dimension to her somatic anxieties, a form of conversion, was finally being explored in the group. But despite her intelligence and determination to get through these difficulties, and the many attempts made in the group to link bodily and emotional pain, they were met with her blocking behaviour that people came to call her ‘classic dead bat’ (a phrase from cricket where a batsman uses a strategic block to protect his wicket). An especially painful romantic disappointment took place just before the Christmas break, which she always found difficult anyway, having a limited family to return to for the holiday. The eve of New Year’s day – a Friday – saw her admitted to the Accident and Emergency department (ER) of a hospital in her parents’ locality, where she was not known, suffering from acute pain. The familiar back pain was now complicated by abdominal pain as well. Her years of illness had acquainted her with different symptomatic pictures that she probably ‘traded on’ and, as the day wore on, the clinical staff became

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worried she might have acute appendicitis. With a skeletal staff on duty and only limited scanning facilities they decided to operate when the combination of her imploring behaviour and symptomatic complaints left them concerned she could become dangerously ill the day following, when they would have no staff available for procedures. After the break she brought the group a story of how successful she had been in getting a medical team to take out ‘a perfectly healthy appendix’. There was something triumphant in this story. When we could ‘conquer’ our own reactive dismay in the group to explore these issues therapeutically, they were revealed to have at their core a masochistic protest arising out of terrible self-hatred. The man courting her had gone off with someone else, and she imagined the other members of the group were with loved ones she did not have. People felt that both the content of the story and the manner of its delivery carried an attack on their own less aggravated experiences over Christmas. The story gave the group access to her ‘six degrees below zero’. But only when Michaela’s tendency to alienate and antagonise others by the harm she did to herself could be contained could we then work with this therapeutically. In the months following, the triumph turned to shame and then to more directly acknowledged fear that she would always drive everyone except doctors away from her body. Once this deep-seated anxiety about being found ‘untouchable’ emerged at the level of ‘zero’ in the group, where it could be shared with others who had similar problems, we could build on her outsight – her understanding of similar dynamics in the lives of others – to at last generate some insight. Self-harm as a form of protest against injury by others became a group figuration that allowed everyone access to these primordial levels of frustrated hope.

Commentary In search of a therapeutic stance that can see to resolutions even when people are found at six degrees below zero, Erikson gives an account of much younger people in acute symptomatic difficulty: There was triumph as well as fear in the eyes of that little girl when she sat in her mess in the early morning and watched her mother come in; and . . . quiet satisfaction in the boy’s remote face even when manifestly (Continued)

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(Continued) bloated and uncomfortable . . . (but) to react to the child’s tyranny with angry methods would only make things worse . . . These children loved and wanted to be loved and very much preferred the joy of accomplishment to the triumph of hateful failure. Do not mistake a child for his symptom. (Erikson, E. 1995:59)

At ‘six degrees below zero’ there is no likely prospect of reflective understanding. Groups have the advantage over individual psychotherapy in such cases because they work directly through challenges made between members in the relational dimension of the current domain. At the same time they work through outsight in the reflective dimension of the transference and projective domains, and in the reparative dimension of the primordial domain. Taken together the three dimensions of psychotherapy working in these domains can at last generate understanding and change. Tables 13.1 and 13.2 and Figure 13.1 first provide an account of Foulkes’s original description of these four levels and then they go on to set out a more contemporary approach to describe them them as domains. Putting the four domains to work The group-analytic model is a psychosocial therapy that begins and ends with the current domain – the lived reality of people’s actual experience – that is brought to the group as the presenting source of people’s difficulties with the world they live in. The link between the current domain in the group and the current domain outside is the single most frequently addressed subject in group-analytic psychotherapy, as Chapter 11 has already demonstrated in Figures 11.2 and 11.3. The current level remains the continuing touchstone for evaluating the benefits of psychotherapy. If the dynamics of this domain are not altered by psychotherapy then the rest of the undertaking is called into question. It is through the current domain that the group begins and ends. It is where ‘it all begins’, it furnishes the domain of entry to the group and it is the one in which people leave when they go. Without fruitful and focussed attention given to the structure, process and content of the current domain none of the other domains can yield their therapeutic potential. Beneath this is the transference domain, the domain of whole-object transference where members find their family relationships replicated. And then beneath this is the projective domain where members come to ‘carry’ for one another ‘partobject’ issues in fragments of emotional life that are often grappled with in fleeting and fractured terms. One person emerges as a group’s scapegoat, another as its victim, another expresses the envy felt by all but carried openly only by one. And then beneath this projective domain is the deepest of the four in what Foulkes termed the archaic or primordial domain. It is sometimes the most hidden and at other times the most transparent as the unconscious comes vividly to life in the

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circle of exchange through metaphorical language, allegories, dreams and daydreams. Nitsun provides a contemporary discussion about the relevance of these domains, taken in their original outline as levels in his discussion of sexuality and the way it is shaped at each of these levels (Nitsun 2006:154). The primordial level is described by Usandivaras, whose paper, though dated, is the single most original account of the subject (Usandivaras 1986). The conductor’s decisions about intervention will be guided through the process of location, translation and interpretation on different terms, determined by, which of the group’s four domains is the governing one at any therapeutic moment and which of them may be providing a defensive arena of avoidance or denial. This chapter goes on to explore the play and interplay between these domains in Vignettes 13.6 and 13.7. Beneath these four domains are the much more basic process dynamics described in Chapter  10 which work on these domains and interpenetrate them. This original portrayal of experience as a set of layers shows the distribution of experience from the surface features of the visible group through a descent into the deepest areas of unconscious life. But an account in these terms does not, unfortunately, do justice to what the active process does in the course of an animated exchange. For example, in Table 13.1  Foulkes’s four levels of communication in group: Original and current formulation Level Name

Group experience (Foulkes 1964)

Group experience (modern formulation)

1

Current

Group experienced as representing community, public opinion etc., and the conductor as a leader or authority (Foulkes 1964:114) – or any normative association like the ‘authority system’ of a school or office. Conductor frequently seen as something like a teacher, other authority figure or leader.

Extended to include all social constructs in people’s lives including family, school and workplace, current reality of members’ outside lives, problems for which and the terms on which they enter the group and the link between inside and outside the group.

2

Transference Corresponds to mature object relations experienced in the ‘macrosphere’. Group represents the family, the conductor father or mother and the other member siblings (Foulkes 1964:114/115).

Group contains representatives of mature or whole-object relations in terms of family. Fellow members seen as siblings, conductor as one or another parent and often the group as a whole is one parent or the other. (Continued)

340  III  The dynamics of change Table 13.1 (Continued) Level Name

Group experience (Foulkes 1964)

Group experience (modern formulation)

3

Projective

Corresponds to primitive, narcissistic ‘inner’ object relations in psychoanalysis. Other members reflect unconscious elements of the individual self. Group represents as outer, what are in truth inner object relations.

Group reflects unconscious elements or fragments of the individual and becomes outward projection of ‘inner’ part-object relations. Individuals/group as a whole may embody parts of the self. Passing emotional fragments – envy/injury/consolation – projected onto individuals who introject and identify with them.

4

Primordial/ Archaic

Primordial images occur according to the concepts of Freud and Jung concerning a collective unconscious.

Primordial images found in the group’s experience represent the deepest and most hidden areas of unconscious life. These images can be visible and transparent or may arise through association; as dream content; or through the group’s capacity to compose a metaphorical language including symbols drawn from and then going beyond its own experience.

Vignette 4.3 on page 121, a young man brings into the group a dream in which one of the older women murders his father. The woman who is dreamt about cannot respond to the dream at the primordial level to which it belongs. Instead she becomes painfully defensive and says, ‘How dare you dream about me murdering your father! I’m not a murderer!’ She challenges his unconscious, which expresses dream content at the primordial level. She is responding to dynamics at both the current and the transference levels. But she challenges him according to her misguided belief that his dream has challenged her at the current (realitybased) level – as if he had some kind of ‘intention’ to have this dream and thought she could be culpable in his father’s murder. In Vignette 10.9 on page 267, a woman who missed the last session arrives in the group as a latecomer to find an

13  Four domains of communication  341 Table 13.2  Four ‘regions’ of the group described now as domains: With conductor’s role responsibilities Number

Domain name

Conductor’s functional roles

Role-responsibilities of conductor

1

Current

Convenor

Dynamic administration holding, containment

2

Transference Therapist

3

Projective

Convenor, therapist, Spontaneous and direct speech; group member interpretation

4

Primordial/ Archaic

Therapist, group member

Reflection, interpretation

Promote group construction of metaphor and allegory, provide interpretation

unexpected new member. She has a catastrophic reaction and wants to take flight but is contained by the conductor. Later she challenges the conductor by saying, ‘How could you hurt me so!’ The mishap at the current level is responded to at the projective level first and then, when the sense of catastrophe is successfully contained and the woman’s flight is pre-empted, she enters a complaint against the conductor at the transference level, as if the conductor were the mother who colluded with her incestuous violation. The ‘as if’ confirms that the work is being done in the intermediate territory. The very use of the term ‘levels’ is inappropriate as we work with fluid, fluctuating and graduated differentiations of experience. But the differences need to be differentiated in order for them to be understood and worked with productively. In the example that follows, Vignette 13.6, a member brings the group an account of her longing for an unattainable man. She is well known amongst us in her desire for the impossible because, amongst her other reasons, these are the kinds of longings that satisfy her fantasies, without threatening her fear of intimacy by anything so challenging as a real man with whom she might make a real connection.

Vignette 13.6  The longing to be a ‘princess’ inside and outside the group

Gillian has been in group therapy for some time and is only slowly getting the measure of herself as a late developer who has been out of touch with any desire for male company until well into her adult life. She finds these new moments of longing a relief, but they are also distressing because they seem without any prospect of fulfilment. She is a

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woman in a teenager’s body. She is also a distinguished musician who performs in a well-known chamber group and accepts invitations to play her instrument at private events where – from time to time – there are celebrities in the audience. Her playing does attract attention, but the only men in whom she has any interest are much older than she is, with titles, fortunes and circumstances very different to the picture she has of her own ‘common grammar school upbringing’. She hasn’t yet learnt to discriminate between the interest that her music generates and the likely interest a man might take in her as a woman. There is now a new member in the group – Nora – who is a psychotherapist herself. She selected this group partially because it would give her training credentials in the field. She has recently had correspondence with the conductor – who is a training group analyst and is well known in her own training community – about the terms on which she can present this group experience to her training body to gain a credential. She recently raised this correspondence in the group, as he advised her to do. Earlier she expressed concerns to the conductor in the correspondence that she was ‘courting his special interest’ and apologised for doing so outside the group. He then responded with a transference interpretation, also by correspondence, saying, ‘There is no need to apologise. It’s understandable you are seeking me out in this way. We all want to be like royalty in the lives of the people who matter most to us’. Now, as she listens to Gillian talk about longing to attract the attention of an ‘aristocrat’ outside, Nora makes a humorous comment about longing for an ‘aristocrat’ inside the group and says she finds it a relief to discover that she’s not the only woman here who wants to be a princess! We laugh at the pointed humour, but Gillian cannot – or will not – see the point. Nora’s comment turns the outsight she gains from observing and listening to Gillian to insight about herself. Gillian will not take up Nora’s insight and will not let in any understanding until the story of Cinderella, introduced by one of the other members, makes the issue allegorical in the primordial domain for the life of the group as a whole. And then she begins to see the light!

Commentary The current domain is where the group begins. Gillian longs for a partner, but her desire takes the form of projective longing of an unrealistic kind to invoke a future with a fairy-tale man like Prince Charming, recruited from amongst the

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Current

Transference

Projecve

Primordial

Figure 13.1  Four levels of a group’s communication described as domains: Current, transference, projective, primordial

celebrities she plays for at concerts. The group takes account of her unrealistic fantasies at the current level and – from amongst them – Nora takes up the group’s outsight in people’s perception of Gillian and turns it on herself in the transference domain to deepen her reflective understanding of herself. She turns this self-scrutiny into insight through which she can laugh at what she understands about her unconscious longing to have the conductor to herself, in one form or another. The group laughs with her – and with Gillian – but Gillian remains several degrees below zero and feels she is being laughed at. It remains this way until the group enters the primordial domain to remind Gillian of the story of Cinderella. It is the allegory that finally wrests her from her resistance, and it takes her away from the defensive use of the concrete she has always relied on to avoid and deny the understanding that people keep putting in her path. She usually retreats from resonant forms of empathy by attending only to concrete detail. People say that until now they have put understanding her (Continued)

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(Continued) way like stepping stones she can walk on through the deep water that frightens her. She has continued to kick the stones away and has refused to get in the water. Now, finally, she is on the first stepping stones of self-understanding. This evocative language speaks with ‘the voice of the symbol’ at the primordial level. The conductor has kept out of the confronting exchanges, using his role instead to attend to the discourse and enrich its resonant impact at the primordial level. Phrases are picked out and re-framed, metaphor is unpacked and references are made to the correspondence between Gillian’s unconscious longing for a magical solution to her desire and the role of the fairy godmother in Cinderella’s story. This also has the critically important additional benefit – as well as leaving Gillian’s defences safely intact for now – of allowing the group to process a developed metaphor in the story of Cinderella that provides no intrusive narrative. The group follows the lead provided by someone else’s insight and this eventually generates a mirroring form of resonance in Gillian which is self-expounding through free-floating discussion and which – to use Cox’s formulation at the opening of Chapter 9 – provides imagery ‘that can reach the depth without stirring the surface’.

1 Current 2 Transference 3 Projec ve 4 Primordial/Archaic

1 2 3 4

Figure 13.2  The four domains of a long-term analytic group

13  Four domains of communication  345

Figure  13.2 describes the ‘outward availability’ of the group’s dynamics in the current domain of first engagement in the different figurations described by Vignettes 13.1 and 13.2. As the enquiry deepens in 13.1, the current and primordial domains impinge on each other in the dynamics of the group as a whole, but there is relatively little work done with either the transference or projective domains. In Vignette 13.2 the group’s opening at the current level leads to deepening experience in both the transference and projective domains, but it is not until the primordial domain is activated and explored that anything transformative begins to happen. The location of the current domain on the ‘outside’, with the core of the group’s life in its unconscious on the inside, indicates that this is a long-term, developmental group. The work of ‘the crying group’ This concluding vignette describes an experiential group meeting at a conference for mental health professionals in Israel that included participants from many European countries. There are 10 people in the group with three men including the conductor and seven women, and it meets five times over three days. In the first three meetings 16 subjects are generated by free-floating discussion and in the second two there are a further 10 subjects. Each of the subjects in the narrative that follows is named when it is introduced in the group and, though the subject is not referenced again, the subjects – once introduced – never go away. These figurations, a term that encompasses both the subject and the interpersonal dynamics that generate it, arise out of each other through free-floating discussion. The subject matter in terms of content is extended all the time. The figurations undergo increasingly complex elaboration and, as they do so, the process dynamics widen and become much deeper. In the first three meetings we begin in subject 1: with the need for containment; 2: move on to threats and ‘executions’ at the workplace; 3: then move on to tension between political conflicts outside and personal issues inside the room; 4: tension between men and women; 5: latecomers; 6: the care that women give each other across generations from grandmother to mother and daughter; 7: inclusion; 8: the envy of others’ energy; 9: the problems of dealing with difficult – and envious – mothers; 10: the meaning of boundaries that identify forbidden territory; 11: death; 12: children’s helplessness over their parents’ bereavement; 13: avoidance of sorrow by caretaking for others; 14: and who cares for the caretakers?; 15: dissociation; 16: grief; and finally, 17: crying and the work of ‘the crying group’. In the last two sessions the seven further subjects introduced include 18: letting go; 19: the Holocaust; 20: protection of children; 21: survival of family lines and retrieval of family history; 22: the absence of good men in family history; 23: the discovery of good men in the group; 24: what’s a woman to do; 25: how to improve marital terms; 26: and finally, life and its validation.

346  III  The dynamics of change

Vignette 13.7  The work of the ‘crying group’: Analysis of 25 subjects, their figurations and the four domains

The meeting convenes with an empty chair kept vacant for the late woman and the chairs are set out in good weather on a terrace just outside the meeting room. As people take their places the wind builds up, the temperature drops and, when I consult the group on their seating preference, people agree that we need to meet inside, so we move. Once reassembled, there is consensus this is a much better arrangement, and all the following sessions take place inside. Subject 1: Containment - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Now we are safely seated, though still with an empty chair, one of the women speaks about the drama of a presentation earlier in the day at the conference. It is relevant to conflict at her workplace, where people are being discriminated against in prejudicial ways. Their work status is threatened if they take up certain positions. She describes someone as facing ‘execution’, losing their very job, for supporting colleagues who were being discriminated against. She puts her head forward and, with her hand, mimics the action of an axe coming down on the back of her neck. Subject 2: Threats and ‘executions’ at the workplace - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - One of the two men speaks up to protest against having outside conflicts brought into the room. He says we have enough work to do together here and, as sympathetic as he may be about her issues, he’s not come to this small group to deal with the politics of the world outside. He is gruff and uncompromising. Subject 3: Tension between political conflicts outside and personal issues inside the room - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - In the course of subjects 1 and 2, tension between the personal and political, conflict becomes an issue in the group. But the man, though prompted by the others, won’t ‘declare’ his own agenda – he says he’s not ready. One of the women says her husband is just like him. He won’t allow her to express herself, and when she opens the door for him, he won’t go through, he won’t express himself either. Subject 4: Tension between men and women - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

13  Four domains of communication  347

The latecomer arrives, apologises and sits down, breathing heavily. She had to get her children to her mother to be cared for so she could attend. Her mother’s not very well either and isn’t great with the children at the best of times, so she stayed on a while to make sure all would be well before coming on to join us. Subject 5: Latecomers, and Subject 6: The care that women give each other across generations, between grandmothers, mothers and daughters - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - The latecomer is welcomed in the group, her frustration about late arrival is explored, she is given some cues to orientate herself in ‘a room full of talking strangers’, as she puts it, and then several of the other women come forward to describe the tension in their own lives between motherhood and work. They’re often facing painful issues between their care for their children – their duties as mothers – and their careers. There is a rich and interactive discussion in which the newcomer emerges as an incorporated member of the exchange. Subject 7: Inclusion - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Another woman from the opposite side of the group expresses her envy of the newcomer’s energy; her vitality is seen to emphasize the tension between the constraints of women’s duties in the home that keeps their heads down and their working vitality outside the home, which is shown in the newcomer’s poise on arrival. A lengthy discussion ensues about envy. Subject 8: Envy of others’ energy - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Another woman expresses fury towards her own mother, largely to do with the mother’s envy of her, and she recounts a story of the mother’s approaching 80th birthday in which she – the mother – made life impossible for her and her brother by frustrating all their best endeavours to do things right by her, in terms of the celebration they’re trying to organise. A number of others join her in related stories about parents’ envy of their own developing resources. Subject 9: Difficult mothers and their envy of their own children’s resources - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

348  III  The dynamics of change

The initiator of the account of envy in the room goes on to give an account of a recent break in the course of the conference when – a few hours ago – she went outside for a short walk and came across a sign saying, ‘No Entry: Cross This Line At Your Own Responsibility!’ She says it’s been on her mind, but she really wants to talk about it now. When asked what she did, she said of course she crossed the line – she wanted to see what was on the other side. There is warmth and laughter in the room as she says this. She speaks for everyone and we can all identify with her curiosity and adventurous spirit. Asked what she found, she says, ‘Nothing, it was no different on one side of the line than the other’. There is more laughter and an emerging sense of cohesion. Subject 10: Forbidden territory, boundaries and their pointlessness - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - The man who was resentful about having time taken up with workplace and political conflicts goes on, in the course of an exchange involving several on the subject of men and women, to tell us that his wife died two years ago. She developed a rare form of lung cancer that was first treated as bronchitis and then as pneumonia. When it was finally diagnosed she had so much metastatic illness that she only survived for a further six months. Their youngest was nine at the time, their middle child 11 and their oldest 14. They recently commemorated the second anniversary of her death. He assures us the children are doing well enough. He appears to be quite severe with himself and strangely matter-of-fact with the group. There is a long, stunned silence followed by efforts from several to offer him consolation and concern, but there is a shared sense of being overwhelmed by a reality that we’ve no resources to deal with. Someone says it feels as if we’ve come to the line we cannot cross. After several attempts to engage with him in care that he repudiates, he is asked if he has a sign up saying, ‘cross this line at your own risk’. He goes on to tell us of the strain he is under to care for the children on the same terms and to the same high standard that his wife would have done, had she been alive. This was what they focussed on whilst she was dying. He can’t really expect the children to help him. He protected them from his wife’s suffering whilst she was dying and saw her through the illness to its end. In the course of caring exchanges with several of the others, he explains that the only person he could ever allow to help him with sorrow was his wife. And with some humour he tells us of the resentment he feels, that she can’t now help him with her loss. Subject 11: Death - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

13  Four domains of communication  349

The woman with whom he had the first conflict re-enters the discussion, actively talking to the man whose wife died. She recounts the circumstances under which her own father died when she was a child and, placing herself amongst this man’s children now, explains to him just how hard she found it to be close enough to her mother to console her. It was more than 50 years ago now but she can still remember her own sense of loss and then her helplessness in the face of her mother’s grief. She begins to weep and becomes distraught as she tells him that her tears are for him. This is not fully convincing. Her long-standing, unresolved grief is as palpable in the room as the grief of the man. Other people proffer comfort to both of them and there are no dry eyes left in the room, except those of the bereaved man. Subject 12: Children’s helplessness in their parents’ bereavement - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - She goes on to tell him how sorry she is for his own loss and makes clear we’re not his children and can be helpful if he’ll allow us to be. She invites him to tell us about his adjustments these last two years. He does so and, as we hear more from him about his devotion to his children’s needs, we see him not only as a caretaker but a master caretaker who set his own mourning process aside to attend to the children’s sense of loss. He continues to do everything for them that his wife would have wanted. One of the other members recounts the tragic death of her husband, who was killed in an aeroplane crash years ago, when she was only 31 and had two little children. At the time she had a promising career as a musician but gave it up to develop a career that allowed her to support the children. They are now in their 40s, one is a physician and the other a psychologist – like her – and their children are a delight. She knows she did the right thing by them all, but she still misses her instrument. The grief at that time was overwhelmed by the sense of shock. She’s surprised to find herself so emotional now, shedding tears in the room for the first time in many years. Subject 13a: Avoiding sorrow of one’s own by caretaking for others Subject 13b: Who cares for the caretakers? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Admiration round the room for the man’s strength of character and for his mastery of self turns to envy as others whose lives have also been touched by tragedy have found themselves much more compromised by vulnerability. They first admire and then envy his strength. But this then turns to recognition that there is something seriously wrong with how he is in the room as people slowly come to see that the absence

350  III  The dynamics of change

of affect in his makeup – his intolerance of his own vulnerability – is more of a liability. The woman who has lived without tears for her lost husband for so long reaches out to him with tears in her eyes now, but he shrugs off her distress and won’t go near his own. Subject 14: Dissociation - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Later I  ask him what his wife’s name was. He tells us and  – with prompting from me and others – he goes on to talk about her burial, her name on the headstone and their devotion to one another from the time they met as students. Others join this recollection of their happiness, and the group takes up, with respect and appreciation, how much they both lost with her death. I ask him if his wife would have wanted to know he was being cared for now? He is matter-of-fact in reply. Others ask where his own parents are now, and his wife’s parents. He tells us that his wife’s parents both predeceased her and died a long time ago. She had enjoyed a sense of family with his own parents and his extended family, who cherished her. In fact, she was so attached to his father that when he died her illness accelerated and she died herself just two months later. There is another stunned silence in the room as we take account of the enormity of his losses. The discussion moves on to his own role in the family now, caring for his mother and her loss; for his children and for their loss. As we do so, giving space for him to bring us his own loss – and not retreating from the challenge we have mounted to explore his coping patterns – his composure breaks, and his eyes fill with tears. Someone passes him the tissues; he begins to weep bitterly and the room fills with everyone’s tears. Subject 15: Grief - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - This account concludes the first three sessions. In the next two sessions we hear from the bereaved man about how he learnt of this conference and was encouraged to attend by friends and associates. He leads the discussion in the first of these concluding sessions. He tells us that after our last session he spent the day walking round and crying outside. He cried a lot when his wife died and then again after the funeral, but since then there has been too much to do – his children’s vulnerability and his mother’s give little room for his own. They all need him and, as well as these personal things, he has a very demanding job. Comments from all the others assure him that he has a safe place amongst us to share his sorrow. Care for him by the group is ‘soaked up’, and he goes on to talk like he’s never been listened to

13  Four domains of communication  351

before. For the next two sessions we stay close to his grief and he tells us at several points that he now knows why he came here. It’s clear that he has a strong and supportive social network, but even amongst them he’s never been heard speaking with a voice that suffered injury. One of the women tells us that after the last session, when she re-joined the rest of the conference, they were mindful of her tears and the tears of our other members, and we now have a reputation in the conference of being ‘the crying group’. We now make up a group that has become both cohesive and coherent, and we enjoy a shared sense of safety and a reluctance to explore vulnerable emotions outside this safe setting. Subject 16: Crying, and the work of ‘the crying group’ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Differing patterns of resonance take the conversation back to each of the 16 subjects – the 16 figurations – as the group works its way through the next two sessions and introduces 10 further figurations. One of the women tells us of her mother’s recent death and the fact that she took her identity card to register her death and make the funeral arrangements. She has mislaid her own and now carries her mother’s card with her, as if she has become her dead mother. She doesn’t want to let her go, she realizes, and needs help with this. The group responds with closely attuned enquiries and suggestions. Subject 17: Letting go - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - The spectre of execution as a solution to a conflict opened the first group, and the death of a woman, a mother to her children and the sole confidénte to her husband, concluded the second. In the third session one woman introduces a new subject – the problems faced by letting go of her now-dead mother. And half way through the third session a woman introduces a new subject, another spectre of death arising out of the Holocaust in which her mother’s parents both perished. She was the latecomer to the group and now, as an integrated member, she tells us that, for her children’s sake, she has finally found a small photograph of her maternal grandparents taken during the first phase of the Nazi occupation of France. They stand elegantly dressed on a famous boulevard in the weeks before yellow stars became obligatory. The date on the back and reference to the street location make all this clear. This is the only connection she has with her grandparents, who were amongst the first to suffer imprisonment in Drancy, the concentration camp in Paris, from where they were deported to

352  III  The dynamics of change

their death. They saved their daughter, aged two, by placing her in a convent, together with this one little image to keep their memory alive. She survived, she was rescued after the War by distant relatives and she came to Israel at the age of eight, when she was adopted. The family cherished her but she had a poor relationship with the adoptive father and had little to do with them once she had her own children including our latecomer. We recognise that after the grandparents we have heard about three generations of women in her family, and people invite her to tell us where the men are. She reports that the original ‘good’ man was her dead grandfather. He bears a striking family resemblance to her son and the image is now enlarged in the children’s bedroom. We have still to hear about the men in her own life, and one of the women asks her if there aren’t any good men here in the room. There is warm laughter in the group. It leads to a lengthy exchange about relations between three generations in different families outside, and developing trust of men by women, inside. But the issue of a woman leading her life with or without a man remains the central thematic subject for the group. Subject 18: The Holocaust Subject 19: The protection of children Subject 20: The survival of family lines and retrieval of family history Subject 21: The absence of good men in family history Subject 22: The discovery of good men in the group - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - A number of the group’s women are struggling with relatively un­available men in their marriages, referred to as ‘classic alpha males’, who cater for everything except the emotional needs of their wives and children. One of the younger ones says – of these deeply unsatisfying marriages  – ‘What can a woman do?’ She has a broad and engaging smile. She tells of her husband’s unavailability and, on the basis of what she tells us about their relationship, she is encouraged to smile at him as she does to us. Encouraged to stand her ground for what she needs but does not get, it comes as a surprise that she could make it different at home both by giving more of herself to her husband and by expecting more from him. She becomes a resolving emblem for the other frustrated women, who gain confidence in the exchange to go home and stand their ground or to find therapists to help them as couples. The presence of a male conductor and of male vulnerability in the group introduces both hope for difference at home and confidence that ‘maleness’ and avoidance do not go together. One of the older women tells us of how she has stood her ground for decades with a husband she will neither leave nor

13  Four domains of communication  353

tolerate if he overrides her. She has had to separate several times, but at last they are together happily and their bond will endure. Subject 23: What is a woman to do? Subject 24: How to improve marital terms? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - In the concluding session the women with difficult men take heart from the exchange to consider what it might mean to improve the terms of their relationships. We can all see the impact the group has had on them. Whilst people are sharing appreciation with one another for our productive exchange and saying goodbye, one of the members brings in a poem written by Pablo Neruda, an epitaph to a dead woman entitled La Muerta, and gives it as a hard-copy gift to the group and puts it into the hands of the bereaved man, who reads it out to us. The one bringing the gift had looked it up on the internet and printed it out overnight to bring it in. A profound depth of sorrow runs through its imagery and comes across from Spanish into English and Hebrew. Evocations lend emphasis to its concluding line and overall themes: taking the risk of loving, facing grief and moving on. This becomes the emblem through which the group concludes its work, and one of the members undertakes to send it out from the website on which it was found to all the group’s members. Subject 25: Life and its validation La Muerta by Pablo Neruda If suddenly you do not exist, if suddenly you no longer live, I shall live on. . . . . . . . . . . No, forgive me. If you no longer live, if you, beloved my love, if you have died, all the leaves will fall in my breast, it will rain on my soul night and day, the snow will burn my heart, I shall walk with frost and fire and death and snow, my feet will want to walk to where you are sleeping, but I shall stay alive, because above all things you wanted me indomitable, and, my love, because you know that I am not only a man but all mankind.

Subject

The need for containment

Threats and ‘executions’ at the workplace

Political conflicts outside and personal tensions inside the room

Tension between men and women

Latecomers

Care that women give each other across generations from grandmother to mother and daughter

Inclusion

Envy of others’ energy

Problem of dealing with difficult (envious) mothers

Number

 1

 2

 3

 4

 5

 6

 7

 8

 9 C & T

C & T

C

C & T

C

C

C

C

C

Domain of subject: C = Current T = Transference P = Projective A = Archaic/ primordial

4

2

5

4

3

5

3

5

4

Significance of subjects 1

Table 13.3  Progression of subjects and figurations in ‘The crying group’

Mothers and Daughters, envy

Envy

Containment

Mothers and Daughters

Inclusion, Containment

Men and Women

Containment, Inside and Outside

Death

Containment

Figurations 2

Mothers and Daughters 2 Envy 2

1

4

1

Inclusion 2 Containment 3

1

Containment 2, Inside and Outside 1

1

1

Frequency score of figurations

Meaning of boundaries that identify forbidden territory

Death

Children’s helplessness over parents’ bereavement

Avoidance of sorrow by caretaking for others

Who cares for the caretakers?

Dissociation

Grief

Crying and the work of ‘The Crying Group’

Letting go

The Holocaust

Protection of children

Survival of family lines and protection of family history

Absence of good men in family history

10

11

12

13

14

15

16

17

18

19

20

21

22 C, T

C, T, P, A

C, T

C, T, P

C

C

C, T, P

C & P

C & P

C & T

C

C & A

4

4

4

5

4

5

5

5

5

5

4

5

5

Men and Women Holocaust

Holocaust

Holocaust

Holocaust = death, dissociation, grief/crying

Moving on

Grief/Crying

Grief/Crying

Dissociation

Dissociation

Dissociation

Death

Death

Inside and Outside death

(Continued)

Men and Women 2 Holocaust 4

3

2

Death 5 Dissociation 4 Grief 3

1

2

1

3

2

1

4

3

Inside and Outside 2 Death 2

Discovery of good men in the group

How to improve marital relations?

Life and its validation

23

24

25 C, T, P, A

C

Domain of subject: C = Current T = Transference P = Projective A = Archaic/ primordial

5

4

4

Significance of subjects 1

Moving on, Life

Moving on, Life

Men and Women, moving on, Life

Figurations 2

Moving on 4 Life 3

Moving on 3 Life 2

Men and Women 3 Moving on 2 Life 1

Frequency score of figurations

1

Subjects are rated for their significance on a scale of 1–5 with the least significant rated 1 and the most significant, for the life of the group, rated 5. 2 Figurations are defined as thematic processes that include the intrapersonal, interpersonal and transpersonal dynamics of the moment.

Subject

Number

Table 13.3 (Continued)

13  Four domains of communication  357 Table 13.4  Frequency score of figurations during life of group Figuration

Frequency

Death

5

Containment

4

Dissociation

4

Holocaust

4

Moving on

4

Grief/Crying

3

Life

3

Men and Women

3

Inclusion

2

Mothers and Daughters

2

Envy

2

Inside and Outside

1

Commentary Vignette 13.7 illustrates the complex working role for the conductor of a group of mature health professionals like those who comprise The Crying Group, where the role is much more like orchestration than analysis. The orchestrating tasks have as their guiding objective, the maintenance of open channels between the group’s four domains so each can remain pervious to the influence of all three of the others, as described in Tables 13.1 and 13.2 and illustrated in Figures 13.1 and 13.2. Earlier in the book, for group therapy with mature populations, Chapter 12 identified a decrescendo in the conductor’s analytic tasks which, devolved to the work of the group, led to a sense of agency, being and belonging, first described in the work of Millard in Chapter 1.

Findings There are 12 figurations during the life of this group. The dominating figuration of the group, the one with the highest frequency score in the table, is Death, which emerges on five different occasions. In descending order from its frequency at 5 are those with a frequency score of 4 that include Containment, Dissociation,

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Moving on and the Holocaust. Those with a score of 3 include Men and Women, Grief/Crying and Life. Those with a score of 2 are Inclusion, Mothers and Daughters and Envy. And the last of these, Inside and Outside, has a score of 1.

Note 1 Wikipedia, holography: http://en.wikipedia.org/wiki/Holography

Bibliography Erikson, E. (1995). Childhood and Society. New York, Norton. Foulkes, S. H. (1964; reissued 1984). Therapeutic Group Analysis. London, George Allen and Unwin. Reissued Karnac. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Neruda, P. (1994). La Muerta from Five Decades: Poems 1925–1970. New York, Grove Press/Atlantic Monthly Press. Nitsun, M. (2006). The Group as an Object of Desire: Exploring Sexuality in Group Therapy. London, Routledge. Pines, M. (1986; 1998). Coherency and Disruption in the Sense of Self. British Journal of Psychotherapy 1986, 2 (3): 180–185. Reprinted in M. Pines (1998). Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London, Jessica Kingsley, pp. 211–223. Usandivaras, R. (1986). Foulkes’ Primordial Level in Clinical Practice. Group Analysis 19 (2): 113–124.

Acknowledgements: Extract from Foulkes and Anthony (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach, with permission from E. J. Anthony; extract from ‘La Muerta’ by Pablo Neruda reproduced with permission from Grove Atlantic Press and Agencia Literaria Carmen Balcells SA; Table 13.1 reproduced with permission from the Group Analytic Society.

Chapter 14

Lost or found in the transference? Transference, countertransference, projection and identification in groups

The past is never dead. In fact, it isn’t even past. (Faulkner, ‘Requiem for a Nun’: Act 1 Scene III) There was a child went forth every day And the first object he looked upon, that object he became And that object became part of him for a day or a certain part of the day . . . His own parents, he that had father’d him and she that had conceiv’d him in her womb and birth’d him, They gave this child more of themselves than that, They . . . became part of him . . . The family usages, the language, the company, the furniture, the yearning and swelling heart, Affection that will not be gainsay’d, the sense of what is real The thought if after all it should prove unreal. (Whitman 1958:290–291) There is in each of us a fundamental split between what we think we know and what we know but may never be able to think. In the course of the transference and countertransference the psychoanalyst may be able to facilitate the transfer of the unthought known into thought, and the patient will come to put into thought something about his being which he has not been able to think up until then. (Bollas 1987:282)

The more troubled people are the more the shadows of their past relationships distort and impair their lives. This chapter looks to pioneers in psychoanalysis and group analysis – and to current practitioners – to see how principles of transference and countertransference can be called on to help people find themselves and one another in therapeutic groups. These principles, like their associated constructs of projection, identification and projective and introjective identification, have origins and development coterminous with psychoanalysis, so there is an

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extensive literature. The selection of sources here focuses on helping understand these concepts in group therapy where transference is one of the four domains of meaning and projection is another, in line with Foulkes’s account described in Chapter 13.

Opening steps in theory and practice Transference and the other three domains of meaning in groups Chapter 13 described how, in Foulkes’s later account, transference is located beneath the current and above the projective level of a group (Foulkes 1964/1985:114/115). I have proposed a revision of his notion of four levels to view them instead as domains of meaning, each of which can be seen working on, or working in relation to, any of the others. Although these two chapters are written to be read independently of one another, Chapters 13 and 14 need to be taken together. The summary given in the next paragraph is intended for readers who may not have read the previous chapter. A group’s current domain is the ‘reality’ of what people join when they begin. It is on a level with the real world lived in outside, the world people move on to when they leave. The group’s other three domains are generated in (what Winnicott calls) the ‘intermediate territory’ comprised first of the transference domain of whole-object relations – mothers, fathers, brothers, sisters and others. Behind this is another more obscure or hidden projective domain of part-object relations, for example in the case of a man who always finds women intrusive and sees intrusiveness in each of the group’s women, whether or not it is there. In this domain projection does not involve attributions that belong to whole people but, rather, to fragments of past acquaintance that may be welcomed or feared. Behind this, in turn, is the primordial domain of archaic meaning crystallised by symbols and metaphors. The projective and primordial domains work together generating a visible field that brings the hidden world of unconscious conflicts and anxieties to life. In another example aggression is ‘attached’ projectively to a newcomer, who carries its consequences and identities with them as they confirm her worst misgivings about herself as she is isolated and antagonised and becomes the group’s scapegoat. The group’s figurations involve the interweaving of process and content, of thematic and relational dynamics, that link the domains across their dynamic fields. The advance given to the field by Foulkes’s understanding of these four levels, it is suggested, becomes even more productive when we redescribe them as domains, as Chapter 13 sets out to do. When clinical problems become new discoveries – the group-analytic ‘turn’ Nitzgen gives an account of what we can call the group-analytic turn that took place when Foulkes first brought people together in groups in outpatient

14  Lost or found in the transference?  361

psychotherapy and in-patient psychiatry between 1940 and 1945 (Nitzgen 2008). He discovered that the transference he had been trained to work with did not help him understand a combined sequence of multiples in the room. Seven or eight people were of course all sitting there, each of whom was governed by different transference reactions. But none of these individualised narratives helped explain what he found happening. He was startled to discover that the group behaved with a new and different energy ‘as if’ it had a mind of its own. The sense of being inspired by a new discovery is as real in these early group-analytic encounters described in his first book (1948) as it is in Freud’s original discovery of transference itself described between 1895 and 1911 (Freud 1912). The texts of pioneers are marked by this capacity to turn distractions into discoveries and obstructions into new sources of knowledge. Freud, Foulkes, Fleming These two landmark events, Freud’s recognition of transference and Foulkes’s recognition of it in a group, were milestones. The first involved the discovery that an individual’s emotions could be transferred from their unconscious into a therapeutic relationship; the second that emotions amongst strangers could be transferred into a group with revealing consequences and beneficial results. Both Freud’s and Foulkes’s discoveries were adventitious at their time – products of chance and circumstance – harvested by great investigators, as in the discovery of penicillin. In 1928 Fleming was investigating agents that could combat infection by working against microbes and he made the accidental discovery that the obtrusive presence of mould in a petri dish, something that at first sight interfered with his research, might yield what he sought. It took another 10 years for others’ research to turn Fleming’s discovery into scientific knowledge. The human sciences including depth psychology have grown in the same way. Freud went through his own ‘psychoanalytic turn’ when the transference pattern that worried him and his colleague Fliess was turned into a principle of treatment based on his recognition that it involved repetition of the past and distortion of the present, in line with the past. However, he continued to regard countertransference as a kind of distracting problem and it was not until the work of Heimann and her colleagues in London, described below, that countertransference became a real resource with the publication of her celebrated paper in 1950 (Heimann 1950). Transference in the three main models of group psychotherapy Transference and countertransference can be profound resources. They provide principles of clinical demarcation between the three most widely practised models of group therapy. In the Tavistock model transference is the governing issue but is still conceived in its originally restricted form in the basic assumptions of a two-person psychology arising between the conductor and the group as a whole. In the Interpersonal model transference was not considered until the fifth edition of Yalom’s text where Leszcz brings it into a central place (Yalom

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and Leszcz 2005:201–229) and it is seen to be ‘omnipresent and radically influences the nature of the group discourse’ (2010:205). In the group-analytic model transference has always been a central therapeutic principle, and, in the light of his early discoveries, Foulkes created a new therapeutic vocabulary to describe ‘group-specific’ factors. He created a new therapeutic method and a new model to support it. But he did not live to see the changes in metapsychology that he thought should follow and ended his life half way between the old paradigm of classical theory in psychoanalysis and his radical new method that had a poorly developed theoretical frame. The study of transference brings these issues to prominence, and the chapter seeks to address and resolve some of their anomalies. However, text and scholarship can distract us from the clinical focus of the enquiry, and Vignette 14.1 serves as a cautionary opening.

A cautionary opening: Reading Fraud and Junk

Vignette 14.1  Reading Fraud and Junk

Mike is a jazz musician with a band, a life and a reputation, as he now puts it. He and his wife recently attended for some ‘top-up’ sessions and are doing well together. They first came to see me years ago after he had a fight with his best friend in his partner’s living room. It was the friend’s ‘stag night’ when – as he put it – they were both ‘stoned out of their minds and pissed as newts’. There was blood and injury, and the police were called. Evidence for Mike’s prosecution was held back by his friend and partner, now his wife, on condition he had psychotherapy. After six months of individual sessions with me during which he ‘dried out’ of a serious drink and drug habit, he joined an intensive group. It had a number of people with university backgrounds and it was at times in a state of defensive intellectualisation. Mike had a large presence and big voice, but his first weeks were spent quietly on the margins. This changed when he eventually allowed someone to enquire into what had brought him to join us. He was shy to begin with but was provocative with his humour and, with a straight face and speaking in a thick East End accent said, ‘Well, I’ve been on a habit a long time. I don’t know myself and I hurt the people I love. How I came to do it all I just don’t know. And I don’t know how to find out. I left school without much of an education and don’t know where to look. You guys are all talking about these books you read. Where I grew up we didn’t have any! And what would Fraud and Junk have to say to someone like me? I just don’t know?

14  Lost or found in the transference?  363

Commentary Our laughter then is with me now as I write. He learnt what ‘Fraud and Junk would have to say’ in the group without ever opening a book and left some years later to establish his life as a professional musician after passing on to others in the group his own radical gifts of insight and encounter. He was a talented musician who had never realised himself. His transference with me, with the group and with its members was fraught with early injury. We got to know only too well what early losses he and his siblings lived through and how much rage required resolution. Whilst he was serving out his notice before leaving the group he brought us the latest of his many saxophones to show us ‘the instrument’, as he called it, which was to take him on to an interesting future. He gives us not only wit by his story but also a defined originating problem and an unqualified good outcome that makes the work we do feel specially worthwhile. But it does not always go quite like this.

Transference in psychoanalysis and group analysis The group hiding under the couch in psychoanalysis Transference is a set of projections and identifications – shadows from the past – first recognised in the earliest forms of psychoanalysis where it was called on to investigate the past – ‘there and then’ – as it was replayed during psychoanalysis or therapy, in order to bring steadily to light the patient’s unconscious distortions as they arise in the therapeutic relationship (Freud 1912). Freud’s Classical theory involved, as we will see below, a restricted definition of transference that was believed to arise only between therapist and patient. This was retained as a working frame of reference by Anna Freud and the B-Group of the British Psychoanalytic Society of which Foulkes was a member. Object relations theory and its influence on the developing relational paradigm – across the field – has amended psychoanalytic practice, which now explores the dynamic present, the ‘here and now’, both to see how it is shaped by transference and to so amend transference that it can allow current realities to be freed from the hold of the past. The writing of Bollas, quoted below, is one of the best representative accounts of how transference is worked with in psychoanalysis today and describes the approach that sits most comfortably with group-analytic practice. Sutherland has pointed out that there was never any ‘thinking circle’ comprised of Winnicott, Balint, Fairburn and Guntrip, those who pioneered some of the relational changes in object relations theory (Sutherland 1980) in the same period that Bowlby pioneered attachment theory. Foulkes lived and worked amongst these other pioneers. At the time of his death he had an early draft of a new book

364  III  The dynamics of change

intended to address these matters. Anthony takes up this vision and describes how, in individual psychoanalytic practice: The analytic situation (is) . . . in fact haunted by groups from the primary family organisation onward and . . . the air (is) clamorous with the voices, supporting and persecuting, of friends, relatives and enemies who make up the social orbit of the patient. (Anthony 1978:39) He calls this ‘the group under the couch’ and describes how it ‘continues to exercise its unseen effects throughout the treatment (in which) the patient has to learn how to deal with them (the other people under the couch) as well as with himself and his analyst’ (Anthony 1978:39). Joining the circle: Transference in groups How then is transference worked with in groups? Anthony describes how the group analyst brings out ‘the group under the couch’, settles them down in a circle of chairs, transforms each of them into a patient and not a projection and joins the circle himself for . . . a face-to-face encounter (Anthony 1978:39). The past is drawn into the dynamic present through transference that emerges inevitably through the shadows cast in the group by its members’ histories. Using Winnicott’s language first, the group becomes a facilitating environment that provides holding and containment (Winnicott 1965, 1985). Its intersubjective dynamics are opened to an active process of play, enquiry and replay that moves freely between ‘there and then’ and ‘here and now’. Using a closely related language – that of attachment theory – the same process can be described in Bowlby’s terms as the creation in the group of a secure base that allows exploration and enquiry. Bowlby conceived of: Attachment theory (as) a way of conceptualising the propensity of human beings to make strong affectional bonds . . . and of explaining the many forms of emotional distress and personality disturbance, including anxiety, anger, depression, and emotional detachment, to which unwilling separation and loss give rise. (Bowlby 1977/1979/1989:151) Our goal is to equip people to come out of the shadows and find a voice for themselves. These shadows of past injury are cast onto other members as projections and stimulate identifications and counter-identifications, creating a climate all of their own. They comprise what Bollas calls, ‘the world of the unthought known’ in the quotation that opens this chapter, including ‘. . . the countless rules for being and relating that have been operationally determined’ in the family of

14  Lost or found in the transference?  365

origin (Bollas 1987:279). These are pooled in the matrix through the most elemental of a group’s dynamics, the process dynamics discussed in Chapter 10 that include socialisation, exchange, resonance, valency, mirroring, condensation and amplification that bring the group to life.

Process dynamics, the projective and the transference domains The complexity of the group situation can be made more so by the different constructs and outlines in various branches of the field. Foulkes devised the language of ‘group-specific process’ – re-named in Chapter 10 as process dynamics – to deal with these new discoveries whilst retaining the psychoanalytic language of transference. Table 14.1 sets out the framework he devised with Anthony that gives eloquent shape to the new paradigm (Foulkes and Anthony 1957/1984:51). It is a masterly portrayal of the group-analytic frame of reference, and it is like the Rosetta Stone of group analysis in that it allows us to read two languages against one another – classical psychoanalysis and group analysis – and decode their congruence and differences. The table is unfortunately not discussed in their text, nor do Foulkes and Anthony provide a differentiated picture of transference at work in the group as it affects, and is affected by, the process dynamics of resonance, reciprocity, mirroring and amplification, described in Chapter 10. So on their own account we cannot see what ‘purchase’ there is between process dynamics (Foulkes’s group-specific factors) and transference dynamics. Though Foulkes devised group-specific factors precisely to describe the new situation Table 14.1 makes no reference to them. As Dalal and Weegman have correctly identified, Foulkes as a psychoanalyst remained within the older paradigm of classical theory and based his work with transference on what Chapter 4 describes as a one-body psychology (Dalal 2000; Weegman 2014). In the years in which Foulkes was developing his theory the other new relational paradigm in psychoanalysis was arising out of the two-body psychology of object relations theory. Its focus on projection and projective identification had not yet matured and its proponents included some of Foulkes’s closest associates. And yet, strangely, he kept his work as a group analyst apart from them and their influence. We can now take advantage of the maturation of a relational perspective, and in Figure 14.1, I introduce a construction that links the different bodies of theory to forge one coherent picture of a therapeutic group at work.

Foulkes and object relations theory – an historical excursion: One-body, two-body and three-body psychologies Before we come to it some further history may equip us to find our way. The Controversial Discussions between Anna Freud and Melanie Klein in London

Table 14.1  The transference (‘t’) situation in psychoanalysis and group analysis Foulkes and Anthony (1984: 52)* Source & Focus

Psychoanalysis

Raw material as to subject matter

Verbal communication, relaxed control ‘Free association’ of patient

Group Analysis

Spontaneous contributions of members ‘Free-floating discussion’ ‘Free group association’

Translation from symptom to meaning From complaint to problem (conflict)

Making repressed unconscious conscious Interpretation by psychoanalyst

Interpretation by group analyst with the active participation of all members Group as a whole as background of interpretation

Resistances, defences

Made conscious

Made conscious, including collective and interactional modes

Raw material as to relationship

Behaviour and expressive (non-verbal) communication Two-person situation Transference regressive, infantile Counter-transference Relations to other people are outside the T-situation

Multi-personal situation Multiple transference relationships All within T-situation

Nature of therapeutic (transference) relationship

Regression encouraged by situation Relative anonymity and passivity of psychoanalyst Transference neurosis fully established Problem of dependence & fixation on psychoanalyst

Regression not encouraged by situation Relatively realistic role by group-analyst and interaction with others Transference neurosis not fully established Less dependency problem

Therapeutic processes and principles

No manipulation of transference situation Emphasis on insight and on contrast between past and present

In addition: emphasis on reaction and experience in the present situation (‘here and now’) Corrective experience ‘ego training in action’

* Table 14.1 is reproduced from page 52 of Group Psychotherapy: The Psychoanalytic Approach by S.H. Foulkes and E.J. Anthony (1984) by kind permission of James Anthony and the publisher.

14  Lost or found in the transference?  367

during World War II led to the emergence of an Independent Group in the British Psychoanalytic Society including Strachey, Winnicott, Balint and later Heimann. They incorporated the depth of clinical understanding in Kleinian thinking without taking on Klein’s metapsychology (King and Steiner 1992). Along with Fairbairn they came to be known as the British School of Object Relations and contributed to the shift in prevailing patterns of understanding from the psychoanalysis of instincts in a one-body psychology to a two-body psychology focussed on infantile experience and the parent–child relationship.1 Pre-oedipal bonds became the governing influence on therapist–patient relations in the transference. The work of this group was introduced to North America by Sutherland, where it was taken up by Kernberg, Spotnitz, Ormont, Epstein, Greenberg, Mitchell, Ogden, Scharff, Cashdan and others, and it has helped recast the prevailing patterns of thinking and practice in relational terms (Sutherland 1980). Foulkes was outside London working in Exeter and Northfield during the Controversial Discussions and kept a distance on his return. Anthony and Pines confirm that his closest associates were Anna Freud and members of her B-group. Whilst Foulkes developed his own practice and became an influential teacher and training analyst in the British Psychoanalytic Society, he was at the same time working on his novel discoveries in group analysis and developing what he called ‘the model of three’, the constellation of family relations that underlies a group-analytic group described in Chapter 8. He was active in creating one set of foundations for what we know today as the prevailing relational paradigm for psychotherapy that relies on his three-body psychology described in Chapter 4. But his work and writing omitted and actively excluded the other set of foundation concepts in this relational paradigm – object relations theory and its two-body psychology – that was under development amongst members of the Independent group. Foulkes’s closest associates in London included members of this circle like Balint and Winnicott and, though their writing makes reference to his, Foulkes’s own writing makes very little reference to theirs. In his practice as a psychoanalyst he retained a perspective that kept him close to Anna Freud and her later development of ego psychology, but despite the world-wide influence of her classic text, The Ego and the Mechanisms of Defence (1937), his writing about groups introduces virtually nothing of what she wrote about defence mechanisms. Some of these different anomalies have been addressed two generations later by Dalal (2000), Levens (2011), Nitsun (1995) and Weegman (2014), who have made their own contributions to the development of theory and practice. However, the originating problems in our basic constructs are more complex than demarcation between an ‘orthodox’ and ‘radical’ Foulkes and a favouring of the latter, as Dalal proposes. There is much yet to be done to address our own history and developing paradigm. The pages that follow set out to make good on the missing elements of Foulkes and Anthony’s account in Table 14.1.

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The projective domain: Linking transference and process dynamics In the triangle there are process dynamics in its foundation and transference dynamics at its apex. Between these are projection, introjection and identification, the constructs of current relational practice in psychoanalysis. So Figure 14.1 returns to a picture of the layering of experience in a group (a picture that was set aside in Chapter 13 in favour of a different picture of four domains of meaning), with its foundations set in the most basic process dynamics out of which projection and introjection emerge and out of which – in turn – transference and countertransference emerge. The unconscious of the group’s individual members shapes its dynamic process in which transference exerts dynamic pressure from the top transferential layer down to process dynamics in the bottom layer. At the same time, the social unconscious of the group works up from the basic process dynamics in the foundation matrix to influence the transference in the top layer. The dynamics between transference/countertransference in the top layer and process dynamics in the bottom layer take effect on each other through the intermediate level. This is made up of projection, introjection and projective identification that can be accessible as ‘available’ dynamics in the group, where they can be looked at and recognised. They also take effect through introjective and projective identification that are usually hidden or unavailable to conscious scrutiny until they drive

Transference & Countertransference

Projecon, Introjecon, Idenficaon Projecve & Introjecve Idenficaon Process Dynamics Socialisaon, Exchange Resonance, Valency, Mirroring, Amplificaon, Condensaon

Figure 14.1  Transference and projective levels of experience in a group

14  Lost or found in the transference?  369

transference/countertransference dynamics into such distorted forms that they become evident. However, this diagram and the accompanying explanation convey a linear picture of dynamics at work as they go up or down. We know this is inaccurate, first because it is incomplete and second because it is linear. So Figure 14.2 replicates the layered experience, but it is now conveyed by two identical triangles that are inverted in relation to each other. They both describe the same group as its dynamics move in a circular way between its different layers of experience. Transference will invariably work to shape the process dynamics whilst these dynamics – in turn – contribute to the way in which the group shapes the transference. So depending on where we locate the viewer’s eye, transference can be either at the apex of the triangle or at its foundation, and from this picture we can see just how circular and interconnected everything really is. The other serious

Process Dynamics Socialisaon, Exchange Resonance, Valency, Mirroring, Amplificaon, Condensaon Transference & Countertransference

Projecon, Introjecon, Idenficaon Projecve & Introjecve Idenficaon

Projecon, Introjecon, Idenficaon Projecve & Introjecve Idenficaon

Transference & Countertransference

Process Dynamics Socialisaon, Exchange Resonance, Valency, Mirroring, Amplificaon, Condensaon

Figure 14.2  Circular and reciprocal movement between different layers of group experience

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shortcoming that arises in both Figures 14.1 and 14.2 remains the problem of linearity. This was resolved in the earlier construction of Figure 13.1 where the idea of layers or levels was replaced by domains, each of which could have a formative influence on any or all of the others. The challenge of turning Figure 13.1 into an accurate, three-dimensional representation of Figure 14.2 — which is probably the only way to do it – must be left to others! How does the understanding of these layers or domains equip us to develop a group’s therapeutic potential? Bollas poses the same question in a slightly different language: In what ordinary way, then, does the unthought known become thought? . . . In the same manner that it partly developed: establishment through object relations. It is only through the subject’s use and experience of the other that . . . representations of that experience can carry and therefore represent the idiom of a person’s unthought known: which . . . brings us to the transference and countertransference. (Bollas 1987:280)

Transference and its differentiations The ‘T’ situation We will make our way through the differentiating categories that modify transference and using Table 14.1 as a guide, will apply them to group psychotherapy. These different forms of transference are discussed after the table and then, following an excursion into the literature and its history, we return to definitions and descriptions of transference in groups in vertical and horizontal, simple and complex, and positive and negative forms. The subject encompasses so much in the practice of group-analytic psychotherapy that it cannot be dealt with in one chapter. So when the differentiated forms of transference are later introduced, each one will be followed by guidance to the reader as to where they will find illustrations for each form elsewhere in the text. Foulkes and Anthony described their model of group therapy as a transference situation in which ‘past and present must meet. The past – which was Table 14.2  Different forms of transference: Simple, complex, vertical horizontal Form of transference

‘Simple’

‘Complex’

Vertical

Simple vertical

Complex vertical

Horizontal

Simple horizontal

Complex horizontal

Alignment of Transference

14  Lost or found in the transference?  371

unconscious, repressed, or never experienced in such form as could be recalled except through repetition in behaviour’ – is accepted as present in the transference situation (Foulkes and Anthony 1957/1984:60). They call it the ‘T-situation’ and they use it to embrace all the therapeutic dynamics of the group. They distinguish it from the small ‘t’ the situation in which individualised transference dynamics arise between one member of the group and another. Unfortunately these distinctions do not give a clear guide to clinical practice. The further differentials distinguish between vertical and horizontal transference, between what I call here ‘simple’ and ‘complex’ transference, and between positive and negative transference. For example, a relationship between two people in a group might be governed by transference in an evident and bounded coupling. At a point in time this becomes figural for the group. This is what Foulkes and Anthony called transference with a small ‘t’. The valency they have for one another has the group as a whole as its context or ground. These two may have something of importance to work out with one another through empathic or malignant mirroring during which the other members of the group, including the conductor (if she is not part of this coupling) serve as witnesses. Their reparative dialogue can then become a nucleus for a widening discourse in this spirit that comes to include the group as a whole. So-called simple figurations of this kind are described in Vignettes 1.2, 3.1, 4.2, 10.2, 10.4 and 13.2. In complex transference, the big ‘T’, there is a constellation of relationships that are transferential in nature and there may be positive terms in one of its elements that may be bound to a negative set of terms in another of its elements. So, in the transferential constellation of a group there may be an idealising, positive vertical transference towards the conductor by two of its members, and they may be embattled in a negative and hostile, horizontal transference with most of the other members, who return their scorn in kind. The scapegoating dynamics and extruding pressures at work in a group at this moment in time have their origins in a kind of split transference. Simple and complex transference figurations are described through the text, and a guide to the vignettes they are illustrated by is provided in Table 14.3. Restricted and extended definitions of transference Freud, Strachey, Sandler The debate about definition is important. In the use coined by Freud transference describes an emotion arising between the patient and analyst in psychoanalysis that involves the patient’s repetitive distortions based on their earlier relationship with someone else (Freud 1912). It was widened for psychotherapy at large, but even so, it continued being employed on terms governed by this restricted definition. In The Patient and the Analyst, Sandler and colleagues (1992) contrast this with the more useful definition which was by then in current practice called the extended definition, the one used by group analysts today, which we will look at below. Before moving on, though, we can review the key features of transference

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in its original, restricted use in Strachey’s ‘classic study’ (Strachey 1934), because so much of it is still relevant to the work we do in groups. Current psychoanalytic work with transference in the English-speaking world takes Strachey’s work, rather than Freud’s earlier classical theory, as its source of definitions. The defining features in the psychoanalytic paradigm represented by Strachey are that transference becomes a central and governing preoccupation of the patient, a kind of neurosis in and of itself, with associated distortions and complications in the patient’s relationship with the analyst. It eats up the whole analysis, in Strachey’s words, in a regression that the course of analysis is intended to resolve through mutative interpretations addressed to both its concrete and symbolic meanings. Balint and Alexander This way of understanding and working with transference is counter-posed by the new relational paradigm introduced to the field in the literature of Balint in the UK (1933, 1939, 1949) and Alexander (and French) in the United States (1946), both of whom were analysands of Ferenczi. They brought his originating relational shift or ‘turn’ into psychoanalytic practice in the 1930s and 1940s. Alexander’s contribution is considered in Chapter 2. Balint describes a series of commonplace examples outside therapy in which ‘a very intense emotion takes hold of (a) person . . . (that) is lived out on something else . . .’ (1933:175). He describes transference as ‘an important, general phenomenon . . . which permeates the whole of our social life’ (1933:175) and goes on to say ‘transference is a general feature of human life, every­body is always transferring his emotions to everybody within reach’ (1933:187). His celebrated summary of the change brought to the clinical field by this extended approach (1950) emphasises how the ‘libidinal’ features of the patient’s transference are matched by the analyst’s towards the patient, ‘even if we call it “counter-transference”, or “correct analytical behaviour”, or “proper handling of the transference situation”; this relation, too, is libidinous’. In this account he turns psychoanalysis into an intersubjective psychology (1951:231). We can see how he lays the groundwork for Foulkes’s later picture of group analysis as ‘a form of psychotherapy by the group, of the group, including its conductor’ (Foulkes 1975/1986:3). Other key elements of Strachey’s early study are of direct relevance to groupanalytic practice. He cautioned on the use of interpretations and illustrated how – to be deployed as mutative – they would only be addressed to the therapeutic relationship and would not work outside it. He also advocated that the analysand could only be presented with small segments of reality at a time so they could be assimilated and metabolised. The focus of an interpretation was to make transparent links between the past, the present in the session and the patient’s life in the outside world. Figure 11.2 is based on Strachey’s original demarcations among the past, present and outside world, and his modalities of time and place are adapted here for group-analytic use. Figure 11.3 follows it to describe our current focus on the dynamic present. It maps out the progression of group discourse towards resolution and change in the here and now, which is found to express the presenting

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past. We can see much of this represented in the psychoanalytic column of Foulkes and Anthony’s Table 14.1. And in the group-analytic column we can see how they vary the use of interpretive work to bring in the group as a whole. In Chapter 17 we will see how carefully Foulkes incorporated Strachey’s basic tenets in the way he recommends transference should be interpreted in a group. Current literature on transference: From Balint and Winnicott to Bollas, Spillius and Ogden I date the ‘current’ literature on transference using Balint’s own demarcations in the evolution of psychoanalytic technique (1951). He names the first period as Freud’s original hypnotherapy that leaves its only legacy in the use of the couch; the second was governed by the interpretation of content; the third period by the interpretation of either transference or defence; and the fourth, the period he introduced, is governed by the restricted use of interpretation and a focus – instead – on emotional communication in the transference (1951:233–235). Many practitioners in psychotherapy and psychoanalysis call on more than one of these approaches and, in consequence, technicalities in the differentiated use of transference according to these stages in the evolution of psychoanalytic technique remains complex. Many practitioners call on more than one of these approaches. In addition there have been many further developments since. Foulkes was not the only psychoanalyst with inconsistencies in his writing and practice. The most reliable single guide to the field is Frosh (2002, 2006, 2010, 2012), whose publications can be relied on for a balanced and comprehensive account that will be of immediate relevance to clinical practice with groups. The work of Bollas consolidates and extends the emphasis given by Balint to view transference as a form of emotional communication that makes transparent ‘the unthought known’ (1987, 1993, 1990). His further original contribution is in the development of the aesthetic and symbolic that will be called on in Chapter 16. Winnicott’s classic study of ‘Hate in the Countertransference’ (1947) is essential reading for most of us and lays down foundations for later work by Temple (1996), by Gordon and Kirtchuk (2009) and others, who provide excellent overviews and clinical guides to transference and countertransference in general and forensic settings. Spillius and O’Shaughnessy (2012) provide an up-to-date account of ‘projective identification: the fate of a concept’ addressed by classical psychoanalysts, Kleinians and others working in many different countries, including historical and classical papers by Bion, Rosenfeld, Feldman, Joseph, Sandler and others. It provides an invaluable resource to augment the only two group-analytic publications on projective identification in groups by Rogers (1987) and Rafaelson (1996). In the United States Epstein and Feiner pioneered the application of countertransference in the Modern Analytic school (1979), Ogden has brought a distinctive clarity and simplicity to an otherwise complex field (1992, 1993) and Cashdan (1989) has developed a distinctive approach in the use of transference and countertransference that he calls object relations therapy. The brief definitions

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that follow are drawn from a wide range of sources, but I am guided in presenting them by the clarity of the contributors named in this paragraph. Current definitions Transference We can now define transference in the extended form given by Sandler and associates (1992) as a feature in all our relationships in which behaviour, relationship patterns, emotions, fantasies or all these psychological attributes arising from childhood experience are lived out in later relationships – in this case in the group – as if they belonged there. The key is in the phrase as if that allows us to recognise we are in what Winnicott calls the intermediate territory (Winnicott 1951). The group-analytic approach works to set up and cultivate the as if and develop the riches of the intermediate territory between states of longing and belonging in the group. We will see in Chapter 15 how people ‘step into and out of the pictures of themselves and one another’ formed in the transference. Countertransference Refers to all the above, as attributes of the therapist, which are available to her/ him, as sources of information about a client, couple or group. Projection Describes the attribution of emotion to another when its origins lie within the self. Identification Describes the placing of the self with another, in terms of behaviour, relationship patterns, emotions, fantasies or all these psychological attributes. Projective identification Describes a four-stage process involving, first, the unconscious attribution to another of aspects of the self; second, an accepting response by the other of those attributes that are induced in them so that they become incorporated or owned as part of the receiving person’s own self; third, the recipient of the projection identifies with the emotions induced in them; and fourth, a belief comes to be held by both parties, that the projected attributes originate from the wrong person.

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Introjective identification Describes a two-stage process involving, first, attribution to the self, or the incorporation in the self, of aspects of another and, second, an identification or placing of the self with these other attributes including behaviour, relationship patterns, emotions, fantasies, or all these psychological attributes as if they belonged there. Transference to the conductor, to the group and between members Elsewhere in their text Foulkes and Anthony differentiate between the vertical analysis of the psychoanalytic process and the horizontal analysis of the groupanalytic one (Foulkes and Anthony 1957/1984:42). We can now take advantage of this differentiation by calling on the work of Grotjahn (1983:3) and Scheidlinger (1982:75) writing in the United States and Konig (1991a; 1991b) in Germany to help simplify the issues, all of whom draw from their reading of and close association with Foulkes. Grotjahn describes: Three trends of transference in groups . . . One transference relationship is to the central figure, the therapist, which is similar to the transference neurosis in psychoanalysis; the second . . . is extended to the peers in the group, and forms an important therapeutic agent; the third . . . develops in later stages of the therapeutic group process . . . the transference to the whole group as an early, preoedipal mother. (Grotjahn 1983:3) Differentiation between these transference forms is illustrated in the vignettes throughout the book. Table 14.3 provides a summary of which vignettes illustrate the different forms of transference and countertransference. Simple and complex transference In a group there may be a transferential bond of a ‘simple’ coupling of two whose dynamics, set against the grounded context of the group, can become figural and highly charged. This can arise between two group members on the horizontal axis or between one member and the conductor on the vertical axis. The work of therapy will lie in the unravelling process that brings out the significance of this seemingly ‘simple’ coupling for its two participants and for the group as a whole. There will also be transferential bonds of complexity involving a number of participants where the axis of transference will run in both directions, horizontally and vertically, and where the dynamics can only be understood by use of the term figuration to capture the thematic content of a complex situation and

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Table 14.3  Illustrations of transference and countertransference in the text Term/type of transference

Vignette numbers

Simple transference figurations

1.2, 3.1, 4.2, 10.2, 10.4, 13.2

Complex transference figurations

2.4, 2.5, 4.4, 4.5, 5.3, 8.2, 10.10, 11.2, 13.6, 14.3, 15.2

Transference to the conductor

3.1e, 8.1, 8.2, 9.1, 10.1, 10.9, 10.10, 11.2, 12.1, 13.6, 13.7, 14.2, 14.3, 14.4, 14.6, 15.2

Transference in the group as a whole or to the group as a whole

2.1, 2.2, 2.4, 3.1e, 3.1d, 5.6, 8.1, 8.2, 9.1, 10.1, 10.4, 10.5, 10.9, 10.10, 11.2, 11.3, 12.1, 13.1, 13.3, 13.4, 13.5, 13.7, 14.2, 14.3, 14.6, 15.2, 15.4, 16.4

Simple transference amongst members

1.2, 3.1a, 4.3, 10.2, 10.3, 10.10, 13.2, 13.7, 14.2, 14.5

Complex transference amongst members

2.1, 2.4, 2.5, 3.1c, 4.2, 4.4, 8.2, 9.1, 10.4, 10.10, 11.1, 11.2, 11.3, 13.3, 13.6, 13.7, 14.3, 14.6, 15.3, 16.3, 16.4

Countertransference

1.1, 1.3, 2.4, 3.1b, 3.1e, 5.1, 5.3, 5.6, 8.1, 8.2, 9.1, 10.4, 11.2, 11.3, 12.1, 13.1, 13.4, 13.6, 13.7, 14.2, 14.3, 14.4, 14.5, 14.6, 15.2, 15.4, 16.1, 16.3, 16.4, 17.1, 17.2, 18.1

bring thematic content together with the relational dynamics with which they are bound up. A group’s dynamic movement will see a constantly changing interplay between simple and complex transference in its vertical and horizontal forms. This is illustrated already in the ‘T’ situation described above, where the further distinction between positive and negative transference is introduced. Table 14.3 gives guidance to where in the text these and other forms of transference are illustrated. Positive and negative transference Psychotherapy that does not begin with a positive therapeutic alliance is in most cases doomed, for the trust required of a favourable positive transference will have no foundations to grow on. It is likely to also be doomed if does not venture into the negative dimensions of the transference. As Bowlby described above, people attend for psychotherapy carrying the stigmata of injury and disappointment. Unless these can be carried into the re-vitalising process of transference – in a way that allows the hurt to have its own presence – then the person involved is unlikely to enjoy the full benefits of the process. Not all who attend for group-analytic

14  Lost or found in the transference?  377

psychotherapy will need to live through rage, hostility and bitter disillusionment towards the conductor and fellow group members in palpable despair over early injury that might have brought them into therapy. But hurts will have their place and, unless they do, therapy is unlikely to resolve them. A therapy group that reveals and contains injury will be one capable of resolving it. A therapy that cannot allow the negative will likely be working in a superficial way and can easily stumble from the one ‘false solution’ of facile optimism into the other ‘false solution’ of the anti-group, where the group itself can then become mis-regarded as a primary source of people’s difficulties. Transference that is of striking importance for its positive or negative features is described in most of the vignettes, and no purpose would be served by identifying particular cases, as all the vignettes serve as illustrations. Transference in structure, process and content Relationships among the individual member of a group, the conductor and the group as a whole give a wide context to the place of transference. The structural picture taken from Chapter 9 can be integrated with transference as it arises in a group’s process dynamics in Chapter 10 and with the transference emerging in the content of free-floating discussion in Chapter 11. It includes both the vertical form of transference to the conductor as a transferential mother or father and its horizontal form in which relations with fellow group members are affected by dynamics arising out of real or imagined sibling relations. In the projective domain distortions of perception and understanding, free-floating affect and unconscious fears and anxieties emerge in the process dynamics and will have vital bearing on all aspects of a group’s life. And, as will be explored in Chapters 15 to 19, links between the projective and primordial domains are always there to be discovered as they affect, and are affected by, the symbolic and narrative content of the exchange and in the transference of whole-object relations. There is then the transference of the group as a whole in its relationship with the conductor and – with the conductor – in its bearing on the emotional life of each of its members. Transference in monologue, dialogue and discourse We could also consider an approach to transference that would move it away from individualised considerations to focus on process dynamics by using monologue, dialogue and discourse as organising terms, following the analysis given in Chapter 4. Transference and countertransference could be considered as they arise and are worked with in each of these primary forms of communication. The catalogue of vignettes running through the text could all be explored in terms of just how transference arises through monologue, in some cases, and in others through dialogue and discourse. There is no such study currently available, and it is to be hoped that this will be taken up in the field.

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Transference and countertransference in group-analytic practice – illustrations The vignettes introduced here illustrate those aspects of transference and countertransference that call for special consideration. The first of the vignettes that follow, Vignette 14.2, gives a rounded picture of transference in both its vertical and horizontal forms as it arises with the conductor and between individuals and shows the conductor at work locating the group’s immediate disturbance, translating the disturbance into the language of the common zone and providing a developmental understanding through an interpretation that links the past, the present and the world outside the group. She does this by using the language of the group itself. The next two vignettes, Vignettes 14.3 and 14.4, illustrate positive and negative transference at work in a group and describe the ‘simple’ form of vertical transference that arises between one member in each case and the conductor, illustrated in both their positive and negative aspects. Positive and negative transference are described in different groups run by the same conductor at a difficult point in his life. In the first case positive transference sees the group through difficulty and leads to a good therapeutic outcome with reparative consequences for the group as a whole. In the second case, negative transference leads to the departure of a member from an otherwise therapeutic group. Vignette 14.5 describes horizontal transference between two members whose sense of alliance as ‘good sisters’ in a positive transference was interrupted by changes in the group that left them counter-posed against each other. The ensuing negative transference, with its origins in their respectively troubled relationships with their real sisters, generated a new figuration for the group that struggled with their tensions for some months before creating a finally reparative outcome as the benevolence of their bond was restored. The last vignette of this series, Vignette 14.6, gives another rounded picture in conclusion with transference arising in both its vertical and horizontal forms. It serves as a model for the self-contained position of the conductor at a ‘decrescendo’ point in the life of a mature group where we see ‘psychotherapy in the group, of the group, including the conductor’. Location, translation and interpretation of complex vertical and horizontal transference Vignette 14.2  Who took my place and when was it taken? Location, translation and interpretation of vertical and horizontal transference

A psychotherapist in supervision described her group at a critical point in its life of many years. Several long-standing members were leaving appropriately, one newcomer had just arrived and two further members were due to join after the others left. The inevitable emotional turbulence affected everyone including the conductor and

14  Lost or found in the transference?  379

became a background consideration as one of its members took the foreground. Tamara had previously been the group’s newest arrival and was insecure and sensitive to processes of arrival and departure. Her discrediting and hostile comments were expressed through negative transference against the conductor, with whom there had previously been a good alliance. People knew her history involved a tragic displacement when her mother developed multiple sclerosis during her first year, became bed-bound for several years following and then died. Her father re-married the woman he had relied on for the care of his two daughters and, just one year after the mother’s death, they married and had another child together. Their new-found happiness was extended to the father’s first two children, but at each threshold event in the life that Tamara went on to lead – going to nursery, starting at school and seeing her siblings pass through these stages – she became antagonistic and hostile, as she was in the group. She was a successful school teacher who worked with children and had a degree of self-awareness that allowed her see her own adjustment reactions as situational and governed by a history she had not yet understood or come to terms with. In the charged climate of the group’s transition, she ‘seized on’ one of the chairs, for which she made an exclusive claim. When one of the other women – Karen – sat on it inadvertently, Tamara attacked her on aggressive terms for ‘taking her place’. Karen was startled by the aggression, showed her distress, apologised profusely and returned ‘her’ chair. The conductor challenged Tamara both because of her aggression and because the group did not have a defined protocol about seating privilege. The conductor’s intervention is framed here at the current level and was – wisely – framed to safeguard internal boundaries for the well-being of the group as a whole. But Tamara’s indignation on being so challenged then led to weeks of spoiling behaviour in which she made envious attacks on anyone who had anything if she did not, and she seemed determined to discredit the conductor. The situation was finally understood and engaged with, but only once the conductor was able to pick out the phrase ‘you’ve taken my place’, hold on to it, frame it and then reframe it in the transference in order to later say, ‘Of course you’re angry. Most people reach the age of 5 facing their first challenge of leaving home for school. By then you already had four tragedies in your history – your mother’s illness, then her death, your father’s remarriage and then your baby sister. Each one took your place. It’s hardly surprising you should be upset when it looks like Karen’s ‘taking your place’. We have your history alive

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for us in the room now. You lost your place four times over before you were five. And perhaps I’m a safe person to receive the anger you originally felt with both your mothers and your father, because you know I can see you through. You do have a place of security amongst us now’. The relief was palpable for the group as a whole, for the conductor and most of all for Tamara, who sat with it silently in tears for the rest of the session.

Commentary Other members who had found it uncomfortable to own or acknowledge their own insecurities and anger did so by open identification with Tamara, and she was seen to have served the group as a whole, acting as its litmus paper for the many insecurities introduced to the process dynamics by the challenges brought to its structure as its membership shifted.

Positive vertical and complex transference Vignette 14.3  A group dream of Grandfather wearing the conductor’s face: Positive vertical and complex transference

When Peter first joined the group he was part of a developing current in which its membership rose from four to six and then seven. There was a high level of trust and a sense of gathering strength in which people worked together on terms that were both cohesive and coherent. The depth of understanding in their exchanges was matched by steady progress in people’s personal development outside. Peter had been in the group for some time when the conductor went through a stressful period. The conductor’s difficulty – visible in his unusual degree of tiredness – seemed to call into question the group’s sense of purpose and progress. However, these anxieties had no voice or expression and remained unspoken. Peter brought a dream to the group in which his much-loved grandfather was lying on a sick bed and, as he turned to face Peter, it was clear he had the conductor’s face. There were no verbal exchanges, just a glance and sincere eye contact. Peter was moved as he recounted the dream, he puzzled over its significance and he called for people’s help with its meaning, looking directly to the conductor as he did so. He had

14  Lost or found in the transference?  381

been one of the more engaged of the group’s members since he joined. People knew him well and were aware that the conductor’s physical resemblance to his long-dead grandfather played a part when he chose him for his therapy and joined this group. It is most fruitful when the group does the work, even when dreams like this are laden with transferential meaning. People explored how Peter’s identification with the conductor was manifest in the dream, forged by his unconscious mind, in which the face of his conductor was fused with the body of his grandfather. They took up how the dream brought to the group Peter’s heightened sense of regard for the conductor based on what they knew about his own sense of equivalence between these two cherished figures. They knew that his grandfather stood in for much that privation had left him without, as his own parents had not provided reliable attachment or security.

Commentary For some sessions this dream became a focus for the group’s work. On finding in the conductor a symbolic equivalent to his grandfather, Peter was able to work at his development through the transference in the group in which he was later able to resolve many long-outstanding issues. The dream’s wider significance shaped the common zone and helped give location to the group’s sources of anxiety. The work of therapy was to translate the unconscious communication of anxiety from the symbolic form of the dream into a language that all could understand in the common zone of shared experience as described in Vignettes 4.4 and 4.5.

Vignette 14.1  Continued The group had come to know Peter’s history through different narrative episodes. When he left secondary school he was due to move in with this grandfather, who was the only family figure whom he could look up to. He was looking forward to living with him whilst attending university. The grandfather had been a Holocaust survivor and, though he re-established himself after WWII and raised a family successfully, his later years were spent in

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poor health. He died unexpectedly, without warning, and partly as a consequence, Peter, who was on the verge of moving in with him, never made it to university. Without the home his grandfather could have provided and without his backing, he could not succeed at entry exams that he attempted several times. By the time he joined the group he was living through repeating cycles of early disturbance carried over from childhood into his adult life in which self-sabotaging anxiety undid his attempts to move forward. But he did succeed in finding his way to therapy, and he was now making real and significant progress that included a good beginning in a new psychotherapy training.

Commentary The transference interpretation given to the dream came from the group in which the conductor played a key but not exclusive part. It did not come at once, and the focus for its delivery was more in the nature of a construction that served to locate the group’s underlying disturbance. These were not ‘words of wisdom from on high’. The conductor took up the dream as an indication of Peter’s concern about the conductor’s own well-being and offered this construction to the group, suggesting there was a worry expressed by the dream, and shared by the others, that the challenge of seeing the group thrive might be too much for the conductor. He suggested the dream indicated a shared worry that the conductor might perish with the job barely begun, as happened to Peter’s grandfather. Once equipped with these sources of understanding, other members were able to come forward with fears and misgivings of their own, both about the process of therapy and about the conductor, that they had not been able to articulate before. The value given to the dream for the imagery it provided, which was then brought to bear on immediate relationships in the room, follows closely Friedman’s Three Uses of Dreams in Group Psychotherapy, where their ultimate use serves transformative purposes addressed to the content and process dynamics of relationships in the room. With these profound worries and misgivings brought openly into the transference the group went on to see its members flourish in their development (Friedman 2011).

14  Lost or found in the transference?  383

Disillusionment: Negative vertical transference

Vignette 14.4  Disillusionment: Negative vertical transference

Gillian joined a stable, long-standing group with seven members and soon found a place for herself amongst them. They learnt that she was the only daughter of two distinguished academics who brought their scientific disposition to bear on her upbringing, giving her admiration but little affection. Everything in her upbringing – including emotions – was measured and nothing was free or spontaneous. She qualified as a doctor and became a respected pathologist, carrying the family tradition for scrutiny, but lived with no close friendship and well into her 40s had no intimacy. When she developed an orthopaedic problem in her hand she was seen by a hand surgeon and – as she sat beside him whilst he held her hand – she fell in love with him. The hand problem was treated, but she lost her heart to this other doctor and plied him with so much importuning correspondence afterwards that he was forced to break off all contact. She became depressed for the first time in her life, found her way to a therapist, joined his group, and for a period of infatuation she engaged enthusiastically with others in a quick but uncertain form of identification. The group had the same conductor described in Vignette 14.3 and was run in parallel with this other group in which positive transference saw people through the conductor’s own difficult period. Members there were carried by their own buoyancy, by fellow feelings of trust and by a sense of safety already engendered through good past experience. In this group Gillian had a hasty and over-identified ‘romance’ with the conductor in the group and then became convinced that he was ‘second rate’ like her father, whom she discovered to have ‘feet of clay’ when she learnt of his poor scientific performance. She had set her sights on finding a therapist who was ‘an outstanding alpha male’, as she put it, who could help set her on her feet as a woman. And here she was with a man who even drifted off to sleep in the room during the group just like her father used to do when she went home. She no longer went home as she couldn’t bear to see his inadequacies, and she came to feel the same way about the conductor. Her sense of disillusionment became an increasingly hostile form of negative transference in which she constantly held up to the conductor her own pictures of his inadequacies. His receptivity, analytic understanding and continuing kindness and the close, supportive

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contact provided by other group members busy with their own work, to good and visible effect that she refused to see, did nothing to allay her concerns. Not even the positive transference towards the conductor from others in the group nor the resonance of identifying emotion that might have served as an antidote to her own developing negative transference seemed to have any effect. Gillian hesitated in her backtracking withdrawal when the construction put on her behaviour by the conductor and other group members was that she was punishing the conductor for her father’s inadequacies. This led her to withdraw her notice to leave, and she remained in the group for some further time.

Commentary The full force of Gillian’s negative therapeutic reaction had a contaminating effect on the group that was driven to increasingly extreme forms of defence. Some members blamed her for her intransigence, and others blamed the conductor either for bringing her in or for failing to meet her demands. She wanted what she called ‘quantitative measures’ that could be calibrated to demonstrate progress. She became known, rather critically, as ‘the quantitative measure’, and people first scapegoated her and then withdrew. When the ‘quantitative measures’ were not forthcoming she left the group for a course of cognitive behaviour therapy elsewhere. Unfortunately this was sustained for only a few months and was then also left behind as she continued her search. The group was left with an uneasy sense of relief that did not change until the arrival of newcomers created a new climate.

Changing horizontal transference Vignette 14.5  Good sisters, bad sisters and good sisters again: Changing horizontal transference

Allison and Fiona had been in productive group therapy for some time when the conductor announced he would be moving the group to a different location. It was an early-morning group, and the new address posed a problem for some of its members, so, after a period of discussion, the time was adjusted to make attendance easier. One of the

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women came by underground and the other by car. They agreed that the driver would collect the other one off the train, together with anyone else who came out then, and bring them on the short ride to the consulting room. But the arrangement proved difficult. It served these two only, and one would inevitably arrive before the other. Despite their best efforts the plan ended up making them both late. They would come into the group together feeling self-conscious about themselves and irritated with each other. They each had a younger sister in their families of origin who had a favoured position, and both carried feelings of injury about these younger sisters who had displaced them. Before the move sibling issues were reported on and complained about as matters that belonged to life outside the group, but there was no evidence inside it of any sibling transference. One morning as they settled down 15 minutes late Allison challenged Fiona’s poor timekeeping. Allison came out of the underground, couldn’t see Fiona’s car anywhere and didn’t know whether to wait or walk. When Fiona eventually arrived she was ‘all smiles and no apology’ and behaved ‘like a girl who could do no wrong’ even when she was in the wrong. Fiona’s reply, aggravated by her self-consciousness and sense of shame, challenged Allison for keeping her waiting many times in the recent past. This went on for some time, drawing out comments of different kinds from the others and, despite the group’s best endeavours, they began to antagonise each other when either one spoke. Their pairing had been broken and neither could do anything right in the other’s eyes. Some weeks later the lift arrangement was suspended and they began to arrive separately and at different times but – unlike the earlier arrangement – within a reasonable margin. The later one would take a challenge from the earlier one, but as often as not the roles were reversed. As the attendance pattern was steadily corrected the hostile temperature between them mounted. Their respective life patterns at home were difficult and troubled. One had a difficult marriage that the other said she would find unacceptable. The other had a difficult career that the other said she would find unacceptable. They each saw the other living out terms of life they themselves could not tolerate, but instead of the compassion and understanding they once gave each other, they were now hostile. Eventually, some months into this standoff, one of the others was able to capture with some humour how closely each one looked to the other’s faults in order to find and name them. Neither of the two caught up in what had become a malignant mirroring were able to respond to the group’s humour until Allison said to Fiona, ‘I’ve got a sister just like you. Even when she’s in the wrong she behaves like a girl who can do no wrong and everyone loves her’. In the silence that followed

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one of the others said, ‘Just say that again. Say it again so you can hear yourself. Did you hear yourself? Fiona’s become your bad sister. It’s not her you’re shouting at!’ Others joined the exchange, and people fell over each other to join the discourse. Eventually it had both women in tears that turned to laughter. In the sessions that followed they were both relieved to have the other one back again and to have understood something shaming about just how ‘constructed’ their bad sister was – and how much a product of their hostile projections. They were both relieved to discover just how important they were to each other. The pairing in this hostile dialogue was later understood to hold essential features of their troubled sisterhood outside. The emerging bond that matured between them allowed each to respect the other’s differences and stand by their friendship. When one said, ‘I wouldn’t like to have your sister’, the other replied, ‘I wouldn’t like to be your sister’, and everyone laughed.

Commentary The jealous anxiety about sisters’ privilege and the enmity this led to were transferred from their past and from the current the world outside the group, into the arena of its immediate exchange. Here their antipathy became a problem for everyone and, held amongst people who witnessed it in the circle, it became a matter for curiosity and humour that eventually allowed both women to laugh at themselves rather than antagonise each other.

Psychotherapy in the group, of the group, including the conductor

Vignette 14.6  Dreaming together about the conductor wearing her apron and withholding delicious soup

A colleague reported this vignette to me exactly as it took place some years ago. She is a senior psychotherapist in the field and was conducting this group in her private practice. At the time it was comprised of seven members who were making good progress working together in ways that brought all four levels of the group into play.

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The vignette arises out of a group dream that one of them brought in. Jacob – the dreamer – is now at a stage in his own development in which he is much appreciated by the group as someone who gets to the essence of what goes on. In the language of this group he can be relied on ‘to be in touch’. He brings a dream to the group halfway through the session. He tells the group that ‘I had a dream about us – I’m sure it was the group. There is a long, well-scrubbed wooden table outside the house; it is warm and there is a hum of insects. I sit at the table on a wooden chair and wait for dinner. There are others with me on wooden chairs. All the chairs are full and we all wait. Then you [he points to the conductor] come through the kitchen door with a tray. You have an apron on and you carry a tray with bowls of steaming soup. It smells lovely, there is one bowl for each of us, but you don’t dish them out. You put the tray down at the head of the table and you expect us to help ourselves. You say, “That’s it, that is the last time I cook for you”. You turn round and go back into the house and I wake up’. There is intense interest in the group. Jacob the dreamer turns to me and says with a challenge and anger in his voice, ‘What makes you think we can feed ourselves? You had better make sure we can . . .’ A woman says, ‘I don’t usually eat soup . . . it’s kid’s stuff . . . though she [her mother] always said that a good thick soup is very nourishing . . . and easily digestible . . . better than sandwiches . . . but I always got sandwiches for school . . . they say Kennedy [JFK] always ate soup when he was tired’ . . . A young man says, ‘And look what happened to him . . .!’ There is laughter that quickly dies down. Two group members talk about the sort of meals they had as children. One says he ate alone in the kitchen straight after school. Another describes happy family meals with parents and siblings until his mother died suddenly ‘and then all was gone, meals and all’. He gets tearful but bites back the tears. Jacob turns to me again and says, ‘Look what you’ve done!’ Then he becomes thoughtful and remembers that the table in the dream was like the table in the country he came from – South Africa – where they often ate outdoors. He describes a Christmas table laid outside, a jolly celebration. He speaks with great longing for those far-away days. His family emigrated to the UK, and Jacob never again felt he had a home. The enormity of this loss was picked up by the other member who had lost his mother and who had said, ‘all was gone, meals and all’. For a time people’s different memories of past losses resonate with one another until a member who finds it hard to bear psychic pain in others turns to the conductor and says, ‘You have been withholding

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of late, very different from before. The question is whether you’ve have had enough of us. I mean, what makes you think we are ready to do it all by ourselves? Sometimes I am fed up with the so-called care you give us, and then I sometimes think it is good for us, the right nourishment’. And then someone else says, ‘There is a difference between Alcoholics Anonymous and a therapy group’. Turning to me she says, ‘I don’t want therapy stuffed down my throat, but I do want help and that’s what you are here for, that’s what we pay you for’.

Commentary The group dreams together and no interpretation is given. We can see the interplay between group content, which includes the conductor; group transference; individual transference; and associations which lead straight to the dreamer’s childhood via the childhood associations of other group members. We can also note changes in the group matrix from a regressed mother-bound state through a painful weaning towards a greater degree of group and individual autonomy and psychic responsibility, which is both desired and feared.

An account from another mature group concludes this chapter. One year earlier members had been preoccupied by their mothers’ injuries and fathers’ neglect, which were commented on by lines from Larkin’s poem They fuck you up, your mum and dad. One of its newest members, a man who spent his first months in the group sitting through others’ narratives as an acute observer but with little to say, became increasingly articulate. His marriage had broken up at the same time as the company he created crashed. On arrival he was not only depressed but shocked by the gravity of his losses. As time saw him benefit we learnt of the support he enjoyed from his own good mother. The group’s preoccupations with hurtful histories brought him forward to comment on the Larkin poem, which he knew. He recounted Adrian Mitchell’s alternative version which startled us, not only because of its content but because its spontaneous recitation marked the first change in his outlook. He had become known as the crumpled heap sitting in the corner and, with the poem, he became the spokesman for

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good parents. This resilience would see him out of the group in time to come. The contrasting tone of the two poems stands as a commentary on progress in the emotional tone or climate of a group that can move the transference into a reparative dimension. Philip Larkin This Be the Verse They fuck you up, your mum and dad,     They may not mean to, but they do. They fill you with the faults they had     And add some extra, just for you. But they were fucked up in their turn     By fools in old style hats and coats, Who half the time were soppy-stern     And half at one another’s throats. Man hands on misery to man.     It deepens like a coastal shelf. Get out as early as you can,     And don’t have any kids yourself. Adrian Mitchell This Be the Worst (after hearing that some sweet innocent thought that Philip Larkin must have written: ‘They tuck you up, your mum and dad’) They tuck you up, your mum and dad, They read you Peter Rabbit, too. They give you all the treats they had And add some extra, just for you. They were tucked up when they were small, (Pink perfume, blue tobacco-smoke), By those whose kiss healed any fall, Whose laughter doubled any joke. Man hands on happiness to man, It deepens like a coastal shelf. So love your parents all you can And have some cheerful kids yourself.

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Note 1 There is an extended discussion of one-body, two-body and three-body psychology in Chapter 4, where the terms, drawn from the writing of John Rickman, are defined and discussed.

Bibliography Alexander, F., and French, T. M. (1946). Psychoanalytic Therapy. New York, Ronald Press. Anthony, E. J. (1978). The Group-Analytic Circle and Its Ambient Network: 2nd Foulkes Lecture. In Group Analysis 11 (Supplement 1): 1–18. http://gaq.sagepub.com/content/11/2/ S1.citation. In M. Pines (Ed.), (1983), The Evolution of Group Analysis. London, Routledge. Reissued 2000, London, Jessica Kingsley, pp. 29–53. Balint, M. (1933). On Transference of Emotions. Budapest, Gyogyaszat. Reissued in Primary Love and Psychoanalytic Technique. London, Hogarth Press 1952. Reprinted by Maresfield Library, London 1985, pp. 174–187. Balint, M. (1939). On Transference and Counter-Transference. International Journal of Psycho-analysis 20: 223–230. Reissued in Primary Love and Psychoanalytic Technique. London, Hogarth Press 1952. Reprinted by Maresfield Library, London 1985, pp. 213–221. Balint, M. (1950). Changing Therapeutical Aims and Techniques in Psychoanalysis. International Journal of Psycho-analysis 31: 117–124. Reissued in Primary Love and Psychoanalytic Technique. London, Hogarth Press 1952. Reprinted by Maresfield Library, London 1985, pp. 221–235. Bollas, C. (1987). The Shadow of the Object: Psychoanalysis of the Unthought Known. London, Free Associations Press. Bollas, C. (1990). Creativity and Psychoanalysis. In C. Bollas, The Mystery of Things. London, Routledge, pp. 167–180. Reissued in M. Gerard Fromm (Ed.), The Spirit That Impels: Play Creativity and Psychoanalysis. London, Karnac, pp. 3–20. Bollas, C. (1993). Being a Character: Psychoanalysis and Self Experience. London, Routledge. Bowlby, J. (1977). The Making and Breaking of Affectional Bonds. British Journal of Psychiatry 130: 201–210; 421–431. Reissued in J. Bowlby, (1979; 1989). The Making and Breaking of Affectional Bonds. London, Tavistock and Routledge, pp. 150–187. Cashdan, S. (1989). Object Relations Therapy: Using the Relationship. New York, Norton. Dalal, F. (2000). Taking the Group Seriously: Towards A Post-Foulksian Group-Analytic Theory. London, Jessica Kingsley. Epstein, L., and Feiner, A. H. (1979). Countertransference. New York, Jason Aaronson. Faulkner, W. (1950). Requiem for a Nun. New York, Random House, Inc. Foulkes, S. H. (1948; reissued 1983). Introduction to Group-Analytic Psychotherapy. London, Karnac Classics. Foulkes, S. H. (1964; reissued 1986). Therapeutic Group Analysis. London, Karnac. Foulkes, S. H. (1975; reissued 1986). Group Analytic Psychotherapy: Method and Principles. London, Karnac. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Freud, A. (1937). The Ego and the Mechanisms of Defense. The International Psycho-analytical Library, No. 30.). London, Hogarth Press.

14  Lost or found in the transference?  391 Freud, S. (1912). The Dynamics of Transference. Standard Edition 12, London, Hogarth Press. Friedman, R. (2008). Dreamtelling as a Request for Containment: Three Uses of Dreams in Groups. International Journal of Group Psychotherapy 53 (3): 327–344. Friedman, R. (2011). Dreams and Dreamtelling: A Group Approach. In J. Kleinberg (Ed.), Wiley Blackwell Handbook of Group Psychotherapy. Chichester, Wiley, pp. 479–497. Frosh, S. (2002). Key Concepts in Psychoanalysis. London, Palgrave/Macmillan. Frosh, S. (2006). For and Against Psychoanalysis. London, Routledge. Frosh, S. (2010). Psychoanalysis Outside the Clinic. London, Palgrave/Macmillan. Frosh, S. (2012). A Brief Introduction to Psychoanalytic Theory. London, Palgrave/ Macmillan. Gordon, J., and Kirtchuk, G. (Eds.). (2009). Psychic Assaults and Frightened Clinicians: Countertransference in Forensic Settings. Forensic Psychotherapy Monograph Series. London, Karnac Books. Grotjahn, M. (1983). Basic Concepts of Group Psychotherapy. In M. Grotjahn, F. Kline and C. Friedman (Eds.), (1983), Handbook of Group Therapy. New York, Van Nostrand, pp. 3–7. Heimann, P. (1950). On Countertransference. International Journal of Psychoanalysis 31: 81–84. Reissued in R. Langs (Ed.), Classics in Psychoanalytic Technique. New York, Jason Aaronson, pp. 139–142. King, P., and Steiner, R. (Eds.). (1992). The Freud-Klein Controversies 1941–45. London, Routledge. Konig, K. (1991a). Group-analytic interpretations: Individual and group. Descriptive and metaphoric. Group Analysis 24 (2): 111–115. Konig, K. (1991b). Projective identification: Transference type and defence type. Group Analysis 33 (2): 323–331. Larkin, P. (2003). “This Be the Verse” from Collected Poems. London, Faber & Faber. Levens, M. (2011). Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation. MSc dissertation. Institute of Group Analysis, London/ Birkbeck College, University of London. Mitchell, A. (2012). ‘This Be the Worse’ from Come On Everybody: Poems 1953–2008. Hexham, Northumberland, Bloodaxe Books. Nitsun, M. (1995). The Anti-Group. London, Routledge. Nitzgen, D. (2008). 33rd S. H. Foulkes Annual Lecture: The Group Analytic Movement Sixty Years On: Revisiting Introduction to Group Analytic Psychotherapy by S. H. Foulkes. Group Analysis 41 (4): 325–346. Ogden, T. (1992). Projective Identification and Psycho-therapeutic Technique. London, Maresfield. Ogden, T. H. (1993). The Analytic Management and Interpretation of Projective Identification. In A. Alexandris and V. Grigoris (Eds.), Counter-Transference: Theory, Technique, Teaching. London, Karnac Books. Rafaelson, L. (1996). Projections, Where Do They Go? 19th Foulkes Lecture. Group Analysis, 29 (2): 143–158. Rickman, J. (1950). The Factor of Number in Individual and Group Dynamics. In J. Rickman (1957), Selected Contributions to Psycho-Analysis. London, Hogarth Press, pp. 165–169. Rogers, C. (1987). On Putting It Into Words: The Balance Between Projective Identification and Dialogue in the Group. Group Analysis 20 (2): 99–107.

392  III  The dynamics of change Sandler, J., Dare, C., Holder, A., and Dreher, A. (1992). The Patient and the Analyst: The Basis of the Psychoanalytic Process. London, Karnac. Scheidlinger, S. (1982). Focus on Group Psychotherapy: Clinical Essays. New York, International Universities Press. Spillius, E., and O’Shaughnessy E. (2012). Projective Identification: The Fate of a Concept. London, Routledge. Strachey, J. (1934). The Nature of the Therapeutic Action of Psychoanalysis. International Journal of Psychoanalysis. 15: 127–159. Reissued in R. Langs (Ed.), Classics in Psychoanalytic Technique. New York 1990, Jason Aaronson, pp. 321–338. Sutherland, J. D. (1980). The British Object Relations Theorists: Balint, Winnicott, Fairbairn, Guntrip. Journal APA 28 Part 4: 829–859. Temple, N. (1996). Transference and Countertransference: General and Forensic Aspects. In C. Cordess and M. Cox (Eds.), Crime, Psychodynamics and the Offender Patient. London, Jessica Kingsley Press, pp. 23–39. Weegman, M. (2014). The World Within the Group: Developing Theory for Group Analysis. London, Karnac. Whitman, W. (1958). ‘There Was a Child Went Forth’. In Leaves of Grass. New York, Signet Classic, pp. 290–291. Winnicott, D. (1951). Transitional Objects and Transitional Phenomena. In Through Paediatrics to Psycho-Analysis. London, Hogarth Press, pp. 229–242. Winnicott, D. (1958, 1975). Through Paediatrics to Psycho-Analysis. London, Hogarth Press. Winnicott, D. (1965, 1985). The Maturational Process and the Facilitating Environment. London, Hogarth Press. Yalom, I., and Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy 5th Edition. New York, Basic Books.

Acknowledgements: Extract from ‘Requiem for a Nun’ by William Faulkner, copyright © 1950, 1951 by William Faulkner. Used by permission of Random House, an imprint and division of Random House LLC. All rights reserved; extract from Walt Whitman, ‘There Was a Child Went Forth’ from Leaves of Grass, Philadelphia: David McKay, [©1900]; reproduced with permission from Bartleby.com, 1999, www.bar tleby.com/142/; extracts from Bollas (1987), The Shadow of the Object: Psychoanalysis of the Unthought Known, reproduced with permission from Christopher Bollas; Philip Larkin, ‘This Be the Verse’, from Collected Poems, used by permission of Faber and Faber and Farrar, Straus & Giroux; Adrian Mitchell, ‘This Be the Verse’, used by permission of United Agents on behalf of the estate of the late Adrian Mitchell.

Chapter 15

Longing and belonging in the intermediate territory

Transitional phenomena have become diffused . . . spread out over the whole intermediate territory between ‘inner psychic reality’ and ‘the external world as perceived by two persons in common’, that is to say, over the whole cultural field. . . . My subject widens out into that of play, and of artistic creativity and appreciation, and of religious feeling, and of dreaming, and also of fetishism, lying and stealing, the origin and loss of affectionate feeling, drug addiction, the talisman of obsessional rituals. (Winnicott 1951/1978:229–242) Central to my thesis is that early pre-verbal experience, which I suggest remains throughout, is not overlooked and disguised or distorted by premature post-oedipal translation. This entails an acceptance of that which has no words. Winnicott’s concept of a ‘holding environment’ goes some way to address this, as does the recognition of bodily and feeling states which words cannot fully capture. (Mary Levens 2011:36)

The key issues of holding, containment and play are explored here as they arise in therapy groups.1 In the group-analytic model play is a key to the work, for it is done through free-floating discussion. Through its play with words and the play of experience that may have no words, a group can provide both an arena for containment and a platform for exploration. The interplay between the thematic terms longing and belonging will be used here as registers to explore a group’s prevailing affect. These terms have their origins in Winnicott’s understanding of the infant’s mother both as his first object and as his original environment (Winnicott 1963). A  group can represent either or both of these figures  – object or environment – at any point in its progress. It can provide a containing environment for its members (James 1994), and it can also become or provide the object(s) of their desire (Nitsun 2006). There is a flux of movement between silent and active exchange and between narrative – the recounting of stories about the past or outside world – and the drama of the moment. This can allow the shifting focus to explore existential

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anxieties and help locate the emptiness in a group’s circle of associations – what Wilson calls the whole in the middle of the group – where it can address its members’ individual fears about ‘touching the void’ (Wilson 2005). Group defences are often organised around primary but unstated and deeply hidden, unconscious anxieties that must ‘seemingly’ be avoided. These anxieties include the absence of meaning within the self, the absence of a self within the person, the fear of being found by another, the fear of never being found by another, the fear of never being found acceptable by another and many more. They underlie the issues people face in the vignettes that follow. The chapter takes up a developmental moment in a child’s play illustrated by the first vignette and then traces the work of group therapy through three further vignettes, concentrating in the second on how an individual’s confusion between longing and belonging underlies a serious character problem that enjoys an opening sense of reparation at a key moment, early in his therapy. It looks in the third vignette at how a person’s underlying sense of homelessness – of living with neither longing nor belonging – can be aggravated by life events that call on the group to provide a kind of psychic skin – an auxiliary ego – until the lost person can re-integrate. She finally does so by proffering the holding that another person needs at a critical moment, and it follows the progress of these individuals through the group over time. It looks in the fourth vignette at how a large group can capture an acute, underlying sense of grievance in the homeless mind, and it explores how this can enjoy reparation in a moment of reprieve.

Longing and belonging The terms longing and belonging generate by association a series of complementary titles that have a similar interplay or dialectic and hold a kind of emblematic significance. They include ‘eros and attachment’, ‘love and security’, ‘intimacy and identity’ and ‘desire and equilibrium’. No one is a stranger to the language of longing and belonging. As well as vignettes from small and large groups this chapter will explore historical source material and the cultural field that includes poetry and music. Therapeutic use of metaphor will be explored more fully in the next chapter’s study of metaphors and metamorphosis. Here I will look at the mutative agency of metaphors to see how they arise from the symbolic register acquired in the first use of language illustrated by Vignette 15.1. Symbolic language helps us distinguish between the real, the constructed and the representational in our cultural life. This is a similar set of distinctions to those opened up in Chapter 5, and I will call on them to help clarify how, when psychotherapy works to change people, it involves experience that is constructive, de-constructive and re-constructive. When we move beyond the real, when we go into the representational domain to involve ourselves in the de-construction and re-construction of other people’s lives, we invoke an order of symbolic and metaphorical experience that has its origins in their earliest states of longing and belonging. In order to work therapeutically with these states, group therapy does

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not necessarily require the kind of long regression involved in psychoanalysis. Successful work with the child hidden in the person does not require of the person that they become a child in therapy. Usandivaras opened an excellent discussion of the subject of regression in group analysis in a fine study, but unfortunately it was a long time ago and the creative promise of his contributions was interrupted by an early death (Usandivaras 1989). Nitsun has an important contribution on the subject (1988) and these issues call for current attention. The earliest symbols continue to inform the most evolved and sophisticated. They can be reached and re-shaped by work done in the here and now and can help to re-shape the basics so members can grow out of a ‘false self’ – out of what can also be described as parataxic distortions – and so find authenticity and a truthfulness of self. We construct our first pictures of the world through experience like that of the little boy at play in Vignette 15.1. It allows us to consider how we ‘step into and out of one another’s first pictures’ for the rest of our lives. The image of people who step into and out of each other’s pictures will be used to look at the work of a therapy group following someone’s dreamtelling as the group plays with the ensuing associations in Vignette 15.2. Different levels of meaning – between the constructed and representational worlds – are played with in the group as it struggles with congruence and conflict between different people’s attachment styles as they relate to one another in the room (Glenn 1987). The therapeutic arena is set by counter-balancing congruence and conflict. If there is only congruence in a group then it can ‘bed down’ as a refuge or asylum that may be a necessary resource for the fragile, the psychotic or the traumatised. The work may be highly effective as a supportive rather than dynamic form of psychotherapy. If there is only conflict in a group then the anti-group consequences can lead to implosion, splitting or premature departure. Successful dynamic group therapy arises out of the struggle that every group lives through – and which it is the conductor’s duty to maintain – of balancing congruence and conflict.

Play, creativity, religious feeling, dreaming, fetish, lying, stealing, origin and loss of affection Winnicott lists some of the special qualities that derive from an infant’s transitional objects. He goes on to describe how this object’s fate ‘Is to be gradually allowed to be decathected, so that in the course of years it becomes not so much forgotten as relegated to limbo . . . it does not “go inside” nor does the feeling about it necessarily undergo repression’ (1978:233). During therapy the group’s symbolic register is generated from the world of lost meaning that was ‘diffused . . . spread out over the whole intermediate territory between “inner psychic reality” and “the external world as perceived by two persons in common” ’. What had been ‘relegated to limbo . . . is not forgotten and . . . not mourned’ but emerges in the group where it can represent its members’ ‘whole cultural field’, like Blake’s ‘world in a grain of sand’. The intermediate territory generated by the group allows us to explore the subjects Winnicott points towards – ‘play . . . artistic creativity and

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appreciation . . . religious feeling . . . dreaming . . . fetishism’ and the others in his list (Winnicott 1978:233). How can fields as disparate and unrelated as these be connected? How can we relate them to the symbolic and metaphorical in psychotherapy? The representational world has its origins in the transitional phenomena arising between the infant or developing child and its mother or primary carers. I will be using the language of longing and belonging to explore some of these questions. Winnicott describes the mother or her equivalent as the person who sets the infant’s environment or the one who provides the infant with his first object. The infant develops two kinds of relationships at one and the same time – that to the environment-mother and that to the object, which becomes the objectmother. The environment mother is human, and the object-mother is a thing, although it is also the mother or part of her. (Winnicott 1963/1985:182–183) This originating distinction between the object mother and the environment mother can be called on to clarify the distinction between longing and belonging. The nature of what is sought for in a state of longing and the texture of emotions associated with this state – its evocative connotations, the kinds of neediness entailed and the way in which the state can only be requited by intimate proximity – all point to the figure of the object mother as its originating source. By contrast, the emotions associated with belonging (and with not belonging) – the need for identity and security, for a sense of place and a sense of confidence that the world can be lived in and inhabited with purpose – all point to the environment mother as the originating source of these primary emotions. Or so it may at first appear. I use Winnicott’s reference to the symbolic makeup of the cultural field and its origins in early childhood to help us look at longing and belonging. Bollas did this with a passage from Freud’s Mourning and Melancholia (1917) and created The Shadow of the Object (1987), which is further explored in Chapter 16. The connections Winnicott describes involve play and artistic creativity, religious feeling and dreaming, fetish and obsessional rituals that bring to the fore the seemingly ‘magical’ powers of the talisman. Added to this mix are the additional symbols of national and religious identity to help identify the underlying sentiments – religious or national identity – through which states of longing can come to generate a sense of belonging that can enhance or corrupt the integrity of the individual. This is the territory in which group psychotherapy operates. In Chapter 2 we saw how the work of a therapy group developed the reflective dimension out of the relational and the reparative dimension out of the reflective. The reparative dimension was seen there to include the corrective recapitulation of early family life. A small group can yield this sense of corrective recapitulation when longing is transformed into belonging. We predicate our work on the assumption that early experience of injury or suffering underlies most disorders,

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whether they are neurotic or arising in someone’s character or personality. These underlying issues can be addressed, and some of them can be resolved in group therapy.

Fractured times – the age of anxiety There are many seeking psychotherapy with needs and concerns that cannot be identified in the language of descriptive psychopathology, as Chapters  1 and 6 make clear. We live in an epoch opened by Auden’s epic poem The Age of Anxiety (Auden 1948) characterised by problems of meaning and identity recently described by Hobsbawm as Fractured Times (2013). Problems of alienation and anomie lie behind many of the other problems presented for help when people are referred to groups. In shifting the ground of this chapter’s enquiry to focus on life without longing or belonging, we are in territory most eloquently described by Berger in The Homeless Mind (Berger 1974). Here we are touching the despair of the homeless mind. Group analysts have contributed to our understanding of these issues in papers by Adlam and Scanlon (2005), Wilson (2005), Bledin (2003, 2004) and Punter (2010). Matthew Arnold anticipated this period in a poem, Dover Beach, he wrote in 1867. Chapter 5 quoted from one passage of this poem. Here is another: The sea of faith Was once, too, at the full, and round earth’s shore Lay like the folds of a bright girdle furl’d. But now I only hear Its melancholy, long, withdrawing roar, Retreating to the breath Of the night-wind down the vast edges drear And naked shingles of the world. Ah, love, let us be true To one another! for the world, which seems To lie before us like a land of dreams, So various, so beautiful, so new, Hath really neither joy, nor love, nor light, Nor certitude, nor peace, nor help for pain: And we are here as on a darkling plain Swept with confused alarms of struggle and flight, Where ignorant armies clash by night. (Arnold 2004) The redeeming quest in Arnold’s picture of the approaching modern world is the poignance of personal love. Both states, longing and belonging, govern and colour this quest. He turns to the action of the tide and sees in its retreat a metaphor for the loss of faith in the modern age. Belonging – states of mind and

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identity governed by ‘the sea of faith’ – suffers attrition in the modernity of our world. Consolation for its loss is sought in the much more private and intimate world of personal love. As he appeals to his beloved to ‘come to the window’ and enjoy ‘the sweet night air’, in the previously quoted passage, we can imagine the tenderness between them as they talk quietly and then stand in silence looking onto the French coast watching the lights. We know they have found a private world of security together as longing comes to replace belonging to provide – as it can – the last refuge against ‘the eternal note of sadness’ described in the earlier quote from this poem in Chapter 5, which is the despair of the homeless mind.

The real, the constructed and the representational There is always a vernacular in a group’s language built out of its members’ remembered and unremembered histories that is elaborated on terms that are unique for each group. Every group can generate coherence in the construction of a distinctive set of references that Elias calls figurations, which Foulkes and Anthony brought into psychotherapy (Foulkes and Anthony 1957; Elias 1979, 2009). This focus on language has a purpose that goes beyond the words themselves. All language use that is evocative or denotative – the framework of culture within Winnicott’s intermediate territory – works through idiom and metaphor. The world we inhabit is comprised of the real, the constructed and the representational. In the real world we are biological creatures who are alive now and will all one day die. In the constructed world the realities of our shared lives are built through the accretion of meaning in language that will live on through the sediment of history after we have passed away. Winnicott, Berger and Luckman are real figures in the social construction of our current reality (Berger and Luckman 1991), though none of them are alive today. Beyond this is the representational world of art and literature, the world in which we can hear the voice of the symbol, look for the holy and sacramental and discover the elevated and the significant. This is the world in which interpretation has meaning in group- and psychoanalysis. If we look at the language used in the title of this chapter, longing and belonging, we can see that the dictionary definition of longing is a yearning desire which has as its own vernacular the entire subject of love. Our cultural world is charged with its different idioms in poetry and song. In the language of ‘belonging’ we can recognise the evocative content of a different idiom. It can mean ownership or possession and can also mean identity and identification. When the players in a football stadium are about to enter a contest in the World Cup some of them sing during their national anthem and some do not, but they all know what it means to belong. They belong to their team, their country and their contest. Colours, flags and songs serve as emblems for a particular kind of belonging. ‘Longing’ and ‘belonging’ are in each case emblems of a different kind of feeling world and mood state. One is related more to affects associated with eros, love, intimacy and desire, and the other is related more to affects associated with attachment, security, identity and equilibrium. Winnicott’s differentiation between the mother

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as object and environment lies behind the differences of mood and emotional tone in the affective worlds of longing and belonging. When we couple these two terms to make longing and belonging into one, we create a union of discrete, related but contrasting affects. We create something that stands apart from each of its originating sources, and it becomes an emblem for something subtly different. Someone who lives with longing and belonging enjoys both attachment and security. Someone who lives in a world that has neither longing nor belonging suffers the desolation of the homeless mind. In Berger’s sociology he describes how the sacred is a quality realised in experience and constructed by a canopy of sacred objects and meanings to reflect the collective desires and ideals of our communities that project themselves into the personal beliefs of the individual and into all their groups. There is a relationship between institutions, their forms of work and life, and both social and inner meaning. This sacred canopy is maintained by the social order and in turn legitimates this objective social order through a consensual framework that has subjective meaning. The objective institutions of society are historicised, and the dramas of unfolding life are played out in the light of these inner sources of meaning. And where they are not, the ensuing alienation, bewilderment, fragmentation and isolation can be summed up under the heading of the homeless mind.

Four forms of play – bodies, projections, roles and words The first three forms of play: Embodiment-projection-role Embodiment-projection-role is Jennings’s developmental paradigm (EPR) charting the progression of dramatic play from birth to seven years (Jennings 1998, 1999, 2001). Its three primary components – physical or embodied play, projective play and role-play – require a fourth to make it fully useful for group analysts. This is word play that I will address below, helped by the writing of Pines, Cox, Levens, Wotton and others. The first three of these stages are turned to therapeutic effect by child psychotherapists. Anthony was a pioneer who made these stages of play available for group therapy with children, described for the first time in his 1957 book with Foulkes. The fourth form of play is word play introduced to psychoanalysis by Freud and to group analysis by Foulkes. Table 15.1 puts all four of these forms of play in a development sequence shaped by the authors who describe them. Word play and gesture: The fourth form of play Sources in anthropology, in Mead’s sociology and in the work of group analysts including Pines, Cox and Levens can be traced running alongside these stages of play. This is another developmental profile that has to do with words and meaning. A good deal of what passes between a group and its conductor takes forms that are barely ‘spoken language’. For example, someone begins to say something

Table 15.1  Four forms of play in relational life and the authors who describe them Stage

Description

Dynamics

Authors

1

Physical/ Embodied play

Experiences essential for the development of the ‘body-self’ are laid down first between mother and child.

Winnicott Jennings

2

Projective play

A child responds to the world beyond the body by relating to different people, objects and substances, ‘placed’ and composed in a variety of shapes and constellations through stories and the early objects of representational play like dolls’ houses and puppets. Graduations to this second stage arise between its early form in which transitional objects – standing for the mother – give way to a later form in which the child takes more control and plays out some of her own imaginary characters.

Winnicott Pines Jennings

3

Role play

A child takes on roles, sometimes several in a scene, with a developing sense of design for those played by its significant figures in terms of what mothers, fathers and others do and do not do. One child may play at being ‘on the beach’ surrounded by seashells and treating her cat like a fish in the water. Another may play at Harry Potter and allocate magical powers to some members of his household, withholding them from others.

Winnicott Pines Jennings

4

Word play and conversational gesture

Words function as gestures of consolation or validation that, associated with eye contact of conductor and others, and by feelings associated with words that function as gestures, crystallise the mood of the group, expressing the consolation or validation of others.

Anthropology/ sociology Malinowski Jakobsen Mead Psychoanalysis Winnicott Pines Wright Group analysis Pines Stacy Wotton Levens

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important, falters, stops and then goes silent. The groups sits with the silence and eventually the conductor looks at her and says, ‘And? . . .’ His enquiry breaks the impasse, undoes the obstacles and the person halted by narrative failure can continue with her troubled story until it develops from monologue to dialogue in the group. The interjection, ‘And? . . .’, is accompanied by the conductor’s gaze, concerned eye contact, a nod of the head and a facial gesture that serves as an invitation to continue. At the group’s next meeting in a separate and unrelated communication someone thanks the conductor for the letter he wrote to their GP. The conductor replies by saying, ‘You’re welcome’. The interjection ‘And? . . .’ and the spoken phrase, ‘You’re welcome’ are in both cases gestural communications that belong more closely to Jennings’s profile of the stages of play than to any account of the spoken word. ‘You’re welcome’ is not intended to convey the message that the hearer is welcome. Rather, it is a response to being thanked. The word ‘thank you’ acknowledges gratitude in the receipt of a benefit, and the phrase ‘You’re welcome’ acknowledges receipt of the gratitude. This is reciprocity through gesture of the spoken word but it is not syntactical language. We can take ‘thank you’, ‘you’re welcome’, ‘And?  .  .  .’, and bring them together with Winnicott’s famous ‘Say Taa’, which he draws from the example of a mother instructing her toddler to say thank you, and we can give a term to these forms of communication. When someone gives the child a biscuit her emotion of gratitude will be conveyed by ‘Taa’, not by syntax. In another example, someone comes back to a group after burying her brother who died two weeks ago. She is welcomed and in turn responds with appreciation for the place that was kept warm on her behalf. As the group settles into its proceedings through the kind of pause that often happens after people are seated and composed, it is a while before the conductor – in the absence of such direct expression from anyone else – says, ‘We’re sorry for your loss’, and then the returning woman begins to weep. The expression of sorrow by the conductor helps release emotion, but it does not rely on the syntax of the sentence. The words function as a gesture of consolation that, associated with the eye contact of the conductor and the others, and through the feeling conveyed by his words that express the consolation of others, helps crystallize the mood of the group in ways described by Levens below. The consolation expressed formally speaks for the mood of the group and allows the bereaved woman to feel held. Anthropologists know these as phatic forms of communication. Malinowski coined the term to describe how words work as gestures and his account describes all the uses above. Jakobsen, another anthropologist, revised Malinowski to describe how certain phatic words are used to describe the communication channel itself and do not furnish the content of what is passing through it. In Vignette 4.1 a man who is new to the group is spending its time on a lengthy monologue and fails to see he has lost his audience. The conductor asks, ‘Who are you talking to?’ Whilst the man insists he is talking to the group he realises in a startled way that he is talking to himself. He later comes to appreciate that he needs the group as a witnessing audience so he can hear his own words. The

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conductor here makes use of a phatic communication – according to Jakobsen – to help the individual take account of themselves. Levens, a group analyst in London, calls on her own background in the arts psychotherapies to ‘consider the place of non-verbal communication, alongside the use of words’ (Levens 2011:5). She quotes an early declaration by Foulkes in which he says, ‘I insist . . . on the essential value of verbal formulation and articulate communication for the final conclusion of the therapeutic process’ (1948:153). He says, ‘the medium through which (the therapist) works is communication through words and the ultimate aim is expression in articulate verbal language, which can be understood and shared by all’ (1948:135). She takes up a different position and says, Ultimately I propose some challenge to the primacy given to verbal articulation, whilst not wanting to dismiss or minimise Foulkes’ central theory. I will examine aspects of verbalisation, how language as a social discourse becomes personalized, and ways in which meaning is co-constructed. (Levens 2011:6) She goes on to say ‘words can be used to either express or conceal, creating intimacy or distance and may create a split in terms of lived experience as opposed to the verbalised description of that experience (when) everything (can) become once removed . . . filtered through verbal construction’ (Levens 2011:23–24). She introduces Stern’s account of words that can work like a double-edged sword that, whilst it communicates, can also isolate its users. She provides guidance for the conductor first by invoking her own metaphor that describes the language of the group as ‘a crystal with multitude of facets reflecting many functions and consequences (in which) . . . the loss of relatedness through articulation is . . . yet another consequence’ (Levens 2011:25). And then she describes a crucial link between the work of Foulkes and Cox: Foulkes attempts to convey the subtleties of what is hard to put into words, through the language of the musical metaphor.) . . . (Resonance provides) a model for the group analyst . . . approaching the complexities of language through enhanced use of metaphor. Cox discusses the problem of emphasising explanation of patient’s words (preferring to) . . . make use of empathic understanding. He describes attentiveness to the nuances, to what is not said, defying reductionism, as a way of listening to his patients with an awareness ‘so loosely tuned that its strings could detect the slightest breeze and turn it into music’. (Cox 1987:55; Levens 2011:26) She also calls on Pines’s account of language development. He says, Before language is established as the medium of communication in the child, a language of reciprocity of gestures and games has been built up between

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infant and caretaker . . . There is a gestural dialogue, a play of contingency through which the infant discovers he is an active agent . . . he is a self in relationship with another. (Pines 1998:73; Levens 2011:12) Pines builds on Mead’s description of the conversation of gesture that provides an important backdrop to the idea of calling forth a response from the other. Levens’s own area of concern with group-analytic practice is ‘the way words enter into this drama of the self in relation to the other’ (Levens 2011:12). The literature on attunement (Stern 1998) and empathy (Wright 2009) assist our understanding of what Pines describes as the earliest process of making meaning within relationships. He describes the mother as connecting: What might be random gestures with meaningful ones of her own. By being meaningful to her they become meaningful to her child and thereby to the pair. . . . this process of inserting and acquiring meaning in the mother–child dyad may be disturbed by the attitudes of the mother, according to her fantasies about her child, her own self-experience, her moods and preoccupations. (1998:70; Levens 2011:13)

Stepping in and out of other people’s pictures: Developmental theory, language acquisition and sources of meaning ‘A sleeping man’, said Freud, is not roused by an indifferent word. ‘But if called by name he wakes’ (Freud 1900:SE 4:53). Here we are in search not of names but of words holding emblematic meaning whose work can deliver people from the over-determining influences of their hidden, governing imperatives. The words longing and belonging work in this way and do so to greater effect when coupled. When and how do words first work in this way? We can follow Winnicott’s interest in transitional objects by looking now at a slightly later stage of infancy than the 8- to 12-month period in which transitional objects come into existence as the first possession. The process of symbolisation originates with the most primitive sense of self in the representational schema of the infant as he differentiates for the first time between self and other. As the representational world is extended and externalised the infant’s symbolising process is codified in a language whose semantic field is charged with forms of meaning bearing a close association to the individuals and experiences through which it originates. The way in which a child talks to itself, addresses its mother, relates to a friend, speaks to a doll or stands up to talk in the classroom can be different in each case. All these speech forms can arise in a dialogue between only two people for, as William James has said, relations are of different degrees of intimacy – merely to be with another is a universe of discourse

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(James 1902). Whilst dialogue can generate an almost limitless range of meaning, the terms of a two-person psychology act as a constraint. A group’s complexity promotes the speech form of discourse in a relational field whose dynamics in the ‘model of three’ replicate those of society. In groups the relational and semantic fields – the matrix of interaction and the matrix of meaning – come to play upon one another, giving new significance to early symbolic and representational experience. Their interplay can help revise a person’s own basic assumptions. Thus language is a form of behaviour in the group, a way of referring to experience in and beyond the group and a way of transforming experience in the group. A child acquires the first three-word phrases between 12 and 24 months. Toddlers use these rudimentary sentences to communicate, describe and represent – the representational detail is of most interest.

Vignette 15.1  Postman Pat: Stepping in and out of each other’s pictures

Let us imagine a little two-year-old boy looking at a picture book with his mother in which Postman Pat is driving his delivery van down a muddy road. As mother and child read the book about Postman Pat – they both know it well and frequently read it together – the little boy says, ‘Muddy road, muddy road, very muddy road’, and he follows the narrative as the postman drives through rain and splashes in puddles. He calls out ‘Splash, big splash’, and he laughs as he sees the water spray up in the illustration around the van. Then the postman gets out of his van, walks through the mud and gets covered in it. ‘Postman Pat muddy, very muddy’, he says, and points to the mud on the postman’s feet in the picture. In the next picture the postman is seen approaching the front door of the house where he is about to deliver a letter. There is a very prominent doormat in front of the house. The postman gets on to the mat to clean his feet and the little boy lifts up one of his own feet and puts it on the picture of the mat to clean it, too. It doesn’t work because, small as his feet are, they are out of all proportion to the illustrations. They obscure the pictures, he loses sight of what he is trying to do and he also loses his concentration. But the moment at which he tries to step into the picture is the one that captures our attention. He puts his foot – quite literally – into the representational world. The association of images tells a story that excites him. He has befriended the postman and identifies with his journey. Is he Postman Pat as he tries to step into the picture? Is this the direction of his identification? Or is he taking upon himself the postman’s good behaviour by remembering his mother’s injunctions and cleaning his own feet? Does the

15  Longing and belonging  405

postman come to him, or does he go to the postman’s world? In which direction does the mirroring work? In another account from his mother, the little boy was following a story about some chickens in a farmyard. When the story took some of the chickens to a hiding place behind a pop-up picture, he tried to crouch down behind it to hide there with them. Only when the impossibility of his attempt couldn’t be pursued did he say his name and then say, ‘Too big’. The book is serving its purpose. He is learning to tell the difference between himself and his imaginary objects.

Commentary This little boy imagines the mud on his own feet, steps into the picture to clean them and tries to cross a line that cannot be crossed. The ensuing distraction is part of what equips him to progressively differentiate between the real world, the one that is constructed and the one that is represented. There is a real mat outside the front door of his own home and he often gets really muddy; the constructs involve his mother’s concerns about him messing the floor and the importance of cleaning his feet when he comes in. The representations belong in the book.

Underlying confusion between longing and belonging We invite the members of our therapy groups to use them to learn how to differentiate between the real, the constructed and the representational in the time and space they share. Those who join our groups learn to use them as a forum to investigate their own imaginary objects and tolerate the return of the repressed as the forgotten, the dissociated and the repressed emerge from hidden locations in the unconscious (Fairbairn 1943/2002). Warren is the central character in Vignette 15.2. He struggles with what he calls his ‘fatal attraction’ for transgressive sexuality. Arousal and boundary violations have run together during his adult life and he relates to the ensuing problems as if fate had nothing else in store – he behaves as if he were helpless. Psychoanalysis used to call this a fate neurosis based on Freud’s notion of repetition compulsion. In the interpersonal tradition that calls on attachment theory, following the work of Sullivan cited in Chapter 2, the psychology underlying these patterns is described as a parataxic distortion, a pattern that

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first moulds adult relationships along the lines of unresolved early emotions and then treats the consequences – conflict, injury and disappointment – as if they are the cause of the problem. In Vignette 15.1, the little boy joins the journey in his mind as we all do by reading a novel, watching a drama or following a redemptive journey in a sacred text. The symbolic register calls on the power of the imagination to take us to places other than our own. And then the little boy tries to step into an imaginary picture. Group psychotherapy brings each person to places that are not their own and the group – made up of the ‘soup’ or matrix of shared experience – will have ingredients that everyone present will have contributed towards. But it will also contain many alien ingredients they will find to be uncomfortable or relieving. They will step into and out of one another’s pictures and discover – through the unexpected and unforeseen – representations from their unconscious lives that were hitherto masked by the recurrent constructs of their repeating problems. Warren’s life problem is self-constructed. His inner representational world – what the repeating pattern might really mean – will be discovered during the course of his journey through the group. The longing to be understood and accepted – the basis for most people’s entry to groups – will take time to be transformed into belonging. This vignette describes a key event when transference emerges through a dream as it is picked up by the group and the conductor, who calls on the language of the group and her own countertransference to make an interpretation that helps take Warren beyond his own inner mis-representations.

Vignette 15.2  Was it nice when you kissed the conductor in your dream?

Warren joined a group for help with the pattern described above. He was in his mid-20s and, in the eight years since becoming sexually active was only attracted to, or available for, women who were out of bounds. He was a gifted young doctor whose promise was first realised by his mother and then by his teachers. His first intimate relationship was a secret with his sister’s best friend with disastrous consequences. At university he was courted by his professor, a woman many years older whose attention he invited but would not consummate. When he ‘managed’ to get away he became the caretaker of a fragile fellow student whom he kept rescuing from psychiatric hospitals and enjoying sex with when she was well enough to join him in a sexual bed instead of a hospital one. On seeking therapy he was not aware of the patterning in these relationships and what he complained of was the trouble he was having finishing his MD. The other area of difficulty that he complained of directly was to do with his mother. He was eight when his

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father went bankrupt, his mother became depressed and sought psychiatric help. She also turned to Warren for consolation. The father disappeared emotionally to rebuild a large enterprise, but when he ‘returned’ to the family some years later he found he had ‘lost’ his wife to his son and became irritable and rejecting towards Warren. This figuration must have been a long-standing feature of the family’s life. My colleague – his therapist – was an experienced group analyst who recognised Warren’s underlying oedipal problems, saw him for 12 individual sessions and placed him in a group that she discussed regularly in supervision with me. He was both its youngest and newest member and, though articulate from the beginning, was strangely unaware of the group’s resonance and of his own valency for contact or connection. People were drawn towards him and concerned for how unaware he seemed to be of his mother’s continuing emotional misuse. He first learnt to use the group through outsight, a natural sympathy for others’ predicaments, and gained a place as a mediator who could explain people to each other, but he could not tolerate conflict or aggression. The group began to understand that he had access to himself only through the valency others had for him. He could see himself only through the picture others brought to his attention. Six months on he brought a dream that marked a turning point. He looked at the conductor – a woman of about his mother’s age – and told her directly but with embarrassment that he dreamt the other night that he was kissing her. The dream was in this group room but it had a fireplace and was like a home. The other members of the group were in the room too and people were talking quietly amongst themselves. No-one seemed bothered. In supervision the conductor described how she monitored her own reaction and I could imagine her open, interested and attentive nod of the head as she took receipt of his dream and waited. Her receptivity was expressed through gesture and without words. Cathy, one of the group’s women, asked, ‘Was it nice?’ And he replied, ‘Well, I don’t know, that’s a funny thing to ask, I wasn’t there, it didn’t really happen’. One of the men said, ‘Well of course it didn’t happen, there isn’t a fireplace here, but it happened in your dream. Was it nice?’ He replied, ‘But I wasn’t there . . .’ and was interrupted by another man who said, ‘You’re always the man who wasn’t there. It’s like that line from Edward Lear, “Yesterday, upon the stair I met a man who wasn’t there. He wasn’t there again today, I wish, I wish he’d go away . . .” ’ Another woman challenged the speaker about the source of the poem he was always quoting and a discussion followed about people with a hidden presence. The conductor intervened saying to Warren, warmly

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and without a challenge of any kind, ‘Wherever the lines come from, people seem to think they describe you. What do you think this might mean?’ He was flustered and lost for words. Someone else said, ‘Now you’re not here. That seems to happen whenever you’re close to things that bother you’. Warren got cross, became self-pitying and wanted to withdraw from the exchange. The conductor intervened again, saying, ‘Warren, would it help you to try and answer Cathy’s original question? Was it nice kissing me in your dream?’ By her manner, gestures and demeanour – as much as by the words themselves – she gave him ‘permission’ to have the dream, accepted his emotions and showed she wanted to help him explore its meaning in the context of the group. But he was still lost for words. So she encouraged others to take up his dream and they free associated, ‘playing’ with the dream as they did so. One of the men, Simon, said to the conductor, ‘I’d like to have a dream about kissing you, too’. People laughed and a woman responded, saying, ‘Well why don’t you be honest and talk about wanting to kiss her rather than wanting to have a dream?’ He said in reply, ‘Well I don’t want to kiss her but it would be good to have a hug’. Another one of the women said, ‘Would therapists get into trouble for kissing their female patients as well as their men? I don’t want to kiss you, but you do look kissable and a hug would be great’. There was more laughter in the room and the therapist smiled. With the attention elsewhere and the focus off himself, Warren re-joined the exchange, saying to Simon – the man who wanted a hug – ‘It’s good you talked about hugs. There was no desire in the kiss. It felt warm and comfortable and those of you I can remember in the dream seemed to think it was fine’. Cathy said, ‘So actually, it felt safe and comforting’. Warren, turning to the therapist, said, ‘you were comforting and not erotic. In the dream you were like you are here. It felt good’. Cathy said, ‘So it was nice, nice but not sexual. This is the first time you’ve owned your own emotions since joining us. I think the dream was a group kiss that tells us you’re finally here’. He replied, ‘You people talk about group dreams that seem to me impossible. And now you talk about group kisses. This is ridiculous!’ Everyone laughed including Warren. The conductor joined the serious edge to his protesting humour saying, ‘Warren, your dream and the issues in it have come into the group and we’re “playing” with them. It’s OK. You joined us when you found a connection with Simon’s sense of comfort in the kiss. And the comfort seems to have found you. I believe you’ve been looking for comfort with your mother all your life and it’s eluded you because she intruded on your need with her own unmet desires. You must have

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found a sexual “sting” in every embrace with her because the confusion between your own arousal and your need for security seems to have always bothered you. Here now you can find comfort in a safe environment where you won’t be confused by my desire for you’. Warren sat with this in silence for some time, his eyes filled with tears, and the group held him in safety.

Commentary The group at work here plays at different levels and in different ways. First there is the play of free association out of which Warren’s dream emerges. Then people play with their associations to the dreamer, his person and his presentation that seems to corner the dreamer who first withdraws and is then re-engaged by the conductor. People then play with the dream, to which they bring their own associations, and this re-engages the dreamer who begins to make enquiries about his own unconscious makeup. As he explores the difference between longing, an erotic kiss, and belonging that he comes to see as a safe embrace, we can see him exploring his own representational world. Finally the conductor calls on a transference interpretation to translate the dream content and its associative play into new forms of meaning for the dreamer. Warren is deeply moved, both by her expressed understanding and the sense of mutual acceptance by others. The conductor takes the kiss to stand for the dreamer’s unmet need for comfort and security in contrast to his own mis-construction of intimacy as a vehicle that can only serve arousal. The conductor replays the significance of intimate contact to furnish the dreamer with a newfound sense of legitimacy. The image of the kiss becomes a mutative metaphor. It enters the internal conflicts of the repetition compulsion, reaches the depths without stirring the surface, as described in the opening of Chapter 11, and helps deconstruct Warren’s parataxic distortions. Longing has been a recurrent source of danger for him and its discomforting guilt has left him with no safe place for his own sexuality. The subject matter is a familiar one in this group and others are grappling with related issues. This image, the discourse through which it is explored and the benign relational matrix, all work together to turn longing – the erotic kiss – into the belonging of a safe embrace, which, by the end of this vignette, generates truly reparative experience. As Chapter 16 will go on to describe, metaphors can lead to metamorphosis and allow people to find a place of their own amongst others where they can belong as valued and cherished members.

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The group as auxiliary ego for those without longing or belonging Vignette 15.3  Other people’s babies

Eleanor was described in Vignette 2.5 on page 77 struggling in a group with a disordered mood due to the relapse of a bipolar disorder that first arose in her early adult life from which she originally recovered. It returned when she embarked as a mature student on a teacher training and, in the same year, their mother moved into care and their home was sold. She had been doing well on the course until the recurrence of the mood problem. Two years on now, the family home has been sold, her mother was settled in residential care, and she herself was living in a rented apartment of her own outside the neighbourhood of her upbringing for the first time. Since the account of her early months in Vignette 2.5 she had settled, was no longer symptomatic and had made warm bonds with a number of members. The events that unfolded here saw her emerge as a resource for all. Her mood was stable in this second year of therapy; she was compliant with medication and near the end of her teacher training. The hidden but palpable anger about the terms of an upbringing that involved neglect by her mother and the early death of her father was now out in the open and understood amongst us. Her sense of grievance, now that she had to care for a mother who had never really cared for her, was no longer drawing her down into the bleak, dark places that used to lead into a disordered mood. Her two younger brothers were both getting on well with their lives, and her sister-inlaw recently gave birth to a baby that caused her disquieting envy as she had always wanted children of her own. She never had a relationship in which to raise a child and it was now too late. The brother and sister-in-law wanted to draw her into loving her little niece but she kept her distance. Christine was another long-standing member who had also suffered a childhood of injury and neglect and had lost her mother a long time ago. A generation younger than Eleanor, she now struggled with the unforeseen. She had finally met a man she was devoted to and who – according to the group – was worthy of her. She and her partner wanted to have children. She moved in with him; they got engaged and stopped using contraception. Life seemed to balance favourably for her until she had an ectopic pregnancy that required emergency surgery. She was dangerously ill but had good medical care to see her through and the loving and constant presence of her partner. She had recently been

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advised that the only way she could conceive would be through assisted conception and, on bringing this news to us, she sat in the group in a state of shock and sorrow. We had seen her through painful and frightening weeks, and now she sat with us crying in desperation. Her suffering brought Eleanor forward on constructive terms we had not seen before. Her immediate empathy brought her close to Christine’s sorrow that she led the way in containing. By the time the group was concluded Christine was able to compose herself and look thoughtfully at her options. Eleanor came to the next session with a beautifully wrapped gift that puzzled us all and which she gave to Christine, who was encouraged to open it. Inside was a small photograph album, the kind people buy from baby shops. Eleanor said to her, ‘That is for the baby you are going to have!’ When Christine had it in hand Eleanor said, ‘That’s your hope, just don’t let go of it!’ and we sat together with a mixture of tears and regard. The gift and the hope it represented was to see Christine through a great deal of further suffering, and in the years that followed it was eventually filled with the photographs of the two children she and her husband adopted. At the time, when people later asked Eleanor where her confidence came from in the months that followed these events, she said it came from the group. She found her place here when she finally understood the truth of what Mick had been trying to tell her last year about her ‘unreachable misery’. Her crying was like the crying of calves and cows when they are separated. She really had been motherless. Now she was homeless too and had to rely on the group for the only sense of being at home she could find. When I asked her how she knew she could rely on us so, she explained that our tolerance for her months of tears last year, and our recognition that they were tears of protest, gave her confidence we could hold her safely amongst us.

Commentary The symbolic meaning of this gift worked through the real, the constructed and the representational that came together as a register for hope. The healing sense of ‘a place called home during the group meetings’ as Eleanor put it, gave her inner resources to contend with another’s despair. She found reparative meaning in the group that equipped her to come to terms with the options that life had denied her. Though invited into the loving space of her brother’s new life with their baby, she could not go any where near them emotionally (Continued)

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(Continued) because of her envy for the child she would never have. But when disaster struck the life of a fellow group member she brought hope in the form of an album that would one day picture this other woman’s babies. In the section on the reparative dimension in Chapter 2, the idea that you cannot pay love ‘back’ on the route through which you might receive it, but you do have the option to turn gratitude into generosity by ‘paying it forward’ as described by Arlo, is illustrated here. Resonance was turned into reciprocity, and the transformative benefits of the group’s work were to see both these women – and the other members – through the further challenges their lives had to contend with.

The primary but hidden anxieties identified in the opening of this chapter – the absence of meaning within the self, absence of a self within the person, the fear of being found by another, the fear of never being found by another and the fear of never being found acceptable by another – are addressed in these vignettes. We can see people stepping into one another’s pictures through the interplay of longing and belonging. Eleanor received reparative gifts from the group and paid it forward in the group, as Arlo describes in Chapter 2, by stepping into Christine’s life to provide an unforgettable symbol of reparation that relieved us all. The resolution to her own grief’s most acute state was found in the consolation she offered to another.

Reparation in an aggrieved large group that ‘comes home’ Vignette 15.4  So you want us to eat potatoes? No, we’re coming home!

This vignette describes a Large Group at the annual meeting of an international body of psychotherapists. This organization locates its annual meetings in different centres, and this one took place in Ireland. The caucus of those attending was well represented in the Large Group. There were sub-groups that differed from one another on the basis of their different references or points of allegiance to Irish history or ancestry. So the issue of belonging is an identifying demarcation in which sub-grouping is used as Agazarian would do, to examine the points of coherence or belonging by which the sub-groups organise themselves spontaneously.

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The atmosphere in the first session was tense but productive, and people in due course settled down to talk candidly about their immediate experiences of one another, especially in terms of gender, following a lecture earlier in the day, which had been closely focussed on women as victims and men as perpetrators of violence. Those men who spoke were, to begin with, self-negating and apologetic for their very maleness. Many women spoke up and some expressed a generally critical stance towards the men. Other points of distinction emerged that differentiated between the older or more experienced members of the group and those younger people who had not attended events of this kind before and had to find their voices. When the ‘Irish issue’ did emerge, finally, it followed a reference to the castle in which we met and its history. One of the organisers told the Large Group that the castle had been the administrative centre of British rule in Ireland. The castle had been the home and the symbol of imperial authority. It was a building that had been used to hurt people. In the second and third, concluding session of the Large Group many were taken up with a drama during the course of a formal dinner the previous evening when a sub-group of ‘smokers’ broke the regulations and had their cigarettes on the terrace. The organisers were upset by their failure to honour the rules. The smokers remained defiant about the unimportance of their transgression. Those with Irish roots who had been raised elsewhere and were now back in the country, either for the conference or more permanently, became the spokesmen and -women for the missing conscience of the transgressive smokers, and they became increasingly critical and indignant. In the attack they proceeded to mount over a period of time, ‘the smokers’ became ‘The English’ who continue to flaunt Ireland’s laws, even when they are the guests of the castle. ‘The English’ who were challenged for transgression came mostly from a distinguished clinical centre in London and were unprepared for this mis-identification. Once they were antagonised at least one of them went on to note that the meal had been served late the previous evening, people had been allowed to drink without eating and may well have simply been unwinding. Another one of them, more seriously antagonised, went on to point out how surprised they were by the food when it finally came. They had been expecting something traditionally Irish and this had been more like North African food. This was a provocation that others were just waiting for! ‘So you want us to eat potatoes!’ they challenged. It was an incendiary that had us in polarities of great antagonism for an extended period. The castle was clearly hurting people all over again.

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This continued until one of the women at the back of the circle who had been silent until then challenged the skirmish. She told us she was of Irish extraction but was born in London and had been living there for years. But she was in Dublin now, she said, where she worked and where she was raising her children. ‘And’, she said, ‘It’s not only the potatoes we’ve been forced to eat. We’ve been forced to eat humiliation. We’ve been driven out of our homes and forced to live abroad for centuries. And now we’re coming home. “We’re coming home!” ’ Her voice broke; she became tearful and released a well of emotion that affected everyone. With this declaration of homecoming, the concluding minutes of the Large Group became a reparative arena of personal and interpersonal exchange.

Commentary This moment of novelty can be understood and explored through the metaphor of homecoming that it gave rise to. The group moved from monologue to dialogue then to discourse and then back to close interpersonal dialogue where it rested. And here in this new reparative atmosphere, different people made good with one another in different ways.

Note 1 This chapter was presented in an earlier form as a Keynote Address at the North London Centre for Group Psychotherapy titled ‘Longing, Belonging and the Despair of the Homeless Mind,’ June 2005. I wish to acknowledge with gratitude the contribution made by Liesel Hearst, Harold Behr, Tom Hamrogue and Sylvia Hutchinson to the later drafting of this chapter. It was later presented under the original title to the Reading and Application Seminar of the Israeli Group Psychotherapy Society, Haifa, 2006, and an extract was presented under the title, ‘The Sounds of Silence and the Struggle for Words: Group Analysis in Troubled Times’ to the Israeli Institute of Group Analysis, Tel Aviv, 2012. I wish to acknowledge with gratitude the contribution made to the development of this writing by all the members of this seminar, in particular to its convener Robi Friedman.

Bibliography Adlam, J., and Scanlon, C. (2005). Personality Disorder and Homelessness: Membership and ‘Unhoused Minds’ in Forensic Settings. Group Analysis 38 (3): 452–466. Agazarian, Y. (1997). Systems-centred Therapy for Groups. New York, Guilford Press.

15  Longing and belonging  415 Arnold, M. (2004). The Collected Poems of Matthew Arnold. London, Kessinger. Auden, W. H. (1948). The Age of Anxiety: A Baroque Eclogue. London, Faber and Faber. Berger, P.  (1974). The Homeless Mind: Modernisation and Consciousness. London, Penguin. Berger, P., and Luckman, T. (1991). The Social Construction of Reality. London, Penguin. Bledin, K. (2003). Migration, Identity and Group Analysis. Group Analysis, 36 (1): 97–110. Bledin, K. (2004). What’s in a Name? Foulkes, Identity and the Social Unconscious. Group Analysis 37 (4): 490–491. Bledin, K. (2006). Empty Spaces in Group-Analytic Psychotherapy Groups. Group Analysis 39 (2): 203–213. Bollas, C. (1987). The Shadow of the Object: Psychoanalysis of the Unthought Known. London, Free Associations Press. Cox, M. (1978). Structuring the Therapeutic Process: Compromise with Chaos. Oxford, Pergamon. Reissued by Jessica Kingsley Press, London, 1993. Cox, M., and Theilgaard, A. (1987). Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley. Cox, M., and Theilgaard, A. (1994). Shakespeare as Prompter: The Amending Imagination and the Therapeutic Process. London, Jessica Kingsley. Elias, N. (1979). Conversation with Norbert Elias: Interviewed by Dennis Brown. Group Analysis 30: 515–524. Elias, N. (2009). Figurations in Collected Works of Norbert Elias, Vol. 16. Dublin, University College Dublin Press. Fairbairn, M. (1943/2002). Repression and the Return of Bad Objects. In D. E. Scharff and E. F. Birtles (Eds.), Psychoanalytic Studies of the Personality: Selected Papers. London, Routledge, pp. 59–81. Foulkes, S. H. (1948; reissued 1983). Introduction to Group-Analytic Psychotherapy. London, Karnac Classics. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Freud, S. (1900). The Interpretation of Dreams. SE IV/V. London, Hogarth Press. Freud, S. (1917; reissued 1984). Mourning and Melancholia. SE 14. Vol. 11, Pelican Freud Library. Reissued 1984, London, Penguin Freud Library, pp. 237–258. Glenn, L. (1987). Attachment Theory and Group Analysis: The Group Matrix as a Secure Base. Group Analysis 20 (2): 109–117. Hobsbawm, E. (2013). Fractured Times: Culture and Society in the 20th Century. London and New York, Little Brown. James, C. (1994). Holding and Containing in the Group and Society. In D. Brown and L. Zinkin (Eds.), (2000), The Psyche and the Social World. London, Jessica Kingsley, pp. 60–79. James, W. (1902; reissued 2010). Varieties of Religious Experience: A Study in Human Nature. Being the Gifford Lectures on Natural Religion Delivered at Edinburgh in 1901–1902. New York, Library of America Classics. Jennings, S. (1998). Introduction to Dramatherapy. London, Jessica Kingsley. Jennings, S. (1999). Introduction to Developmental Play. London, Jessica Kingsley. Jennings, S. (2011). Healthy Attachments and Neuro-Dramatic-Play. London, Jessica Kingsley Press. Levens, M. (2011). Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation. MSc dissertation. Institute of Group Analysis, London/ Birkbeck College, University of London.

416  III  The dynamics of change Mace, K. (2009). Phatics and the Design of Community. Proceedings of the 27th International Conference Extended Abstracts on Human Factors in Computing Systems. Boston, MA. Malinowski, B. (1923). The Problem of Meaning in Primitive Languages. In C. K. Ogden and I. A. Richards (1989). The Meaning of Meaning: A Study of the Influence of Language Upon Thought and of the Science of Symbolism. Eastford, CT, Martino Publishing. Mead, G. H. (1934). Mind, Self, and Society. Chicago, University of Chicago Press. Ed. by Charles W. Morris. University of Chicago Press. Nitsun, M. (1988). Early Development: Linking the Individual and the Group. Group Analysis 22: 249. Nitsun, M. (2006). The Group as an Object of Desire: Exploring Sexuality in Group Psychotherapy. London, Routledge. Nixon, P. (1998). Foulkes, Elias and Human Figurations. Group Analysis 31: 5–19. Ogden, T. H. (1993). The Analytic Management and Interpretation of Projective Identification. In A. Alexandris and V. Grigoris (Eds.), Counter-Transference. Theory, Technique, Teaching. London, Karnac Books. Ogden, C. K., and Richards, I. A. (2013). The Meaning of Meaning: A Study of the Influence of Language Upon Thought and of the Science of Symbolism. Eastford, CT, Martino Publishing. Pines, M. (1998). Coherency and Disruption in the Sense of Self. In M. Pines, Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London, Jessica Kingsley, pp. 211–223. Punter, J. (2010). Group Analysis as I Do It: How I Work With the Social Unconscious. Group Analysis 43 (2): 170–180. Schlapobersky, J. (1996). A Group-Analytic Approach to Forensic Psychotherapy: From the Speech of Hands to the Language of Words. In C. Cordess and M. Cox (Eds.), Forensic Psychotherapy: Crime, Psychodynamics and the Offender Patient. Vol.  1: Mainly Theory. London, Jessica Kingsley, pp. 227–243. Schlapobersky, J., and Pines, M. (2009). Group Methods in Adult Psychiatry. In M. Gelder et al. (Eds.), New Oxford Textbook of Psychiatry. Oxford, Oxford University Press, pp. 1350–1369. Stern, D. (1998). The Interpersonal World of the Infant. London, Karnac. Usandivaras, R. (1989). Therapeutic Use of Regression in Group Analysis. Group Analysis 22 (2): 171–175. Wilson, P. (2005). Breaking Down the Walls: Group Analysis in a Prison. Group Analysis 38 (3): 358–370. Winnicott, D. (1951, 1978). Transitional Objects and Transitional Phenomena. In D. W. Winnicott, Through Pediatrics to Psycho-Analysis. London, Hogarth Press, pp. 229–242. Reissued in Playing and Reality. Harmondsworth, Penguin. Winnicott, D. (1963, 1985). Communicating and Not Communicating Leading to a Study of Certain Opposites. In D. W. Winnicott, The Maturational Process and the Facilitating Environment. London, Hogarth Press, pp. 182–183. Wright, K. (2009). Mirroring and Attunement: Self-Realizations in Psychoanalysis and Art. London and New York, Routledge. Yates, W. B. (1992). Collected Poetry. London, Everyman.

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Acknowledgements: Extracts from Pines (1998), Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis, reproduced with permission from Malcolm Pines; extracts from Levens (2011), Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation. MSc Dissertation IGA/Birkbeck College, University of London, reproduced with permission from Mary Levens.

Chapter 16

Metaphors and metamorphosis Symbols, transition and transformation

About suffering they were never wrong, The Old Masters: how well they understood Its human position; how it takes place While someone else is eating or opening a window or just Walking dully along (Auden, Musee des Beaux Arts) Here is a picture of a child establishing a private self that is not communicating, and at the same time wanting to communicate and to be found. It is a sophisticated game of hide-and-seek in which it is a joy to be hidden but disaster not to be found. (Winnicott 1963:186)

The metaphors of a group’s free-floating discussion can lead to metamorphosis as they generate a language of change.1 Between metaphors as agents of change and metamorphosis, their ‘products’, there is a world to be explored in this chapter. We can make a beginning with a mythological fable from ancient Greece retold for a second time in Ovid’s Metamorphosis, his Books of Transformations that shaped Rome’s cultural life (Ovid 2004). In the story of how Daedalus and Icarus, imprisoned on the island of Crete, escape from captivity on wings fashioned by the father, Daedalus cautions his son not to fly too high or too low. Low flight would expose their wings to the sea’s dampness, impairing buoyancy, and flying too high would pose other dangers. In the exhilaration of flight Icarus ignores his father’s advice, goes too close to the sun that melts the wax binding his wings, and he falls to his death in the sea. The allegorical meaning of this powerful, cautionary story – its ‘message’ – warns against hubris to underscore the classical ideal of moderation, the middle path. The Flemish artist Breugel retells the story for a third time in the 17th century in a painting that hangs in the Musee des Beaux Arts, Brussels, The Fall of Icarus. Its ‘message’ is captured in the moment of Icarus’s fall as he plunges headlong into the sea whilst a heedless world continues about its every day business. The scenes drawn from Ovid’s poetry are pastoral with cruel undertones and capture the continuity of

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the commonplace. This story’s ‘message’  – that an individual’s fate is to perish in tragic isolation – arises from the way these scenes are juxtaposed against the boy’s lonely end. Auden retells the story for a fourth time with yet another ‘message’ in 1938 when he visits the museum and describes what the painting conveys: Musee des Beaux Arts About suffering they were never wrong, The Old Masters: how well they understood Its human position; how it takes place While someone else is eating or opening a window or just Walking dully along; How, when the aged are reverently, passionately waiting For the miraculous birth, there always must be Children who did not specially want it to happen, skating On a pond at the edge of the wood; They never forgot That even the dreadful martyrdom must run its course Anyhow in a corner, some untidy spot Where the dogs go on with their doggy life and the torturer’s horse Scratches its innocent behind on a tree. In Bruegel’s Icarus, for instance: how everything turns away Quite leisurely from the disaster; the ploughman may Have heard the splash, the forsaken cry, But for him it was not an important failure; the sun shone on As it had on the white legs disappearing into the green Water; and the expensive delicate ship that must have seen Something amazing, a boy falling out of the sky, Had somewhere to get to and sailed calmly on. (Auden 1966)

About suffering I will explore this story for a fifth time to see what it might help us understand about ‘the human position of suffering’. There is a developing literature of promise in which psychologists are describing the nature of unhappiness and the content of psychological distress that has bearing on the work we do in groups (Smail 2001; Chalkley 2015). This chapter will consider how the metaphors involved in allegory can help group psychotherapy with two populations whose unhappiness might look similar but who pose different therapeutic challenges. First there is the

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work we do with those who – as adults – are affected by tragic or traumatic life events, including life-threatening illness, bereavement or massive psychic trauma in which the unchanging continuity of the familiar world outside, aggravates the alienating consequences of the trauma. In Auden’s words, ‘everything turns away quite leisurely from the disaster’. Second, I will consider those affected by severe character pathology including borderline personality disorder in which the underlying problem involves early experience of disaster that is encapsulated, often hidden from conscious experience and repeated compulsively in adult life. Here it is the person him- or herself who has learnt to ‘turn away quite leisurely’ from their own originating disasters that lie unconsciously within, whilst they repeat them in their external world in sometimes vain pursuit of self-mastery. Auden’s poem can illustrate clinical and conceptual debates about what makes metaphors mutative in psychotherapy, building on the ideas in the previous chapter about longing and belonging. At the centre of the discussion is the key idea of ego training in action. It is first referenced in this book in Table 1.2. I am looking to build on the foundations laid down so far, to develop an integrated frame of reference incorporating advances in group and psychoanalysis. On the group-­analytic side advances include Brown’s ‘Self development through subjective interaction: a fresh look at “ego training in action” ’ (Brown 1994); Pines’s recently collected papers now available for the first time as an integrated body of work (Pines 2015); Leven’s illuminating dissertation on words and language (2011); and Weegman’s most recent book (2014). On the psychoanalytic side they include the writing of Bollas (1987, 1993, 1999/2014) and Montana Katz’s recent collection of critical essays (2013), particularly the contribution by Modell (2011). In psychoanalytic theory there is a developmental line of concepts that evolve from some of Freud’s key ideas which progresses through object relations theory to the work of Bollas. It corresponds to the evolution of group analysis. Bollas and Brown share a common frame of reference. What Brown calls ego training in action, Bollas calls the gathering of the self, being a character whose object choices are: Specific to a potential articulation of self experience . . . When we live according to our desire, we naturally choose objects in the ordinary process of selection. Some objects (a book, a friend, a concert, a walk) release us into intense inner experiencings which somehow emphasize us . . . a form of lifting of the self, as encounters with objects lift us into some utterance of self available for deep knowing . . . an idiom of the self we are by virtue of the character of the evoked. (Bollas 1993:29) The relational concepts shared by the two different bodies of work – group and psychoanalysis – can help both sides to a better understanding of the dynamics of change. The integration I am seeking could help resolve some of the internal problems in each of these disciplines. I will be illustrating the work with different clinical examples. The first two include the two populations already identified. They are illustrated by two different forms of depression which ‘stand for’ each of these population groups. In the first are those with adjustment reactions involving

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depressed emotions that arise out of loss or encounters with tragedy or catastrophe in adult life. In the second group are those whose experience of catastrophe took place before conscious memory and often before their lives had words for feelings. Pre-verbal injury can be carried like a living and recursive catastrophe that individuals find returning to haunt their lives. Group-analytic psychotherapy can be the therapy of choice for both populations. The model’s special benefits for the second population are argued for through another set of clinical examples in the concluding section, where the vignettes provide an account of angels in the consulting room – what Bollas calls mnemic objects – who are discovered in different therapies. These angels are considered first in individual psychotherapy, then in couples therapy and finally in two different kinds of groups. In Chapter  2, I  developed the three dimensions of group therapy to show a progression from the relational to the reflective and reparative. Chapter 4 opened up a distinction between a small group’s relational field and its semantic field or field of meaning. Chapter 5 introduced further distinctions between the real, the constructed and the representational which were explored again in Chapter 15 in the dynamics of longing and belonging. We are now in a position to apply Brown’s study of intersubjective validation to the relational field and Bollas’s study of symbolic objects to the semantic field and to look for the links between them through angels who make surprising and uninvited entry to the consulting room.

The shadow of the object Let us imagine two people coming to see us at the beginning of a course of psychotherapy, each of whom brings a severe depression into the room with her. The first person has a symptomatic depression arising out of a recent loss when she discovered her boyfriend was having another affair and she finally ended the relationship. The second person has a more characterological problem with a depressive makeup embedded in her personality. When strain or adversity turns the susceptible state into a symptomatic one the depression returns, and it has done so episodically for much of her adult life. She has a depressed personality with character problems or borderline features and, even when the going is good, she can often undo her own equilibrium. Mourning and melancholia In the blow the first woman suffered involving betrayal and loss, her external world was left void and empty. We can anticipate that therapy  – individual or group therapy – will see her through the sense of crisis. It will involve grief work to equip her to come to terms with loss and this may lead to changes in her makeup through growth and new internal adjustments allowing her a wiser choice of partner next time round. In due course she may find her way to a happier relationship. In the case of the second woman, strain or injury on the outside brought on by life events – the breakup of a relationship, loss of a parent or other bereavement,

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professional disappointment or another such blow – reveals an internal world that is itself void and empty. Freud first drew our attention to the fundamental differences between mourning and melancholia – conditions that are often otherwise indistinguishable – through his understanding of where the void is located in the state of mind of someone in trouble. ‘In mourning’, he wrote, ‘it is the world which has become poor and empty; in melancholia it is the ego itself’ (1917:254). In both these women’s difficulties the presentations look similar and suggest internal processes of a comparable kind following the loss of a deep attachment. In the first case the broken attachment is to a lover in the world of her present emotions, and grief work will involve a slow but progressive relinquishment of her ties, both to the man outside who is given up and to her picture of the man within who slowly loses importance as she grieves for him. Individual and group therapy can make no claims against one another in this kind of work – they will both provide resolutions of a similar quality. In the case of the second woman, the attachment that is episodically broken is the internal one with the woman’s lost mother in the unconscious world of childhood emotions. We are likely to discover that the originating ties involved a highly ambivalent mother who may have loved her daughter but likely as not also hated her and left the daughter with a highly ambivalent and complex makeup. The recurrent struggle for rapprochement with an internal mother who both invites and rejects love means she is often defeated by loss, even when she regains the bond she struggles for. This conflict stands outside the realm of the conscious. These are the internal correlates of the struggle manifest on the outside as an episodically depressed personality in someone with a character disorder or borderline features. For seemingly intractable or recurrent problems of this kind group therapy has – in my own experience  – many proven advantages, as the angels may help us discover later in this chapter. Freud goes on to describe how, in a state of melancholia  – what we would today call depression – ‘the shadow of (this) object falls upon the ego’ which is then treated as though it were itself an object, ‘the forsaken object. In this way’, Freud writes, ‘an object-loss (is) transformed into an ego-loss’ (Freud 1917:258). Events that put stress upon the external world set in train a process by which the internal world is impoverished. Freud describes how, whilst the object might be given up, the original love for it is retained and takes refuge, he suggests, in the substitutive object of the self. It is the self that is then abused, debased and made to suffer on behalf of the lost object. This is the shadow of the object, a graphic, idiomatic depiction of the truly relational nature of depression. In 1987 Bollas re-acquainted us with The Shadow of the Object as the Psychoanalysis of the Unthought Known in an original text that takes these early formulations of Freud as its point of departure (Bollas 1987). A primitive and hidden disaster If we follow the second of these two women into the world of the unconscious through individual or group therapy we are likely to discover in the early, precipitous and repeated loss of maternal security, evidence of what Bion called ‘a primitive

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disaster’. We are unlikely to discover anything static – there is unlikely to be any simple or one-off event that sets this woman at odds with her internal objects. What we are more likely to find is evidence of an early sense of ‘catastrophe that remains at one and the same moment actively vital and yet incapable of resolution into quiescence’ (Bion 1959:94). This internal sense of catastrophe can often be encapsulated, split off, renounced and disavowed, only to have it return with a force and ferocity that is proportionate to the repeated attempts to deny it. The work of Brown and Bollas will shed light on how problems at this level can best be understood and how psychotherapy can bring change in a resolving process for which the earlier compulsive repetitions can be understood as rehearsals or false starts.

Intersubjective validation and ego training in action Brown provides a moving account of a young man whose small group is able to take on an empathic and maternal role that allows him to open himself to the concern of the other members. At a decisive moment ‘he discovered he had, like others, an internal world, understandable by others, and he was able to take part in the ebb and flow of shared experiences’ (Brown 1994:90–91). Brown describes a point when this man returns to the group after taking flight and is overwhelmed by emotions. The experience brings his therapist close to tears. When he learns of this in the group the man reports on feelings of intense pain in the neck and shoulders, ‘as though being choked’. When this is accurately understood and described as ‘choking on his own feeling’, the man begins to cry and rouses the group to empathic gestures that Brown describes correspond ‘with that stage of development of the nascent self calling for a responsive selfobject’ (Brown 1994:91). Brown describes this as intersubjective validation  – ‘the person’s sense of themselves in relation to others . . .is confirmed by the responses of others in a mutual process of self-discovery’ (1994:89). He goes on to suggest that the process of self-development in group analysis is circular and spiral: the experience of being empathised with and failed enough – as in early infancy – sets in motion three stages of growth and development described in Table 16.1. From these three stages he develops a lucid and simple account of the relational benefits of group therapy. ‘On the way to more mature, intimate and reciprocal Table 16.1  Brown’s three stages of growth and development: Self-development through subjective interaction * In group therapy we can: 1

Make fuller discovery of our inner world

2

Discern differences between old internal object relationships and new ones

3

Learn to attune ourselves to other people’s experience as well as our own

* Table 16.1 is adapted from Brown, D. (2000) Self development through subjective interaction: a fresh look at ‘ego training in action’, p. 83. Grateful acknowledgements are made to the publisher.

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relationships with others, we mitigate the effects of earlier empathic failure and ossification of internal object relationships. I call this self development through subjective interaction’ (Brown 1994:98). After looking at ego training in action we will see more about how this process provides the touchstone for the wellbeing of an analytic group when the semantic field and its symbolic objects have been introduced through Bollas’s work.

Images of survival and transformation Muses and mnemic objects In Greek mythology the Muses were the personification of knowledge and the arts. The nine daughters of Zeus and Mnemosyne (who was memory personified) were worshipped throughout the classical world. Significant objects and sources of meaning in art and aesthetics continue to have arresting, evocative power over us through the memories they are charged by. From Mnemosyne, the mother of the Muses and memory herself, we have a term that is put to wise use by Bollas when he discusses the mnemic power of symbolic objects. The word ‘mnemic’ serves to identify objects that act on us as we act on them and whose resonant capabilities, arising from aesthetics or memory, affect invisible chords within the recesses of the self which come to life in the intersubjective process (Bollas 1993:18). He draws on Winnicott’s work to locate these objects in the domain we have already seen described as the intermediate world, one that is neither inside nor outside the psyche but in the space between the psyche and the social world. He suggests a distinctive repertoire of available such objects for each of us which contain the potential for transformation. And he suggests that psychotherapy works by attunement to these mnemic objects. It draws them from the unconscious and brings them to the surface and where they can create renewal and change. He gives a vivid account of the: True joy in finding an object that bears its experience which we find transformational, as it metamorphoses a latent deep structure into a surface expression (1993:53). Whether this object is a piece of music, a locality or a relationship, (he suggests) that this inner form within us, this outline or shape of the other, dynamic yet seemingly consistent, is indeed rather like a revenant within, as we have been affected by the other’s movement through us, one that leaves its ghost inhabiting our mind, conjured when we evoke the name of the object (1993:56). Mnemic sources in the relational and semantic fields In therapy the dynamic interface between the relational and semantic fields generates its own mnemic objects out of the repertoire that each person brings to the process. These become the driving forces of change that make transformation possible. They derive from the subjective world of therapist and patient(s) alike and come to occupy the intermediate territory, the shared space generated amongst parties to the process. They can best be defined as intersubjective ‘objects’ that only have a true location in the space between therapy’s different members. These intersubjective

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‘objects’ come to life in the context of the group but can be drained of their resonant significance outside its context. Current or past group members commonly report on the discovery that the intersubjective features of their shared experience – an image, experience or event that can be charged with meaning in the group – can be devoid of meaning when past or current members meet outside the group. Levens describes the agency of metaphors in groups ‘to facilitate the work of understanding symptoms’. She describes symptoms as wordless presentations in the light of which ‘the creation of metaphor is an undoing of the symptom which has embodied the problem. Metaphors often carry affect and insight (and) verbal interpretations may be uncalled for’ (Levens 2011:35–36). The generative power of the image and its symbolic associations can work as mnemic sources to bring change. They are studied in the two populations considered here. I will explore work undertaken with those injured in adult life and overwhelmed by massive psychic trauma, and those who carry the stigmata of early and hidden violations in the compulsive repetitions of depressive or borderline life. The symbolic references shared by these two populations will be explored by identifying distinctive mnemic objects – angels – who are a recurrent feature in the four vignettes that follow.

Angels in four places – individual, couples and two forms of group therapy Angels in individual psychotherapy

Vignette 16.1  The angel in the torture chamber: Individual psychotherapy

Darius was a believing Muslim from Iran who – it might have seemed – left religious belief behind him when he came to the UK as an asylum seeker. The Revolutionary Guard – agents of the Ayatollah – killed his father and brother at different times and under different circumstances. After his own imprisonment he spent almost a year in hiding under different false names until his family were able to get him out of the country. Prior to this he spent several years in prison where he was tortured brutally and was only released because they extracted nothing of any consequence and thought their violence had destroyed him as a political opponent, but this was far from the case. He brought clarity of political purpose to his adjustment to life in exile, but even his robust personality failed to protect him from the symptomatic state to which he had been reduced by the events of his recent past. He was in a crushing state of despair and depression. In the corner of the consulting room in which I  saw him there was an examination couch used with other patients by medical and para-medical colleagues. The stainless steel instrument box beside the couch induced flashbacks to his experience of being strapped on a

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bench in prison where they beat the soles of his feet and applied electrodes to his mouth and genitals. Whilst he needed the relief of communication and disclosure that therapy afforded, it took months for him to reveal what is was that made him go into a strange tremor and twitch with anxiety at the beginning of each session. It was only when he made these disclosures that we changed the room for his sessions and began to examine his experience of torture directly. He inhabited a persecutory world of his own, characteristic of traumatised asylum seekers, known today as complex PTSD (post-traumatic stress disorder). He was woken by nightmares so tried not to drop off and so was sleep disordered. During the day he was in a state of chronic hypervigilance and high arousal with paranoid features. He was always uneasy that he might be under surveillance and would turn in the street to confront people who might have been unfortunate enough to walk behind him. His concentration problems – affecting his English classes and college progress – were the most disabling of his symptoms and the first to show resolution as the therapy progressed. The next indication of progress came after a session in which we talked about angels, who featured in many subsequent discussions. Some time later, when there was enough accord between us for the question not to be taken as a judgment or attack, I asked him why he thought it was that, after surviving such horror in prison, his life in exile should now be causing him such difficulty. He chuckled with a sort of black humour and said the answer was very simple – when he left his country he left the angels behind. Whilst in prison, when he heard the torturers’ footsteps coming down the corridor to take him from his cell to the torture chamber, he would recall what he could of a passage from the Koran that describes the flight of angels. The angels would reach him before the cell door was opened and hold him through the pain that followed. When the torturers thought they had him entirely in their power he was really with the angels, and they kept him alive. In England now, however, there were no angels. Despite his occasional visits to the mosque and the reassuring presence of friends and other survivors, he could find no angels at all. When he later joined the group his winning personality earned him other members’ regard when he made a joke out of how even at the London Underground station named Angel, there were none to be found! Why were there no angels in England? The true horror of an ordeal is often visited on survivors during the aftermath of the events themselves. The recurrence of flashbacks and the intrusive repetition of grotesque events in symbolic form, altered by dreams, are among the most common sequelae of massive psychic trauma. We now know these activities as efforts made by the unconscious mind to process the experience, give meaning to it and – if possible – come to terms with it. Psychotherapy for

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those who have survived near-death experience has to attend to the form in which annihilation threatened the self and it must engage with the detail of elemental threat. Darius’s dreams, daydreams, flashbacks and reveries were peopled with a multitude of symbolic opportunities with which we entered his scarred internal world. But where were the angels? They only re-entered the symbolic life of his unconscious when we addressed the detail of his political and religious motivation. They returned to comfort him in his dreams when he discovered the extent to which he felt he had abandoned his political duties by leaving his country. His father and brother had paid with their lives for their political stand – how could he now enjoy a life of any kind at all? The angels themselves had now, in turn, abandoned him. He came to an understanding of this when, in passing, he referred to the fact that no-one safe in exile was entitled to sacred protection  – the angels were too busy protecting those still in prison in Iran. This recognition brought laughter with it and slowly allowed the angels to return. The sense of comfort brought an increasing sense of order, steady diminution in his symptoms and an increasingly directed capacity to ‘play with’ and grow through even the worst of his earlier experiences.

Commentary Bollas describes the object world as a lexicon for self-experience in which object choice is an idiom of self-expression, a means not only of representing unconscious fantasies but of conjuring dense psychic experience, a way of thinking by experiencing. The angel as Darius’s transformational object passed through the four stages in Bollas’s dialectics of self-experiencing described in Table 16.2.

Table 16.2  The dialectics of self-experiencing: Bollas* 1 I use the object: in picking up a book, going to a concert, phoning a friend 2 I am played by the object: at the moment of my ‘use’, the particularity specific to the object transforms me 3 I am lost in self-experiencing: the distinction falls away between the subject who uses the object to fulfil his desire and the subject who is played upon by the action of the object. This is the intermediate area 4 I observe the self as an object: on emerging from self-experiencing or reverie, the subject considers where he has been. This is the place of the complex self (Bollas 1993:30–31) * Table 16.2 is adapted from Bollas, C. (1993) Being a Character: Psychoanalysis and Self Experience, pp. 30–31, by kind permission of the author and publisher.

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Commentary Darius knew as well as I did that there are no such beings as angels on the surface of the Earth, but we both understood that without them he would not have survived. They were not inventions of a tortured mind, nor were they visitations from a benign Deity – they were both and neither. As symbolic intermediaries between ultimate horror and the slim prospect of redemption, they did indeed rescue him. He invoked the presence of angels, he called on them as sources of salvation, and he then allowed himself to be ‘played by’ the object. The angels as his own mnemic objects worked on and with him as if he were an object in their experience, and he came to allow this. Third, in allowing this he entered the imaginary world and allowed himself to ‘get lost’ in it – he entered the intermediary world and came to inhabit it with the angels. And finally, during his second year of therapy, he came to observe himself and review the stages during which he had undergone this kind of healing experience. He was able to look back at where he had come from and addressed himself to me. ‘Yours is the hand of humanity’, he said, ‘that has reached out and saved me from drowning in my sorrow’. The ‘angelic’ – the elements of recovery and renewal that had first protected him in prison and had now taken him forward in therapy – were seen to lie in the relationship we had generated, representing ‘the hand of humanity’. We will return to Darius in Vignette 16.3 and to the band of angels in the group he later joined.

The angel in the family: Couples’ therapy Vignette 16.2  The angel in the family

Gabriele was an Italian banker who attended with his wife Stefanie, and during their years of marital therapy – when they each had therapy for themselves also, she with an individual therapist and he with an alcohol and drugs counsellor  – he struggled with his borderline makeup and the ravages this brought to their family life. Stefanie was complicit in his enactments and was much more a part of the problem than any solution. They came from a circle of wealthy families who lived a privileged life in Rome. Their habituated lifestyle involved the men’s drink, drugs, gambling and serial infidelities. Whilst Gabriele’s father was gambling away a large patrimony he lived on narcotics and had barely

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concealed affairs. Gabriele and Stefanie had both been sent to English public schools from where they attended European universities. They met each other as students in London, where they were now raising their three daughters. By the time they came to see us he had established himself as a distinguished merchant banker. Disaster struck when one of the mistresses he was having an affair with was found by police to be in possession of drugs and they thought he was the source. Prior to this Stefanie had no declared knowledge of mistresses or drugs, but she stood by her husband and the case never came to court. The shock and scandal of these events brought them into therapy, for a prosecution would have threatened his banking status that was already at risk. In the sessions he had the ease and self-assurance of the powerful, compromised by the insecurities, and insights of devastating accuracy found amongst some borderline people. When he felt threatened she was the prime target for outbursts that were often malicious. In the course of their therapy his sense of raw contempt for his wife, indeed for all women except his daughters, became prominent. Given his acumen there was a lot for which he could despise her but none of us were a match for his intelligence, and it took long periods of steady containment  – without retaliatory responses to his provocations – for him to learn how to manage his capacities more responsibly. The challenges that touched him most deeply came from his daughters. Both parents were devoted to their children and they struggled at many levels to provide them with a quality of care that they had never known. His wife would often bring into the sessions his love for their children and their adoration of him. Her own pathology linked her to the children amongst whom she often took refuge when her husband’s overbearing behaviour threatened her. As he learnt to contain his aggression and she found the resources to assert herself, she came away from the refuge that the children provided and grew into an increasingly adult and sexual presence in his life. Well into the therapy, when a long period of stability and contentment had been eroded yet again by an oversight of some detail on her part that he turned on with a savage outburst, I confronted him with an unusual challenge. Why did he choose to live with someone who – it seemed – he despised? He found himself at a loss and at this disarming moment words came tumbling out that had a decisive impact on the therapy. He lost his charm and eloquence and in a series of faltering images described his wife – who sat looking at him with injury in her face – as a woman with the wings of an angel who kept these wings round the children to ensure their safety. She was the safeguard for them all. She was moved to tears and there was a moment between

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them of poignant reparation. In the sessions that followed we came to a better understanding of what these angel’s wings represented. It was his wife’s embrace, he said – the wings of the angel – that kept their home as a place in which the children would always have security. They attended day school and would not have to go to boarding school. The mothering she provided gave them a devotion that neither of their parents enjoyed. Through Gabriele’s identification with his children and the evident nourishment they enjoyed at home, he gained an elemental gratification that had been withheld from him by his parents. The exploration took us back to the disaster that lived within him in a childhood world dominated by a playboy father and a lonely, depressed mother. He was eventually able to see the compulsive repetition of his father’s cycle in his own behaviour with the split-off world of devastating childhood shame now threatening a return one generation later to be visited on his own children. In his counter-identification with his father’s profligate ways he had become an eminent banker. But the lost self of his childhood world lived on within him, and through his previous infidelities and drugs he would revisit this world from the standpoint of the father. He had set these patterns aside from the time of the police investigation but still lived with a permanent craving for both drugs and sexual promiscuity. His two forms of therapy – the couples work and his continued attendance with a drugs counsellor  – gave protection against further re-enactment. When he could see the meaning of these drugs and deceits he was able to slowly relate to his now dead father in less vengeful terms that then allowed him to forgive himself. This was the beginning of a true recovery. At the conclusion of their therapy when asked what had changed most fundamentally for them, he said her angel’s wings now included him in the circle of her embrace. She explained she had known about his drugs and infidelities down the years. She had taken refuge amongst the daughters from where she had learnt to despise him, but she still dreamt of better things. She knew now how much he wanted her sexuality and was relieved to find that he now knew how much she wanted him. When she gave herself to him he filled her with his love. When she thought about him at times of separation she knew he had once again taken on the mantle of her long-dead grandfather, the only figure of respect she had in her family, who used to call her ‘his little angel’. But, she said, she was a ‘big angel’ now, and had her own sexual desires which – at last – he was now honouring. She no longer had to put ‘wings’ round the family on her own. The happiness they found with each other was extended to everyone in their home.

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Commentary The mnemic object in Bollas’s account – wife as an angel to husband and family – is a widely represented symbol in the cultural life of many societies. She emerges here as a figure of grace with an embrace like the wings of an angel for a husband who has a high level of expressed aggression and is responsible for deceitful misconduct and toxic outbursts. She is non-retaliatory, stands by him through betrayal and waits for his return to the reciprocity they enjoyed in their younger years. This is the woman who Welldon describes as ‘mother’ and ‘madonna’, whose angelic disposition is protected in the family and whose husband finds sexuality outside the home with ‘whores’ (Welldon 1992). The resolving process introduced by the threat of prosecution outside engaged them both in successful couples therapy that restored their lost sexuality. It allowed her to grow in strength and maturity as she became a sexually active ‘angel’. The first two categories of Table 16.2, Bollas’s account of the successful use of the mnemic objects and the couple’s ability to be played with by this image in which one of them was an angel, are both evident in this vignette. Bollas’s next two categories emerge in Vignettes 16.3 and 16.4.

Angels in group therapy Vignette 16.3  A band of angels in a group of refugees

These events took place in the centre in which Darius, described in Vignette 16.1, was having his therapy. It provided rehabilitation for refugee survivors of torture and atrocity. After one year of individual therapy he joined the small group described in Vignette 2.1. We were meeting through the events of 9/11 when a major security clampdown took place in London. Many attending our centre were fearful of arrest. Most attending our group were awaiting the outcome of either an asylum application or an appeal against being denied asylum. They had all suffered torture, and most had witnessed grotesque forms of death in their countries of origin – in Algeria, Iraq, Iran, Kosova, Rwanda and Somalia. It was a time of heightened fear, tension and anxiety. We did not know that one of our members had the door of his home broken down in the middle of the night by the Special Branch, who arrested him for interrogation. He was missing for a group session that led to enquiries, and our centre was finally in touch with the Special

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Branch. This group member had become psychotic under interrogation. The police did not know what to make of his mental state and were relieved to be guided by one of our psychiatrists. He was soon discharged and returned to a home without a door in which all his possessions had been turned inside out by the police search. We met with him and brought him back to the group where the other members’ concerns were amplified. The police finally assured him that he had been the victim of wrongful arrest, but on hearing his account of the arrest – he was woken with a policeman in black on top of him with a weapon with a torch on it pointed at his face – we were all shaken. He had a sense of utter wretchedness in his neighbourhood where he was known and where it mattered that they now saw him as a threat. He lived on the fourth floor of a public housing estate that had open balconies into a courtyard. The most chilling disclosure came when he told us that his family – who we knew to all be dead – often came now to see him over the balcony and called on him to join them. He could hear them talking to him and recognised their voices. His mood was febrile, his thoughts were disordered and he had no sustained narrative. By the time this session was over everyone in the group was jumpy. We arranged for his admission to a local psychiatric service where he spent three weeks and joined us for the groups whilst staying there overnight. His hallucinations drove two of the other more fragile members to join him in a form of contagious, post-traumatic psychosis and they all came to believe their dead relatives, who they called ‘the ghosties’, were calling to them from the other world. We understood this as a plea for help with suicidal ideation now their fragile security was threatened, so we also referred the other two for additional psychiatric help. Their PTSD–type flashbacks had become florid visual and auditory hallucinations that took a bizarre and frightening turn, dominated by the mutilated imagery of their dead – ‘the ghosties’, who kept calling them. Jonas, a Catholic from Rwanda with a loud voice and strong personality, did not like the contagion of the dead amongst us, nor did Darius, who was described in Vignette 16.1. By the time Darius joined the group he had a grounded sense of reality through a long course of individual therapy. Jonas and Darius tried to explain these hallucinations as symptoms to those who carried them. One of the men, an Albanian from Kosova whose wife bled to death in his arms when they were shot by Serb paramilitaries, was developing a new relationship with a woman – a fellow refugee from Kosova – and they loved each other. Now, however, his dead wife came back, along with the

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other dead, and they did not like seeing him with a new lady. Jonas and Darius did not like these ‘ghosties’ and encouraged their fellow group members to send them away. This went on for some weeks as the group re-gained some sense of containment, the three with hallucinations settled on their medication and the external sense of threat abated, but the ‘ghosties’ still came to talk to their loved ones. Eventually Jonas told the group about a song he thought we needed to know. He told us about blacks taken from West Africa to slavery in America, of their suffering – like us, he said – and of how they learnt English and became Christians. He was the only group member who was not a Muslim. One of the great songs from slavery, he told us, was about a band of angels who came from across the Jordan river on the other side of death to collect people at the end of their lives and take them to Heaven. He told us it was called ‘Swing Low, Sweet Chariot’. Later several of the others found out about the song on the internet. But, he warned, ‘they won’t come for you if you take your own life. If you ever want them to take you to Heaven you have to wait for them to come’. Islam carries the same prohibition of suicide, and his challenge in this warning provided the sounding board we needed as, along with Darius, they introduced the angels against the ‘ghosties’. We went through a long period of exchange in which the discourse was dominated by serious consideration as to which of these groups would prevail. In the months that followed ‘the ghosties’ disappeared altogether.

Commentary In this group contrasting sets of mnemic objects are counter-posed against each other. The members’ individual and social unconscious are occupied by ultimate experiences of horror. Despite progress in rehabilitation and therapy separately and together, they remain an ‘occupied’ population like war veterans. In Chapter 10 advances in psychoneurology are applied to the understanding of limbic resonance.  A population of violated people will be prone to flashbacks and can be re-traumatised partly though limbic resonance. The limbic regions of the brain are not subject to ‘normative’ regulators that would – in other such cases – give people a degree of control over the imagery that enters the mind. If they can be easily ‘flooded’ by seemingly ‘innocent’ stimulators, how much more harmful are threatening events committed by those they thought might (Continued)

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(Continued) give them security. Their ultimate experiences of horror now emerge as the objects of psychosis called up from their social unconscious. The ‘ghosties’ are described in the group as ‘the contagion of the dead’. They reminded my cotherapist and me of Banquo’s ghost in Macbeth. Each of these psychotic men was backed against the wall, like Macbeth on the stage, overcome by the horror of what they could ‘see’, amplified in the terror of what they heard and saw of the other visitations around them. ‘A band of angels’, introduced by one of the members from his knowledge of Negro spirituals, was set against these horrors. It provided the group with new mnemic objects that, taken seriously in the group and explored as real sources of meaning, helped put the horrors to flight. Without doubt neuroleptic medication ‘did the job’, but the stories of the angels and ghosties are with us to this day in our occasional communications. When Darius told the others how angels had kept him alive whilst he was tortured – described in Vignette 16.1 – he found that the angels that had deserted him on his flight to safety in the UK returned to help the group, ‘like a Gin’ (a genie) said one of them, with the power to restore them all to safety.

The concluding vignette in this chapter is set in a group in private practice for people with complex and enduring psychological problems. It is a long-standing therapy whose members have varying lengths of stay.

Vignette 16.4  Jacob’s Ladder in the group

Melanie opens the session with an embarrassing disclosure. She doesn’t know what to do with herself and doesn’t know how to talk about it. She smiles and blushes and stops and starts again. She was at ‘Grandma’s’ for the week-end – we know what kind of sanctuary she finds there, it gives her the only sense of safety she knows – and she left something behind. ‘Well’, says one, ‘you’ll pick it up next time’. She can’t respond and, looking at the floor in embarrassment, stops again. I can’t tell you and there’s no one else I can tell’. So tell us, says one of the members. ‘It must be very important to make her blush like this’, says one of the women, Nafisa. ‘It was my vibrator’, she says, ‘and the porn movie I’ve been watching when I use it. They weren’t even in a cover. I just left them in the drawer beside my bed and I  know Grandma had other guests who were going to use the room when I left. She will have had to clear that drawer for them and she’ll have found it, definitely’. Nafisa says, ‘I can see it’s

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embarrassing, how did it happen?’ And then she turns to the group and the conductor to say, protectively and on Melanie’s behalf, ‘And don’t you ask her why she wanted her grandma to find it. Oversights happen!’ Melanie tells us some of the story and is squirming with discomfort. There is a kind of forgiving laughter amongst us. She lives on her own and has been making productive use of the group to talk about different and unsatisfactory connections with the men she has been seeing over some time. One of the men says, ‘Well, it’s helped me in my own picture of you. I’ve always thought you were “above it”, and now I know you masturbate like me, and I can feel less ashamed of both of us’. Then he asks Melanie, ‘What’s the worst part, assuming she does find it?’ Melanie replies, ‘Well, she loves me. And when we say good night, or when I say goodbye when I go, she calls me, “My angel”. What will she think of me now?’ Another one of the men asks, ‘Do you think angels don’t have vaginas?’ The whole group laughs, especially Melanie. A serious discussion ensues about whether angels have vaginas. Another of the women says, ‘Your grandma must have a vagina or you wouldn’t be here now’. There is more laughter. Another of the women, Linda, who is sometimes in despair over her suicidal thoughts, reminds us of the peace she finds when, overcome by what she calls her ‘dark pictures’, she visits the city of Bath. Sometimes she goes there for a week-end, takes her notebook and, sitting in front of Bath Abbey, describes ‘the flight of angels’ in the sculpture over the Abbey’s front façade. ‘It’s meant to describe Jacob’s dream’, she tells us. People ask her about the dream and she responds, ‘Jacob had done something dreadful, I can’t remember what’. Nafisa, a Muslim who knows the Koran, tells us what he had done. Melanie returns to say, ‘and then he runs away from home and he falls asleep on a rock. In his dream he sees a flight of angels going between heaven and earth. They’ve got those angels over the front of the abbey, and I make up stories about where they’re going. One of them came to him to release him from his guilt. I imagine I might be visited too’. One of the men says, ‘Well, we try to do that. We tell you all the time you’re not guilty and then you reply by telling us you’re just a piece of dirt in the street. What would the angels think of that?’ There is more laughter. Melanie has been joined by Linda and neither of them is on their own. Discourse in the group has transformed Melanie’s discomfort into something uplifting as it brings us restorative news from Linda who was previously our most depressed member. Another of the group’s depressed members is Mark, an isolated man who is new to the group and withdrawn for much of the time. He has lived on his own for years and tells us there is a song they sing in his

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religious community on a Friday night. He is an observant Jew. It’s called Shalom Aleichem and tells the story of angels that visit on a Friday night. ‘That’s a great melody’, says the group’s guitarist who has heard someone well known playing it on a guitar. He tells us who the famous guitarist is who has set it. Someone else wants to know what these angels do on a Friday night. Mark tells the group about the folklore in the Jewish traditions of Eastern Europe. When congregations gathered in synagogues on a Friday night and then made their separate ways home, people were identifiable and often in danger. ‘So they imagined angels came to protect them on their way home, and they made a song about it. That’s the last song we sing in synagogue on a Friday night service. And I imagine the angels see me home’. One of the other members asks, ‘Are you always home alone?’ He becomes sad when he says yes. Nafisa says, ‘I would like to come home with you and cook, but he wouldn’t let me’, she points to the conductor, and the whole group laughs.

Commentary The group later learnt that on Melanie’s next visit to her grandma’s house she found her vibrator and movie in the same top drawer of the bedside cabinet where she had left them. Her grandma was as loving as ever and she used the same phrase, ‘my angel’, when she said goodbye and goodnight. The group atmosphere, with its qualities of frank, fearless and direct disclosure in the different areas of people’s lives continued as the discourse progressed to other figurations. The lonely man did find a loving woman to cook with for a Friday night meal, and the depressed woman grew in strength and outlook to later meet a man with whom she is now expecting a child. The milestones of progress are visible features of different members’ journeys, and the angels are always available for the group to return to.

Intersubjective validation Traditional analytic tools have done too little to uncover the deeper levels at which character disorder can play itself out. The language of compulsion is itself relatively superficial in giving us access to the dynamics that govern relational patterns including partner choice. In Vignette 16.2, beneath the compulsion that directed Gabriele’s abusive behaviour with his wife and his self-abusing patterns,

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is a searching quality I have learnt to describe as the search for a reparative dream. In turning to his wife with debasing emotions, Gabriele sets his unconscious sights on patterns that are all too familiar, but he returns to these patterns in the hope of being able to set them right. The sense of shame by which his childhood was degraded means that he returns to this very arena hoping for some corrective recapitulation of the original injury. Partnerships with such an interface mean – inevitably – that the commission and reception of such behaviour has to be understood in terms of a shared internal object. Dicks was the first to use this term, which captures the sense of ‘emergence, during the (couples) therapy, of the dominant internal object which both parties seem to share inside themselves, and in the marriage’ (Dicks 1989:205–206). Who is inside what? The tragedy in most such cases is that the return of the repressed or the return to the familiar becomes a reenactment rather than a corrective re-capitulation, and this is most often the case because, at an unconscious level, the other partner is trying to negotiate exactly the same quest in the opposite direction. They get in each other’s way and each ends up re-enacting the very behaviour they are in flight from. We can bring Dicks’s valuable concept from couples therapy into group analysis by considering how, in Vignettes 16.1, 16.3 and 16.4, the dominant internal objects emerge in therapy. In 16.1 they stem from desperate and life-threatening circumstances that are re-visited in individual psychotherapy and emerge in 16.3 as a band of angels that people set against the mnemic objects of their shared psychosis to bring the group a new-found sense of safety. In 16.4 separate and previously unrelated references to angels of different kinds are discovered peopling the group’s common zone where they emerge in its discourse, and they become the binding metaphors of transformative experience. In the literature that opens this chapter  Brown provides us with the concept of intersubjective validation by which we can see how the couple in Vignette 16.2 are eventually able to gain freedom from their collusion. The term describes what I believe to be most valuable in what people provide for one another in the two group vignettes, 16.3 and 16.4. Bollas provides us with a language – a vernacular – with which to address the deeply held symbolic form in which their reenactments have, until now, taken place. In Vignette 16.3 and 16.4 people’s shared internal objects emerge from the discourse of their groups and in their own different vernaculars to acquire a form of words that allows ‘the lifting of the self’, as Bollas puts it. When we explore the discourse and allow the reparative dream that people search for to become a revenant, a new emergent in their ordinary lives, then angels’ wings can become an idiom for both survival and transformation. These are the metaphors of metamorphosis.

Note 1 This chapter is adapted from a paper published under the title ‘The Social World of the Forsaken Psyche’, Group Analysis, December 2001. Acknowledgements are made to Sage for permission for its use. It was first presented at the Study Event to celebrate the

438  III  The dynamics of change work of Dennis Brown held at the Group Analytic Practice, 20 October 2001. I should like to acknowledge the contribution made to its final form by participants at the event, in particular the late Dennis Brown.

Bibliography Auden, W. H. (1966). Collected Shorter Poems 1927–1957. London, Faber. Auden, W. H. (1979). ‘Musee des Beaux Arts’ in Ed. Mendelson (Ed.), W. H. Auden: Selected Poems. London, Faber, p. 79. Bateman, A., Brown, D., and Pedder, J. (2000). Introduction to Psychotherapy. London, Routledge. Bion, W. (1959). Attacks on Linking. In E. B. Spillius (1988), Melanie Klein Today Vol. 1. London, Routledge, pp. 87–101. Bollas, C. (1987). The Shadow of the Object: Psychoanalysis of the Unthought Known. London, Free Associations Press. Bollas, C. (1990). Creativity and Psychoanalysis. In C. Bollas, The Mystery of Things. London, Taylor & Francis, pp. 167–180. Reissued in M. Gerard Fromm (Ed.), The Spirit That Impels: Play Creativity and Psychoanalysis. London, Karnac, pp. 3–20. Bollas, C. (1993). Being a Character: Psychoanalysis and Self-Experience. London, Routledge. Brown, D. (1994; 2000). Self Development Through Subjective Interaction: A Fresh Look at Ego Training in Action. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. Routledge, London. Reissued 2000, London, Jessica Kingsley. Republished in J. Maratos (Ed.), (2006), Resonance and Reciprocity: Collected Papers of Denis Brown. London, Routledge, pp. 107–123. Chalkley, J. (2015). The Content of Psychological Distress: Addressing Complex Personal Experience. London, Palgrave Macmillan. Cox, M., and Theilgaard, A. (1997). Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley Press. Dicks, H. (1989). Marital Tensions: Clinical Studies Towards a Psychological Theory of Interaction. London, Karnac. Freud, S. (1917; reissued 1984). Mourning and Melancholia. SE 14. Vol. 11, Pelican Freud Library. Reissued 1984, London, Penguin Freud Library, pp. 237–258. Langmuir, E. (2010). A Closer Look: Allegory: National Gallery Guide. London, National Gallery Company. Levens, M. (2011). Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation. MSc dissertation. Institute of Group Analysis, London/ Birkbeck College, University of London. Modell, A. (2011). Metaphor, Meaning and the Mind. In S. Montana Katz (Ed.), (2013), Metaphors and Fields: Common Ground, Common Language and the Future of Psychoanalysis. London, Routledge, pp. 59–66. Montana Katz, S. (Ed.). (2013). Metaphors and Fields: Common Ground, Common Language and the Future of Psychoanalysis. London, Routledge. Ogden, T. H. (1993). The Analytic Management and Interpretation of Projective Identification. In A. Alexandris and V. Grigoris (Eds.), Counter-Transference: Theory, Technique, Teaching. London, Karnac Books. Ovid. (2004). Metamorphosis: A New Verse Translation. London, Penguin Classics.

16  Metaphors and metamorphosis  439 Pines, M. (2015). Collected Papers. London, Routledge. Schlapobersky, J. (1994; 2000). The Language of the Group: Monologue, Dialogue and Discourse in Group Analysis. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. London, Routledge, pp. 211–231. Reissued Jessica Kingsley Press, pp. 211–231. Schlapobersky, J. (1996). A group-analytic approach to forensic psychotherapy: From the speech of hands to the language of words. In C. Cordess and M. Cox (Eds.), Forensic psychotherapy: Crime, psychodynamics and the offender patient. Vol. 1: Mainly theory. Jessica Kingsley, London, pp. 227–243. Schlapobersky, J. (2001). The Easy Hand: The Problems of Domestic Violence in Marital Psychotherapy. Journal of the Society for Psychoanalytic Marital Psychotherapy. Schlapobersky, J., and Pines, M. (2009). Group Methods in Adult Psychiatry. In M. Gelder et al. (Eds.), The New Oxford Textbook of Psychiatry. Oxford, Oxford University Press, pp. 1350–1369. Smail, D. (2001). The Nature of Unhappiness. London, Constable. Weegman, M. (2014). The World Within the Group: Developing Theory for Group Analysis. London, Karnac. Welldon, E. V. (1992). Mother, Madonna, Whore: The Idealization and Denigration of Motherhood. London, Karnac. Winnicott, D. W. (1963, 1985). Communicating and Not Communicating Leading to a Study of Certain Opposites. In D. W. Winnicott, The Maturational Process and The Facilitating Environment. London, Hogarth Press, pp. 179–192. Wojciechowska, E. (1993). The Group as Transformational Object: Fusion, Transition, Transformation. Theory Paper, Institute of Group Analysis, London.

Acknowledgements:  Extract from Bollas (1987) The Shadow of the Object: Psychoanalysis of the Unthought Known and Table 16.2 reproduced with permission from Christopher Bollas; extract from W. H.  Auden, ‘Musee des Beaux Arts’ copyright © 1940 by W. H.  Auden, reprinted by permission of Curtis Brown, Ltd., NY; extract from Clews (2011), The Group Analytic Dynamics of Absence: (Re)-Embodied Shame at the Boundary of the Reflective Space. Dissertation Birkbeck College University of London/Institute of Group Analysis, London, with permission from Melanie Clews.

Chapter 17

Location, translation, interpretation The heart of the group-analytic model

The location of a disturbance is a new concept . . . If one looks at a psychological disturbance . . . located as taking place in between persons, it follows that it can never be wholly confined to a person in isolation . . . The total configuration then puts a different emphasis on the disturbance as manifested in any individual . . . (Location of) the group’s disturbances . . . invariably involves the conductor in his position as leader . . . standing not only inside and outside the group but also inside and outside himself at the same time. (Foulkes 1948/1983:127–128) Correct interpretations are not necessarily good interpretations. They can be experienced as attacks and humiliations. Truth is not objective and impartial: it is always personal. It is only in the development of trusting personal relationships that people can reach to and speak out their truths, that then speech will reveal more than it conceals. (Pines 2015a:5)

Whilst sitting amongst the people in my groups I regularly ask myself the question: ‘What is going on here?’ and I am sometimes reminded of a radio play we used to listen to as children in which a group of familiar characters creates an opening scene of comic mayhem on the stage before a studio audience. Finally a policeman arrives who – judging by the laughter on the radio – would have been a figure of ridicule. He calls out, ‘Hello, hello, hello, hello! Now what’s going on here?’ We used to laugh every time. This picture of a ridiculous policeman questioning six comic reprobates is hardly the way to introduce the subject of location that stands at the heart of the group-analytic model. It is not always wise to put the question ‘What is going on here?’ to the group, as it belongs to the conductor, who does not sit in the group as its policeman and should hardly be a figure of ridicule. The conductor’s trust in the group will be revealed by their attentive involvement, curiosity and above all their conviction that the unfolding events have meaning that all can appreciate and which will be of value to everyone present. When frustrating events take place in a group that refuses to yield meaning, the conductor may choose to wait until they do or may express open perplexity and use the policeman’s question if not his tone and can often discover that this will move the

17  Location, translation, interpretation  441

situation forwards. I find that if I am at ease with the ridiculous and can be as surprised as any of the others in the room by the unpleasant or unexpected, this gives me credibility for the challenges to come. I will then need to show that first, I can contain things in the group and second, that I want us to explore the novelty of the difficult moment, as Wotton has put it (Wotton 2011). This personal chemistry can provide the catalyst through which a group can be helped to progress from the relational to the reflective dimension as described in Chapter 2. The term ‘location’ emerged in the first of Foulkes’s books quoted above, and though it was inconsistently treated, disappearing in the text he wrote with Anthony in 1957 and re-emerging in Therapeutic Group Analysis (1964) and again in Method and Principles (1975), it is a key to the approach. In this chapter I am linking it to another of Foulkes’s key concepts, translation, and will bring both these defining group-analytic terms together with interpretation, which is central to psychoanalytic practice. In group analysis Foulkes gave only qualified value to the use of interpretation, insisting that analysis – a broader concept – composed of location and translation – should take precedence. This chapter will discuss these points. In my own practice I have learnt to use these three principles in an integrated way, and I find that the connection between them guides me in all that I do. Our students appreciate this integrated approach but, obvious as the need for integration seems to be, there is a limited literature. Friedman’s recent paper provides a summary of the available writing on integration (Friedman 2014). This chapter sets out to make the case for a working connection between the three principles of therapeutic intervention. The structure laid down through the book in its different dimensions and domains lays the foundations for the account that follows. I have approached Foulkes and Anthony’s available literature for source material on these three principles of therapeutic intervention, and, in Tables 17.1 to 17.4, I have set out as best I can, an orderly exposition of what I believe their writing can yield on these subjects.

The conductor, the baton and the student As a student I was often at a loss and, though there are no shortcuts to competence, the questions and misgivings posed by our students through the generations of training, point to some of the lacunae this book looks to address. In the supervision group in which I had my training we were all inexperienced as we worked together setting up the groups we were conducting in hospital settings to meet the training requirements. One of my colleagues came into supervision one day chuckling about an incident that had taken place in her group’s first session.

Vignette 17.1  Where is the conductor’s baton?

My colleague had a series of preparatory individual sessions with each of her prospective group members as we were trained to do and they then met with her for the first time as a group. It entered its predictable

442  III  The dynamics of change

opening stages of serial monologue (described in Chapters 2 and 4) with edgy and anxious question and answer, followed by silences that she tried not to interrupt. After some 20 minutes one of the group’s members, Basil, a man with a very concrete grasp of circumstance and situation, said, ‘Well, when are you going to begin?’ She asked in turn, ‘Begin what? And he said, ‘begin conducting’. She asked, ‘What do you mean?’ and he said, ‘Well, you told us that you would be the conductor of this group, at least you told me when we met alone. And then you introduced yourself as the group’s conductor at the beginning of the group when we started out this morning. But you’re not doing anything!’ She replied, ‘We began 20 minutes ago, and I’ve been conducting the group since we began’. He said, ‘But you’re not doing anything!’ And she said, ‘What do you think I should be doing?’ He replied, ‘But that’s a ridiculous question. I don’t know what you should be doing. When we met you told me you would be conducting this group and that would help us get better. And now you’re doing nothing. And you’re just dodging my questions!’ Our laughter then is still a source of amusement. If my colleague had answered Basil by saying, at the time, I  will do some location, translation and then interpretation, he may really have got up to leave. It was the first meeting of the first group she had conducted and she overlooked saying anything to prepare her members for free-floating discussion. Our institute’s training hardly addressed the concept at that time. She went on to explain the term and its method of free-floating discussion and called on the rest of the group to help her with Basil’s challenge. He was on the verge of leaving the group but stayed. Later, when they were in the process of terminating the group three years on, she reminded them of Basil’s challenge at their first meeting. For several years they had been working on productive terms between all three dimensions of psychotherapy described in Chapter  2 and they remembered Basil’s bewildered enquiry with humour. ‘Do you know’, he said, ‘I even thought you would come in with a baton!’

Commentary Marteen provides an account – summarised in Chapter 3 on page 91 – that can help with the location of this opening disturbance and demonstrate the progressive utility of our developing frame of theoretical reference now established through the chapters in this book. He describes how people seeking psychotherapy make first contact with a group analyst in a two-person

17  Location, translation, interpretation  443

relationship following which entry to a group can be experienced as a difficult psychic leap. Basil, expressing feeling for the others also, found the leap too far and was probably longing to get back to the safety of a two-person relationship with the conductor. His protest at the manifest level was about the conductor’s apparent inactivity but behind this was a likely protest over the loss of intimacy. The conductor understood that both his protest and longing were expressed on the group’s behalf and provided the first step towards a triadic capacity for relatedness – the beginnings of the ‘model of three’. She brought people to talk to one another about Basil’s protest. She thus turned the dialogue between Basil and herself into discourse in the group. Readers will appreciate the quality of reflective understanding by which the conductor located the disturbance and took the right steps to establish a primary sense of relatedness. Members of the group were limited by the novelty of the situation to the relational dimension and the conductor wisely ‘nursed’ them through their first challenge – which was to establish commonality – without a reflective observation and with no attempt at translation or interpretation. They established commonality by talking about the conductor and spent a lot of time discussing what she did and should have said in their preparatory sessions and opening meeting. She stayed with and encouraged this. The move to the reflective dimension that allowed translation came later, followed by the reparative dimension.

Three principles of therapeutic intervention in groups Figure 17.1 shows the dynamic relationship between the three principles of therapeutic intervention, in which location is given primacy. Without it there will be nothing to translate and interpretation can only be blind. The outside circle of arrows shows clockwise movement from the conductor’s understanding – location – to a new body of meaning created in the group by the process of translation that will be initiated by the conductor and then taken on by the group. The work of translation will then lead on to interpretation. The inside circle of arrows shows the three principles in a steady and dynamic relationship with one another, which is a different way of thinking about these principles. We can see the principles as different ways of talking about the same thing with each principle bringing one emphatic quality out of the widening cycle of development. This cycle of development, viewed according to either set of arrows, involves a progression through the three dimensions of psychotherapy, through the five phases of group development, through the three language forms of the group and through a progression from longing to belonging. At many points of impasse,

444  III  The dynamics of change Locaon

Interpretaon

Translaon

Figure 17.1 Three principles of therapeutic intervention in groups: Location, translation, interpretation

resistance or regression, the conductor will need to call on principles of location to help with the understanding of the moment and see to further forward movement by translating from the symbolic language of symptoms whose constructs and compulsions can be translated into the language of the real, generating new levels of authenticity in a coherent body of experience. By keeping the channels open among the four domains of the group’s experience – current, transference, projective and primordial – she ensures that the unconscious imagery of the primordial can reflect upon and be informed by the current domain’s activity. The projective and transferential dimensions – through which distortions are projected into the circle  – are available for interpretive commentary. So by keeping the holograms pervious to one another’s influence the conductor and the group together can live through a developmental harvest of the group’s selfgenerated metaphors, making them mutative through interpretation, relieving people of the suffering that brought them into therapy and allowing growth to change their lives. Location Foulkes’s first statement on location is given in the quote that opens this chapter taken from his first book. His more fully articulated statements on the subject come from his two last books. Every event, even though apparently confined to one or two participants, in fact involves the group as a whole . . . part of a gestalt configuration, of which they constitute the ‘figures’ (foreground) whereas the ground (background) is manifested in the rest of the group . . . Location (is) the process which brings to life this concealed configuration . . . (and is) not always a simple matter. (Foulkes 1964:110)

17  Location, translation, interpretation  445

His guidance here does not take us to the next step in terms of what the conductor actually does once the concealed configuration has been brought to life. His later guidance is salient but still unclear. He writes that: Location presupposes the conductor becoming aware of the relevant configuration of the observable phenomena . . . he can divine the relevant key in which the group speaks at that moment. Only in speaking back to the group in that same key can he hope to be understood relatively well . . . the good conductor, the good therapist, talks back in the language in which things reach him, in the language current among the members of the group. (Foulkes 1975:131) When the conductor speaks back to the group in its own key and current language, the language in which things reach him, what does he actually say and to what end? Unfortunately, Foulkes is again unclear and provides no guiding perspective. To answer these questions we need to move on to his next concept – translation – and integrate it with location. Once these two principles of clinical work are established in the chapter, we can bring interpretation forward to complete the picture. But we can anticipate that even in the expository detail of Tables 17.1 to 17.4, we will again find Foulkes’s unanswered questions, incomplete formulations and unfinished business. Translation The term is first used in Foulkes and Anthony (1965), where it receives the only comprehensive treatment. Although the term is used again in Foulkes’s two later books he does not add anything new to the notion of translation in these books except better definitions such as the one in Therapeutic Group Analysis, where he defines ‘Translation (as) the equivalent of the making conscious of the repressed unconscious in psycho-analysis’ (Foulkes 1964:111). In his Methods and Principles he says: Analysis is work done in the service of making unconscious meaning or expression conscious . . . a double process going on from below upwards . . . and from the surface downwards . . . translations from one type of expression, from one language to another, from symptomatic and symbolic meaning to a clear understanding of what is at stake. (Foulkes 1975:111) Foulkes and Anthony provide a comprehensive account of translation, and Table 17.1 gives a systematic exposition of their material. They seek ‘the discovery of unknown and unadmitted motives and motivations’ and in ‘establishing a therapeutic situation’ to make these discoveries possible, translation is ‘the ‘all-embracing name for this whole task, which can be compared to the

446  III  The dynamics of change

deciphering of a code’ (Foulkes and Anthony 1957/1984:39). Although this book is the most cogent of all Foulkes’s writing, it still requires ordering to see how best to apply these ideas to the practical tasks of group psychotherapy. I have amended some of the expressions in the text but have tried to honour most of the original language and have used 12 points to bring out the underlying order in their approach. These 12 points are my own construction, and I would encourage readers to review the material directly on pages 55 to 60 of the original book. With the material mapped out below, the richness of the Foulksian paradigm and its clinical utility become apparent. The table makes a practical appraisal of their ideas for use in therapeutic practice. In the section to come, Critical Concerns, I will set out my own concerns about the incompleteness and unfinished quality of Foulkes’s paradigm. Table 17.1  Twelve features of group psychotherapy arising from the principle of translation: Foulkes and Anthony (1957/1984) (Foulkes 1975:55–60) Description/definition of translation

Therapeutic purposes of translation

1

Translation reduces the censorship of communication.

Helps arrive at the repressed and unconscious meaning of people’s symptoms ‘by steps and stages’.

2

Censorship of communication about people’s relations with others in the group, including the conductor, is also reduced.

Cultivates free and frank disclosure of personal feeling and experience.

3

The conductor accepts and encourages communication that might not be made in ordinary social situations.

Allows the social unconscious to be approached.

4

Group members’ personalities come to the fore and become fully and actively engaged.

Allows the group’s members to become fully and actively engaged so they speak and behave as spontaneously as possible.

5

The type of conversation which gradually develops is free-floating discussion.

In free-floating discussion, left entirely to the spontaneous mood of the group and its members, the conductor and group accept whatever comes up at each moment of each session.

6

The above, 1–4, is the material for translation and interpretation.

The whole group becomes engaged in the tasks of translation and interpretation and not the conductor alone.

17  Location, translation, interpretation  447 Description/definition of translation

Therapeutic purposes of translation

7 The fact that people attend because they are suffering and need help acts as a driving force towards cooperation in the therapeutic situation.

Self-revelation about people’s suffering is of enormous therapeutic value.

8 People come to understand and appreciate the mutual nature of exchange.

People gain self-knowledge by the effects they see themselves having on others and by the impact others have on them.

9 The group as a whole is informed by the communication of the individual.

The individual’s communication speaks for the group as a whole.

10 Group members are active participants in the therapeutic process.

People are not merely ‘recipients’ of treatment but agents in their own growth and development.

11 Unconscious meaning, motivation and interpersonal reactions are brought to light.

The work of discovery touches deep emotions and not merely people’s intellect. It includes people’s immediate reactions to others and appreciation of their mistakes.

12 There is work involved in each person’s struggle to make themselves understood and to understand the others. This ‘mental work and interpersonal effort’ is of central importance.

The work releases factors which increase people’s insight and forms a training ground where their relationships with others can be modified and tested.

Interpretation This principle is dealt with systematically in only the last of Foulkes’s books (1975), where it is given a comprehensive account that many years ago during our training we found to be invaluable. However, at the time we also found Foulkes’s way of setting things out frustratingly disorganised, and that view has not changed. Despite this recognition of Foulkes’s many ‘unfinished sentences’ in the account he delivers, as described by Skynner in the introduction, I  have found the clinical guidance offered by his perspective to be of lifelong value. He first makes clear that all a group’s members participate in interpretation and that it takes place all the time. What he then studies in the book is ‘interpretation as a practical tool applied consciously by the conductor’ (Foulkes 1975:113), and he defines this as ‘a verbal communication by the conductor to the group, or to members of the group . . . to draw their attention to . . . meaning of which he thinks they are unaware but may become aware through his verbal help’ (1975:113). He

448  III  The dynamics of change

advises on the value of getting the timing right, ‘when all or some of the members . . . or one particular member, seem very near to understanding something, but seem not quite sure’, and he cautions to use interpretations only when the conductor ‘has waited patiently but in vain for this insight to come from the group itself’ (1975:113). On Foulkes’s account the conductor can make an interpretation in a number of different ways and with different purposes in mind. Tables 17.2 and 17.3 provide a compilation of the ideas he sets out to convey, the first focussing in 17.2 on who does the interpreting, what it is that is interpreted, and to what purpose. Then in 17.3, his further observations about interpretation are set out on terms in which Foulkes is uncharacteristically directive about the ‘correct’ use of interpretation in his approach. He goes to great length to define the manner of interpretation and its purposes, and then – in Table 17.4 – he sets out what he advises against by way of interpretation. In Table 17.3 I have organised the directive detail of Foulkes’s further ideas on interpretation which are described here as his basic tenets. His similarly directive detail about what not to do when it comes to interpretation in groups is given in Table 17.4.

Table 17.2  Interpretation in groups: The who what and why of Foulkes’s approach. Who does the interpreting, what do they interpret, and why do they do it? Interpretation BY

Interpretation OF

Interpretation in order TO

Conductor

1 Defences and resistances

Overcome members’ reluctance to see uncomfortable truths about painful situations.

2 Transference: Big ‘T’ or a small ‘t’

Help people discover links between group present, historical past and outside world.

3 Countertransference

Pass back to individual, sub-group or group as a whole emotions lodged in therapist by projective identification.

4  Group interactions

Linking interpretations seen (by Foulkes) to be neither useful nor helpful. Why?

5 Repetition compulsion

To frame the understanding of regression ‘in service of the ego’ as information about originating trauma/injury now turned into new dependence in group.

6 Childhood experience emerging in group

Allow corrective recapitulation of early family life.

Interpretation BY

Individual group members

Interpretation OF

Interpretation in order TO

7 Boundary incidents and events

Address and resolve problems of authority.

All of 1–7

Expression of developing sense of agency.

Group as a whole All of 1–7

Action in unison.

Table 17.3  Ten basic tenets for conductor’s interpretation in group-analytic psychotherapy from: Group Analytic Psychotherapy: Method and Principles (Foulkes 1975) Basic Tenets for Conductor’s Interpretation in Group-Analytic Psychotherapy (Page references to Foulkes 1975)

Page

1

The purpose of interpretation is ‘to draw a person’s attention to another meaning in the line of thought or action he is just pursuing’. To interpret ‘is to transfer or to translate something from one context to another’.

114

2

Interpretations are given ‘only in order to improve and also deepen communication’.

114

3

Interpretations should ‘start always from the surface of things, from that which is manifestly present’.

115

4

Interpretation works ‘in the service of analysis and is dependent on the total insight . . . total interpretation the conductor forms of what is going in the group at that particular time’.

113

5

Interpreting needs to be ‘distinguished from analysing . . . which is far more comprehensive . . . Interpretation comes in where analysis fails’.

117

6

‘In giving an interpretation we do the work which the patient ought to do’.

116

7

Interpretation is called for ‘when there is a blockage in communication . . . concerned with resistances including transference’.

125

8

‘In order to be mutative, interpretations must be based on the available experience of the moment and as near as possible to the emotional level which seems to be most active’.

123

9

‘Interpretations are brought out in the light of activated experience and in the fire of the presenting emotion’.

124

The conductor needs to be careful in their interventions, for ‘he is likely to be taken as a model and it is important to free the members of the group from using this model function of the therapist as a guide for their own development’. This would be a definite resistance and would have to be analysed.

110

10

450  III  The dynamics of change Table 17.4  Forms of interpretation to be avoided in group-analytic psychotherapy from: Group Analytic Psychotherapy: Method and Principles (Foulkes 1975) Forms of Interpretation to Be Avoided (Page references to Foulkes 1975)

Page

1

Plunging interpretations: They are usually combined with premature and uncalled-for incursions into transference reactions containing as much of the analyst’s as of the group members’ fantasy

125

2

Contradicting interpretations: They involve taking up an adversarial position against the individual, group or sub-group, and from this position contradictions are confronted. They indicate a degree of insecurity in the person using them

127

3

Linking interpretations: When the analyst makes connections for group members he is ‘doing their thinking for them’. ‘These interpretations are ‘popular amongst analysts who are insecure, who feel the need to justify their existence, and are pleased when they can show their analytic functions to the group’. They are ‘harmless but neither useful nor helpful’ as they ‘draw away from the immediate here and now of the transference’

127

4

Classifying or categorising interpretations: which do not ‘stay with the actual concrete experience as it is manifest in group members’ contribution’

127

Critical concerns Translation and limits to the verbal Levens introduces the first set of critical concerns about the principle of translation. She writes that I have questioned the concept of translation, as if bringing the unconscious to consciousness is an end point. It remains to be integrated into the personality and metabolised by the group, with words or not. I hope that in the course of this work, some limitations of verbal language have become apparent. (Levens 2011:30) Levens’s caution about the over-valuation of words serves us well today. We are at a point in time when therapeutic practice has come to embrace the relational dimension of the work, when intersubjective validation, as described in Chapter 16, is seen to be of critical importance and the value set by emotional communication in psychotherapy has come to replace the privileged position of the analyst as the one ‘who knows it all’. As Pines puts it in the quotation that opens this chapter, ‘correct interpretations are not necessarily good interpretations. They can be experienced as attacks and humiliations. Truth is not objective

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and impartial: it is always personal’ (Pines 2015a:5). The governing imperatives in group psychotherapy are found in its relational bonds that set a context for the reflective and reparative dimensions that follow. If the experience is found to be suspect in relational terms for whatever reason, no amount of clever construction in the reflective dimension will bring on reparation. As Pines puts it, ‘It is only in the development of trusting personal relationships that people can reach to and speak out their truths, that then speech will reveal more than it conceals’ (Pines 2015a:5). Location and empty spaces Clews has taken the principle of location and applied it to the understanding of empty spaces in our groups. She writes that ‘there have, and will always be gaps and empty spaces in psychotherapy groups’ (Clews 2011:57). We were recently sitting with an empty space as one of our members was detained in hospital over worry about her pregnancy – then in an advanced state. When I passed on her message that both she and the undelivered baby were doing well and were due for discharge soon, one of the members made an observation whose profundity applies to all absences. He said that her absence at this time had a profound presence in the room – she was so ‘with us’ by being away. True as this was for an unintended and unavoidable absence, it is also true for intended and avoidable absence. Clews goes on to: Explore the meaning of the empty space left by the absentee in an analytic group. The discussion reviews the existing literature and identifies a gap in the way the absentee has been considered in the past. The exploration involves a discussion of the power dynamics implicit in ‘attendance’ and possible meanings of the communication by the absentee on the boundary of the group, or ‘reflective space’ . . . The group is potentially a shelter for thoughts, and a space for relatedness – where what is forgotten can be remembered and un-thought thoughts can be made known. In the presence of a benign witness cohesion can become represented in the mind and hopefully represented in the external world . . . we are in the world of the ‘abject’, the threshold at which things and being inhabit. Group members, (the absentee on behalf of the group as a whole) hover on the edge like the ‘soul of thought’. (Clews 2011:57) When people ‘hover on the edge’ like ‘the soul of thought’, the conductor requires a ‘bifocal’ vision to address the dynamics of the individual, of the group and their synchrony. Vignette 8.1 shows the conductor using locational principles to emphasise issues of authority that have bearing on boundary events thrown up by two of a group’s members with problems of attendance and payment. Vignette 8.2 shows another conductor using locational principles in a very different way. The second conductor emphasises the meaning of an ending by two cherished

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members whose imminent departure is protested against by an unexplained attendance problem in an otherwise stable group. Location in the first case gives rise to the therapeutic use of authority and in the second to an interpretation. Location of disturbance Salm describes how Foulkes: Emphasises the process of selecting the most relevant focus for understanding and intervention. The dynamic matrix of the group holds and expresses a complex process, the ‘total network’ of relationships and communications. The location of disturbance is the process of bringing to light what is the figure and what is the ground in the current configuration (Foulkes 1964:81). It is the conductor’s task to identify where communication is blocked. (Salm 2013:11) Foulkes puts a challenge to the conductor of any group to ‘divine the key in which the group speaks at the moment’ (Foulkes 1975: 131) and, when they elect to participate actively in the discourse, to do so in key as follows: The conductor’s first task is not merely to perceive meaning, but also to place it in the appropriate dynamic setting. I have termed this process location . . . Location presupposes the conductor becoming aware of the relevant configuration of the observable phenomena. Thus he can divine the key in which the group speaks at the moment . . . This location is particularly important when it refers to a disturbance in communication, to resistances or defences that prevent a free flow of communications or their reception and thus the sharing of them. (Foulkes 1975:131) Location by members of the group Vignette 17.2  On making a home amongst strangers

Two new members joined a small group. Sandra was a health professional in her 50s with adult children. Grant was in his 30s with a promising career but lonely personal life. His presenting difficulty was a depressive reaction to his widowed father’s disability and ensuing heavy drinking. Sandra’s presenting problems included the challenge of finding love in the second half of life – she hoped for a relationship with a man but there was a problem with every one of them! Grant was an only child loved by his mother but neglected by the father who now needed him. They survived the loss of the family’s mother five years earlier, but he could no longer deal with his father’s Parkinson’s

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disease. Sandra’s history included an aggressive, volatile father who was cruel towards his children and especially her brother, who became alcoholic. During the first sessions Grant revealed his reliance on drinking to help him deal with the misery of his father’s illness. The following discourse was led by Sandra who recounted their father’s cruelty, mother’s inability to protect them, ruinous consequences in the brother’s drinking and the family’s distress. In later sessions Grant was subdued and reported how troubled he was to hear his future in the story of Sandra’s brother. ‘Coming here’, he said, ‘is a trigger that makes me drink more, not less!’ Sandra called on him to tell the group about his missing mother, and he eventually became tearful as he did so. She responded with tears of her own, and there was a lot of unexpected crying. In later sessions Sandra described how she wanted to protect her brother when their mother failed but, being so little, was helpless. Now, we understood, she is a strong and successful mother, and though new to the group, she led the others in reaching out to Grant and becoming a surrogate for his mother. He later brought us memories of his childhood and was overwhelmed when his narrative reached the account of her death. Now we addressed the unresolved grief-work. Sandra told us of how moving she found it to see him unfold as a man maturing through his tears and coined a phrase that still lives in the group: If you can weep you won’t drink – release the water and you won’t need to take it in as poisonous milk.

Commentary As aliens became allies in the intermediate territory – the transference domain – she ‘found’ her lost brother, and he ‘found’ his lost mother. Behind these discoveries was the continuing presence of the conductor as the good father neither of them had known. But this was not their family. They both made a home amongst strangers, and from their shared unconscious she found where he was hurting by re-visiting the injury she carried; and he found feminine qualities in her that his mother’s death foreclosed on. She keeps Grant with us in the group’s relational dimension, which plays a part in his tentative development outside. As she bears witness this helps begin shifting her own deep despondency about men. All three of psychotherapy’s dimensions – the relational, (Continued)

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(Continued) reflective and reparative – arise in a synchronous way through the locational contribution of one member’s reactive concern in the current domain about the lost woman in Grant’s life. Sandra leads the way in filling this gap, and, when she projects her brother’s history onto him, she wrests a metaphor from the primordial domain to assure Grant that water released will not have to be found in poisonous milk.

Paying Love Forwards Arlo provides the promising notion of paying love forward to explore stories in group therapy where gratitude is transposed into generosity. In her account of reparation between siblings when one of them has the benefit of group therapy, she describes how the group itself becomes a reparative arena in which ‘you don’t pay love back. You pay love forward’. It goes out to the people around you in the group who have helped to bring you to a new threshold of development (Arlo, 2014). All seven of us in the circle became witnesses to a reparative dialogue between these two based on empathic mirroring which turned into discourse round the circle as people resonated to the sense both of injury and resolution with other stories of their own.

Reflections in conclusion The portal moment opens a door to unexpected depth in this book’s last clinical vignette. It takes us to the reparative dimension as it calls up primordial meaning about cathartic release bringing us full circle to connect again with Vignette 2.1 on page 68 in which Jonas asks Mustafa, ‘my brother, what have they done to you?’ This earlier locational moment is also a portal one. It involves the relational dimension of psychotherapy and arises in the current domain. Vignette 17.2 brings all four domains into play – the current, transference, projective and primordial – and arises in the reparative dimension that rests on both the others. In conclusion both these vignettes demonstrate how: We utilise a set of clinical principles that govern the setting, the therapist, the therapeutic method, the group matrix and its language to take what is occasional and exceptional and turn it into a programme that can open the world of ordinary society to many who would otherwise live and die on its margins. (Chapter 1, page 47, this volume)

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A conductor who has benefitted from a fruitful experience of group-analytic psychotherapy themselves can give: These transformative principles .  .  . ‘a group context in which, instead of being put to work by one therapist in an exchange with one patient, they are exercised by the group as a whole’ for the mutual benefit of all. (Chapter 1, page 47, this volume) We are still in the early stages of understanding the how and why of these working processes. This book began with Skynner’s account in the Introduction of how some of the confusion amongst the trainees he used to teach arose from their seniors’ claim to an understanding of clinical theory that was not grounded. This book set out to make its contribution in these areas, but even in this conclusion it is clear we have only just begun. Our clinical practice still relies on a humanity that goes beyond our powers of explanation. My own poignant sense of humility as the conductor during the portal moments described here reinforces the language of Cox and Theilgaard that has already been quoted several times. At such moments ‘a sense of mystery, astonishment, and uniqueness . . . transcends any descriptive technicalities’ (Cox and Theilgaard 1987: 17). Ours is always work in progress, but Tucker points the way to some of our future challenges when she describes how: The process of ‘communication’, of translation of the symptom into a ‘common pool’ of conscious shared language (can) remove the symptom. For the content of the communication that lay beneath the symptom is now available for others to understand in their shared language (and) . . . the individual emerges from (unhealthy) isolation into social (healthy) being. (Tucker 2004:18) This was Foulkes’s basic position which carries what he called his basic law of group dynamics. ‘How is it’, Tucker asks, ‘that . . . shared norms act as an agent of change for individual members of a group?’ (Tucker 2004:16). She answers her question by stating this ‘basic law’ in Foulkes’s own language: ‘The deepest reason why . . . patients . . . can reinforce each other’s normal reactions and wear down and correct each other’s neurotic reactions, is that collectively they constitute the very Norm, from which, individually, they deviate’ (Foulkes 1948:29). She sets out to explore Foulkes’s ‘underlying conception of self’, and she finds in his language and constructs ‘an implicit commitment to a conception of the self’ in which: The self is essentially social as opposed to individualist The self is essentially pro-social as opposed to anti-social Familial and cultural socialization of the self is primary not secondary (Tucker 2004: 21)

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The implications she draws from this understanding are radical and far-­reaching but have barely been developed. Her account extracts from Foulkes’s writing an account of what she calls: The group-superego (that is) pro-social . . . an essentially social concept theoretically rooted in a framework that holds that the ethical values it embodies are primary . . . For Foulkes, the propensity to communicate in an inclusive, fair, socially responsible, co-operative, respectful and democratic way is a primary social phenomenon. (Tucker 2004: 43) She goes on to say that ‘it throws in to sharp relief the therapeutic efficacy of the ethical and political in analytic-groups and that – importantly – it provides a role for the under-represented symbolic father in groups (Tucker 2004:63). Tucker’s own account of norms in flux in a group conducted in London for refugee survivors from Kosova with histories of rape provides one of the most eloquent vindications of the group-analytic model at work. She describes how: One striking thread of the life of the group was the process by which the women were, over time, able to share their experiences of having been raped by paramilitaries. In relation to this it is of note that in the close knit KosovanAlbanian community, raped women are customarily regarded as ‘whores’ and as holding responsibility for their fate. Raped women are no longer considered worthy of marriage. It is usual for their husbands to seek a new partner while punishing their original wives with physical violence. Within this closely woven community this has led to the need for raped women to keep it secret, especially from their husbands. At the final session all the women were wearing their best outfits. (C) said that it would have been her son’s 13th birthday today. She said that she knew now that he was dead and thanked the group (for helping her accept this). There were happy memories of how birthdays were celebrated in Kosovo, about how (C) would have liked to celebrate her son’s birthday, moving eventually to thinking about how she might mark his death, even in the absence of his body. There was a profound quality of mutual response and care in the exchange and I volunteered that there was a sense that together we were marking the death of (C)’s son, the many losses in other members’ lives as well as the end of the group. (D) said, ‘We have left our bodies in this group – we have built a house’. (Tucker 2004: 58) When it is published, this account will be found invaluable for all who work with violence and violation, and the testimony it gives to work of great consequence also gives promise in the areas of clinical theory that this chapter concludes with. Standing behind the author of the 68 vignettes that make up this book is the man now put in touch (by this reference to the symbolic father) with his own identity

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as a father rather than therapist and whose presence I am responsible for through their stories. I have also been the transferential father for many of those described through the book and am now made aware of myself through Tucker’s writing as the under-represented father. It is a new and not entirely comfortable set of emotions. Pirandello’s famous play Six Characters in Search of an Author (1997) has guided me through the construction of these vignettes. When it first came to the stage in London, this play captured the interest of both Bion and Foulkes in their time. Interest in the dramatic and theatrical in Foulkes’s own work represents yet another strain barely addressed in the field. Here too there are promising further developments with the work of Roth (2014) and Mallett (2015) pointing the way. We have a lot to look forward to.

Bibliography Clews, M. (2011). The Group Analytic Dynamics of Absence: (Re)-Embodied Shame at the Boundary of the Reflective Space. Dissertation Birkbeck College University of London/ Institute of Group Analysis, London. Foulkes, S. H. (1948; reissued 1983). Introduction to Group-Analytic Psychotherapy. London, Karnac Classics. Foulkes, S. H. (1964; reissued 1986). Therapeutic Group Analysis. London, Karnac. Foulkes, S. H. (1975; reissued 1986). Group Analytic Psychotherapy: Method and Principles. London, Karnac. Foulkes, S. H., and Anthony, E. J. (1957; reissued 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach. London, Karnac. Friedman, R. (2014). Group Analysis Today – Developments in Intersubjectivity. Group Analysis 47 (3): 194–200. Levens, M. (2011). Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation. MSc dissertation. Institute of Group Analysis, London/ Birkbeck College, University of London. Mallett, A. (2015). The Group as Theatre: Theatrical and Aesthetic Process in Group Analysis. Dissertation for Qualifying Course, Institute of Group Analysis, London. Marteen, L. (2014). The Triangle and the Eye Inside the Circle: Dyadic and Triadic Dynamics in the Group. Group Analysis 47 (1): 42–61. Nitsun, M. (1996). The Anti-Group: Destructive Forces in the Group and Their Creative Potential. London, Routledge. Pines, M. (2015a). Dialogue as the Basis of Human Development. In Collected Papers, London, Routledge. (In press: pagination provisional). Pines, M. (2015b). Listening and the Sonorous Self. In Collected Papers, London, Routledge. (In press). Pirandello, L. (1997). Six Characters in Search of an Author. London, Dover Press. Roth, W. M. (2014). The Birth of Group Analysis from the Spirit of Theatre. Group Analysis, 47: 293–311. Salm, A. M. (2013). Where Is the Problem? Foulkes and the Location of Disturbance. Institute of Group Analysis Library. Tucker, S. (2004) From Group Norms to The Group Superego: The Therapeutic Efficacy of The Ethical and Political in Foulkes. Dissertation Birkbeck College University of London/Institute of Group Analysis, London.

458  III  The dynamics of change Weegman, M. (2001). Working Intersubjectively: What Does It Mean for Theory and Therapy? Group Analysis 34: 515–530. Reissued in E. Hopper and H. Weinberg (Eds.). (2011), The Social Unconscious in Persons, Groups and Societies. Vol. 1: Mainly Theory. London, Karnac, pp. 133–154. Wojciechowska, E. (1993). The Group as Transformational Object: Fusion, Transition, Transformation. Theory Paper, Institute of Group Analysis, London. Wotton, L. (2011). Expecting the Unexpected: A Source of Change in Analytic Groups. Group Analysis 44 (3): 315–327. Wright, K. (2009). Mirroring and Attunement. London, Routledge.

Acknowledgements:  Extracts from Foulkes (1948), Introduction to Group-Analytic ­Psychotherapy, Foulkes (1964), Therapeutic Group Analysis and Foulkes (1975; reissued 1986), Group Analytic Psychotherapy: Method and Principles, reproduced with permission from the Group Analytic Society; extracts from Foulkes and Anthony (1957, 1965, 1984). Group Psychotherapy: The Psychoanalytic Approach, reproduced with permission from E. J. Anthony; Table 17.1 reproduced with permission from E. J. Anthony; Tables 17.2, 17.3 and 17.4 reproduced with permission from the Group Analytic Society. Extract from Levens, M. (2011) Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation, reproduced with permission from Mary Levens; extract from Clews, M. (2011), The Group Analytic Dynamics of Absence: (Re)Embodied Shame at the Boundary of the Reflective Space, reproduced with thanks to Melanie Clews; extract from Salm, A. M. (2013). Where Is the Problem? Foulkes and the Location of Disturbance, reproduced with permission from Anne-Marie Salm; extracts from Tucker, S. (2004) From Group Norms to The Group Superego: The Therapeutic Efficacy of The Ethical and Political in Foulkes, reproduced with permission from Sarah Tucker.

Chapter 18

Conclusion and the last word

If I am not for myself, who will be for me? If I am only for myself, what am I? If not now, when? (Hillel, Ethics of the Fathers 1:14. In Singer, S.) Why are our group members much more likely to note and comment freely on the courage of their fellow members than are we as leaders? Why is courage so seldom mentioned in the . . . literature when (it) resides at the heart of psychodynamic group therapy . . . It seems only fitting as our profession begins to honor human strength and resilience that we pay more attention to our patients’ courage . . . (They) often respond more favorably to optimal responsiveness than to optimal frustration, we need to revitalize our appreciation of the courage . . . (they) display in facing their fears and their impulses as well as the reactions of others. (Gans 2010:189, 204)

This book describes my own journey from the couch to the circle. I set out to find my way and in doing so to put resources at the disposal of others who conduct groups. Some of these resources are new and others newly cast to help us listen for the potential carried by the unspoken and the sometimes unspeakable. We can come alongside people at times of reprieve and, on becoming witnesses, equip our members to testify to forgiving moments of experience that can be redemptive and foster renewal. Our quest is to penetrate the heart of stone that holds the secrets of inner injury, and to do this we need to find form in both its silence and spoken word. Anthony’s Historical Preview opened the book to the subject of resilience that runs through these pages. To open this conclusion it is given a review by Gans in the passage quoted above. Group therapy is not so personalised or focussed as individual psychotherapy can be, but in the forum of the group people can be most alive to the real, the lost and the unacquainted in one another and can harvest gifts of adversity from the most unlikely sources. We work with the past in the present, with the play of words and the play of experience that may have no words. Our practice is charged with paradox. Strangers can create allies out of aliens, turn anonymity into security and make

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common cause of seemingly unrelated injury. In what Foulkes called the common zone we create a shared home for people’s private past that may have distorted their present and continues to stand against their future.1 Can the group-analytic approach meet the challenge of equipping people to free their destiny from their history? The Introduction set out the scope of this book in addressing questions of understanding and change. The Last Word that ends this conclusion provides a commentary from a sub-group of those described in the vignettes who elected to write – without being asked – and furnish their own views on such questions.

Title and scope: A review of the book The title – from the couch to the circle Spotnitz had a title for his book about psychoanalysis and group therapy, The Couch and the Circle (1961/2012), that I have reframed as the title for this book with the help of my colleagues Phyllis Cohen and Stephen Frosh. When he learnt of this book’s prospective title my colleague Thomas Mies introduced me to a journal publication in German, ‘Von der Couch zum Kreis’ (From The Couch To The Circle) by Hans Bosse, written in 2000. There is a journey between these three titles. The first became a foundation text for the Modern Analytic Movement in the United States that today sees the graduation of group analysts at the Centre for Group Studies in New York, where their work is based on that of Ormont, whose indebtedness to Foulkes is documented in his papers and described elsewhere in this text (Ormont and Furgeri 2001). This book takes its inception from Foulkes and Anthony’s Group Psychotherapy: The Psychoanalytic Approach (1957/1984), one of whose authors, James Anthony, sends it on its way with his Preview – one of the last things he was ever to write. Bosse’s paper – the third title – and the continuing development of practice, theory and scholarship in Germanspeaking countries, testify to how group analysis is being once again embraced by the societies in which it first took root. The Frankfurt origins of group analysis are described in the Introduction on page 12. A study of the uprooting of Foulkes and his associates and their creative endeavours in their new host countries forms the substance of my Foulkes Lecture given in 2015, On Making A Home Amongst Strangers: The Paradox of Group Psychotherapy (Schlapobersky 2015). The lecture and the papers associated with it by Adshead, Mies and Wotton are now published in Group Analysis. The 10 clinical studies in Chapter 6 show the model at work in Europe and elsewhere across a range of applications from forensic psychotherapy to private practice and from brief and short-term work to long-term slow-open group analysis. At my own training institute, the Institute of Group Analysis in London, we have seen the graduation of a new cohort of group analysts in every year but one since the inception of the training in 1973. The international co-ordinating body for our training, the European Group Analytic Training Institutes Network (EGATIN), registers 32 training institutes in 23 countries where group analysts are making a major contribution to psychotherapy, health care, organisational development and conflict resolution.

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The Rosetta Stone of our field Pines describes Foulkes and Anthony’s book as ‘the ur-text’ of group analysis in his Tribute here. A key element in their text is a table reproduced in this book as Table 14.1 on pages 365–6 (Foulkes and Anthony 1984:51). It maps out the two languages of classical psychoanalysis and group analysis so we can read them against each other. We could see this as the Rosetta Stone of our field, but nothing we do is written in stone; the fields interpenetrate one another and are in movement on both sides. I set out to describe this movement, show the group-analytic model in a state of dynamic evolution and take account of how widely applied it is by practitioners whose clinical wisdom sometimes exceeds our own powers of articulation. This was Foulkes’s own shadow as I have described in the introduction, and institutions carry their pioneers’ shadows as well as their sources of enlightenment. The struggle with this shadow and the determination to find words for what we do – and do not do otherwise – has exercised me for a long time. I am relieved to be able to put this struggle at the disposal of my colleagues, peers and especially those we call our patients, who are really our first teachers. They have the last word. The climate of change and resolution in a therapy group Three dimensions of psychotherapy and the fabric of ordinary experience In the opening chapter I described a therapy group like the TARDIS, the time machine in Doctor Who that is larger on the inside than the outside, with capacious shared experience and a matrix which, like light, is both a particle and a wave. One account distinguishes its foundation and dynamic properties and the other its relational and semantic fields. Together they generate the three dimensions of psychotherapy through which the group travels – the relational, reflective and reparative – guided by a pilot we call the conductor. The group itself has three dimensions, structure, process and content. There are different ways of charting its development and at least five phases of group life. Its domains of meaning – the current, transference, projective and primordial – are holograms so that you can look through one and in the others see new and different facets of yourself and the people around you. The language of free-floating discussion has three different forms – monologue, dialogue and discourse – that can include everybody. In the common zone of its shared experience the group can grow into an auxiliary ego for each of its members. Resonance, the elementary conveyor of emotion, allows the dynamics of its process to work through the mirrors, amplifiers and condensors of its peopled world to generate new forms of intersubjective validation that allow the group to travel through time and space and come back to the ‘now’. The vehicle is not comprised of anything mysterious or science fictional. It is a fabric woven from the lives of people’s shared experience in which their problems can heal each other. This can happen through processes as familiar as the weather, and it can take its members a long way.

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The journey to become visible and discover agency I hope readers have appreciated the journey, its excursions and its vignettes whose play with words can turn work into play. What is significant outside is worked on to become part of a significant interior. Therapeutic process requires a shift from what is troublesome in the world – reported on in people’s homes and offices, their city or the world at large – to what is troublesome in the room and for the person in the group. It is here that resolutions may be found as the group progresses through a spiral of growth and development to reveal the hidden but active group at work inside each person. The arising moments of reflection and reparation can put people in touch with the world revealed in the group and the group within the self. The work seeks out the locus of members’ agency through which they can come to truly own the responsibilities they carry for what unfolds in the room. This may be an argument, evasion, conflict, storm, flood of tears or an encounter with something life-giving and renewing with origins located in the person who is talking or not. The subject of visibility that can illuminate the process of discovery is recurrent in people’s narrative about what groups do for them. As they come out of the shadows and discover themselves – sometimes for the first time – discoveries made amongst others can then be taken out into the world, and change can be effected in the places that matter. The conductor Process dynamics work therapeutically through the stance of the conductor, who needs to be able to react and respond personally in the relational dimension of the work. He or she can then extend themselves to a reflective process that can generate reparative experience over time. Process dynamics allow play and interplay to provide energy that drives the progression through the different domains of which it is comprised. The exchange begins in the current domain reported on first in the real world of people’s lives and struggles and then in the group itself. The conductor’s own attunement keeps the group’s different domains open to one another and allows progression to the transference and then to the projective and primordial domains. The conductor provides a set of structures that help manage the group. Members provide the content of free-floating discussion that is cultivated by the conductor to turn monologue into dialogue and dialogue into discourse. Structure and content meet in the group’s process dynamics, and process is the axis on which they turn. Principles of location and translation help establish references in the group that frame what is problematic in people’s lives, helping turn identification into understanding so that cohesion can grow into coherence and longing can be transformed into belonging. A group’s process needs to be maintained as a fluid passage that keeps the common zone open to all its members in the shared experience of the theme or subject that we describe as a figuration. This allows movement among the different domains so the current one takes on imprints from the deeper areas of transference that is in turn shaped by projective dynamics that derive from

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the primordial or archaic domain, where the symbolic register provides mutative metaphors that can work for change. As well as this line of influence – traced from the deeply unconscious to the current domain – the direction of influence works in the other direction also, so that the current domain can shape and direct the others. The circular exchange involved in these dynamics is pictured in Figures 14.1 and 14.2. Transference and mutative metaphors: Towards a new integration of old constructs Transference is traced from its origins in Freud’s classical theory, where it was the foundation of his one-body psychology, to its central role decades later in both the developing two-body psychology of object relations and to Foulkes’s three-body psychology of the group. Both these different relational paradigms emerged separately in London over the same period. They remained strangely unrelated though their pioneers knew each other well. They are brought together here as the book illustrates countertransference, projection, identification and projective identification at work in groups. It reviews how these constructs can be applied, how they inform a group’s structure, process and content and how they can be taken up to enrich the practice of its conductor. The play with words and the play of experience that may have no words is cultivated through mutative metaphors to generate the symbolic language of transformation. The framework that makes these links is drawn from the work of Pines, Brown and Cox on the group-analytic side and of Winnicott, Bollas and Wright on the psychoanalytic. Some of the most original work in the developing literature on the culture, silence and musicality of groups comes from recent graduates in our training including Brooks, Haddock, Levens, Verebes-Weiss, Wainstein, Tyerman, von Fraunhofer, Wojciechowska, Wotton and many others. Longing, belonging and the whole in the middle of the group The terms longing and belonging are derived from Winnicott’s concepts of object and environment mother to help readers identify a group’s prevailing affect. They are applied to the figurations of holding-containment and exploration-play. The flux of movement between silence and activity and between narrative and drama allows a group’s shifting focus to address existential anxieties by locating the emptiness in the circle of associations – what Wilson calls the whole in the middle of the group – that can address each of its members’ fears about ‘touching the void’ (Wilson 2005). Through the unfolding stories of the vignettes we see that group defences are often organised around primary but unstated and hidden, unconscious anxieties that must ‘seemingly’ be avoided. These anxieties include the absence of meaning within the self; the absence of a self within the person; the fear of being found by another; the fear of never being found by another; the fear of never being found acceptable by another and many more. They underlie the issues that people face in the vignettes. The conductor can bring about a climate

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of change and resolution that will stand to its members’ lasting benefit by using the principles that stand at the heart of the model – location, translation and interpretation. They can identify, address and help resolve the anxieties that arise in the dialectic between group and personal development. Group defences, divisions and the future The reference given here to group defences is absent in group-analytic literature. This gap brings us full circle back to one of the splits in our field that began in the early division between Foulkes at Northfield and the Maudsley Hospital and Bion and then Ezriel at the Tavistock Clinic. The history is described in ­Chapters 3 and 7. Anna Freud’s work served the Modern Analysts in the United States with their development of group theory and practice that relies on the understanding of group defences. Foulkes was close to her in London but brought little from her work on defences into group analysis in the UK. Ezriel and Bion stood on an opposing side of the psychoanalytic divide of their day – they are aligned with the Kleinian tradition – yet they led the field on work with group defences that Bion described as basic assumptions. Some of us are learning to cross these puzzling divisions and, as we do so, we need to learn from the experience of this recent past not to allow current disagreement to create further schisms in the field that will complicate the work of generations to come. Gaps There are many important subjects in the field that have not been discussed here. The first set of issues that calls for attention – that requirements of space do not allow – relates to subject areas in the professional arena of group psychotherapy. The range of different key topics, each of which has its own literature, include the following: research findings and the evidence base; training; supervision; and the ethics of good practice. They each merit a chapter in further such studies as this one. Another set of gaps relates to regional issues in the international range of group psychotherapy within and beyond the group-analytic model. Group analysis is a thriving discipline in the Balkans and in Greece, Italy and Portugal, where there are long-standing and extended literatures and a wide diversity of therapeutic and cultural practices using basic and applied principles. Beyond the group-analytic model, group psychotherapy in the Spanish-speaking world is thriving also, and their pioneers and innovators have also created an extended literature. As already indicated, in the UK group-analytic psychotherapy with children, with older people and in provision for medical need is poorly developed by comparison with vigorous fields in North America and Continental Europe. I am confined to the English-speaking world by my own limitations and to those publications drawn from other countries in Europe where their approaches are well developed in English like Germany and Scandinavia. I look forward to collaborative opportunities in the future that will allow us to better share our literature with one another.

18  Conclusion and the last word  465

Who does the work and why do we do it?

Vignette 18.1  The patients are the ones who get better and go away

In the early years of my professional life I had the good fortune to work in a department of psychiatry led by a visionary professor, Desmond Pond, trained in both neurology and psychoanalysis. He fostered an integrative approach that challenged the factional conflicts that so regularly beset our work and his humour helped us appreciate one another. As he signed people off for their extra-departmental training he would describe the therapies for which we were enrolling – in my case the group-analytic training – as ‘treatments of indeterminate length and uncertain outcome for which years of expensive training are absolutely essential. Go and enjoy it and come back to tell us what you’ve found!’ Group work was the institutional glue that held our department together and had a profound impact on the in-house training programme for psychiatric nurses whose college – based at our hospital – was always over-subscribed. One of its graduates was the nurse in charge of an inpatient unit where I helped with the group work. He had absorbed our professor’s infectious humour and was now a recondite man of words who would ‘shoot from the hip’ with spontaneous, biting insights that left us laughing. We provided a training facility for staff from other units who came to spend a day with us during which they attended the patient groups, all modelled – in turn – on the work of the Cassel. We would join the visitors for a de-briefing meeting at the end of the day where, as one group were rounding off their time with us once, they used the space for questions to raise this issue: ‘As none of you wear uniforms, how do you tell the difference between patients and staff?’ ‘It’s not a problem’, replied the charge nurse, ‘The patients are the ones who get better and go away!’

Commentary The issues arising from this humour face us in very pointed terms. Why do we do this work? Who is best equipped to do it? How do we train people? How long should a training last? Where should it best take place? How much should be invested in the trainee, on what terms, in what context or setting and to what (Continued)

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(Continued) purposes? How do we safeguard the course and outcome of the therapies that our graduates provide? Do we do enough to acquaint our graduates with the Codes of Practice that their work and their membership of our Institutes will be governed by? And is a Code of Practice a sufficient safeguard for the continuing life of a group analyst? Or should we expect to see their further investment in continuing professional development and supervision throughout their professional lives? Are we in need of appraisal by our peers and colleagues on a similar five-year basis to general practitioners? These questions underlie all the focused considerations that this book set out to explore and will require attention in further studies.

About the vignettes Evidence or illustrations? This book develops through 68 stories – the vignettes – that carry its weight like a spine. They are drawn from my own personal life and the groups I have been in; from my practice and the practice of colleagues and supervisees who have shared their work with me; and from literary and cinematic sources. When it comes to evidence I must acknowledge the bias in the vignettes – it is my own. I have come to this book with the working focus of a practitioner to describe a model and illustrate how it works and sometimes does not. The vignettes are here as illustrations not as evidence. I have not approached past or current members of my groups to secure evidence that would be valid or reliable in meeting research requirements in positivistic canons. The vignettes need to be seen as a reflection of my own makeup and concerns over time. The people I have been approaching with these vignettes during the drafting of this book are the true ‘owners’ of the experience described. Only those vignettes to which they have given their consent are included. The selection of what is recorded or remembered is in all cases my own, but people have in many cases augmented or amended my memories and material with their own. They have been accommodating with the fictional reconstruction that protects their anonymity and, as described in the dedication, I have worked within the Codes of Practice of the International Psychoanalytic Association and Institute of Group Analysis. The need for an evidence base I made a plea in the introduction and in Chapters 1 and 6 for more collaborative work between clinicians and research workers in the field. It follows similar such invitations by Greene (2012). Although today, more than ever, we need valid and reliable evidence for the benefits and limitations of our work, I conclude

18  Conclusion and the last word  467

with modest contributions in this direction. There are several reasons. One arises from the limitations of my own training and focus, another from the relative paucity of literature documenting process and outcome studies in English on the group-analytic model itself, and a third defers to the strength of the model whose use is now so widespread that it can no longer be evaluated independently of the setting and population to which it is applied. As Chapter 6 has demonstrated, the model and its applications vary across the field and put very different requirements on evaluation as between private practice and – say – a forensic setting. The instrument I devised for ‘measuring’ process and outcome in my own groups at the point of people’s departure is described in Table 6.9. It continues to provide results that are of consequence and could be put to use more widely across the field by research workers competent to make these applications. Future studies that address these applications could then take evaluation procedures more systematically into the settings they are evaluating. Method and methodology: Describing people’s own experience How much weight can we give to the evidential content of people’s own stories in the accounts they give of what happens to them in therapy? There are many who believe this is the only evidence that counts. It is a puzzle that psychotherapists troubled by positivistic criteria that allow only quantitative measures or random controlled trials have not turned to two readily available sources to help us make arguments for what we do – amongst those of our colleagues in the forensic field and amongst those who write history. Court procedures rely on expert witnesses to serve the requirements for judicial evidence and we have been developing procedures for the authentication of claim and counter-claim in forensic work for generations. This evidence relies on descriptive detail mapped against observed experience that can be set in context by experienced professionals to support or discredit an argument. This could be the ‘stock in trade’ for psychotherapists looking to make arguments for the benefits of their work. My own background in forensic practice has guided me in drawing up the vignettes, and I would encourage colleagues to consider Greene’s plea that we adopt a more pioneering and adventurous spirit to embrace a wider range of different methodologies when we search our work for evidential terms. Another source of validation can be found in emerging trends of historiography led by Faust, current president of Harvard University, that rely for historical evidence on biographical narrative. In two celebrated texts devoted to the study of women and the American Civil War she established an interest in and legitimate, academic use of diaries and personal biography. Her work has cogency in documented detail provided by the people she studied, who testify to their own life experience (Faust 1988, 1996). Prinsley has used this approach in a study of female nursing and transforming gender roles during the American Civil War in which the force of her argument arises out of the diaries she studied (Prinsley

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2013). Psychotherapists could be making much more active use of diarised and personalised biography, and we could call on emerging methodologies to help us generate principles of evidence and argument – like these diaries that are considered valid and reliable in history – that could be extended to psychotherapy. History is really the mother of all social science and we could find a place for our work amongst her other offspring without forfeiting our scientific standing. I hope that the use of ‘live’ material here will stimulate others in this direction. The 68 vignettes are my own constructions and come via the people described, who have concurred with or amended the material. What follows in ‘The Last Word’ came on an unsolicited basis from those consulted and provides a secondary commentary at the point in time they said ‘yes’, ‘no’ or ‘amend’ to the vignettes. I have approached these people a second time round to secure their consent to appear in ‘The Last Word’ and have selected only from the correspondence of those with whom the current dynamics of therapy have been concluded. The most recent of these eight letters goes back two years, and the most distant goes back more than 20 years.

The last word – eight letters Dear John 1 What a surprise to hear from you and that you have written a book covering your many years of work as a psychotherapist, with me in it. I read the vignettes and have no problems at all with the text. I had forgotten that I had spoken of it never being too late to have a childhood, and I am grateful to be reminded of it. The happy child in me still lives (most of the time). I count my blessings that I am healthy and fit (completed a half marathon charity walk at the weekend), and have two lively children now aged 15 and 12. I have been working part time till the end of June and am currently thinking about what I could do with my skills, but in a less commercial, demanding environment. My husband has had some difficult times. He lost his brother five years ago. Just last year he lost his job and is still looking for work. He still has few words to express his feelings about the loss of his brother in a sudden and tragic way. I spent about a year going on weekly visits to be with his brother’s widow and could only have done that because I had come to terms with all my own losses in life. I do wish you every success with your book, and again, am pleased that by reading about my own difficulties, this may help others to overcome theirs. 2 I still think about the Group and do hear from the others from time to time (but, like you, am sometimes remiss in responding quickly). My time in the Group

18  Conclusion and the last word  469

was so important to me – it gave me the strength to leave my unhappy relationship, of course, but has also had a profound effect on my relationships with my friends and family, especially my children. It is as if the warm, playful, loving part of me has come back to life again, after years of tension and misery. And I feel loved, valued and supported by those around me, so that the inevitable loneliness of growing older is more bearable and there is meaning and direction in my life. And of course, professionally I have warmed up too, and am not afraid to care about my clients and talk of kindness and love, as well as pathology! So thank you. I am so pleased that you are writing the Handbook. Who better to do it? And I am pleased to play a small part in it by consenting to the use of clinical material. Consider this my Formal Consent! What a huge task you have undertaken – your energy and commitment to the work is an example to us all. For my part, I continue to enjoy my children, my granddaughter (the best baby in the world – I do not exaggerate), dear friends, my work and my garden. Since I have promised to open the garden to the public in July, I have become slightly obsessed with it, much to everyone’s amusement. But it does look fantastic, though I say so myself. I met Peter quite by accident on the Southbank a few months ago. I was with Allan and we had just been to the cinema. The three of us had a lively chat with a hug for me from Peter that was delicious. He seemed very happy and composed and told us about his new relationship with great enthusiasm. I am delighted that he continues to thrive – your vignette reminded me of just how instrumental he was in my ‘recovery’: a wonderful man. He sent me a photograph of the two of you at his graduation ceremony – two wonderful men! I feel very privileged to be playing a small part in your current project. Group work is so powerful, transformative: it changed my life . . . 3 Please forgive the delay in responding. Reading this had a profound effect on me, much more so than I expected. I’ve felt the need just to let it settle in me before responding. The short answer is, yes, I happily give my consent to it being used. The longer answer is that reading it has been in itself another step along the road of my journey. I remember the incident in the vignette, and the more I pondered what you’d written, the more I remembered: the people in the group, the room, the atmosphere, my feelings, your own face and voice. What took me by surprise in your account was both the violent nature of the incident, and the extent of its effect. I had underestimated both, certainly in the way I recall them. It also felt very connected to the present, as the central issue continues to be worked out in my life: my father is still alive (my mother passed away in 2008) and lives very close to us, and as he grows more frail my relationship with him continues to change. I have, in fact, been able to talk with him about his absences from our home and my life during my childhood, and have

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expressed my anger about the past; and he has expressed his regret over them, in a way that was very open for him. It’s not easy to talk about, of course, but some important things have been acknowledged between us. My anger about it all feels largely expressed, and what’s left is of a calmer nature. He’s changed, too, and is able to express himself more, for example about how much he values his grandchildren. So, please go ahead and use the vignette as it stands, and I look forward to buying and reading the entire book in due course! And one day I would love to meet up again. With my very best wishes, and continuing gratitude . . . 4 Hope you’re well. Since leaving the group my Tuesday mornings are taken up by going to the gym but I am still saddened after four years not to be seeing anyone any more at your house. The group will always be a moment of my thoughts on every Tuesday to reflect my dark days and how I have engaged with people who are less fortunate than myself where the group gave me courage to carry on to help other people. I am looking forward to hearing about your forthcoming book and a year from now to meet up with the group for the reunion we agreed on. Good wishes to you and your family all the best. 5 Great to hear from you and congratulations on your book. Looks like a page-turner – not something you can say about too many academic handbooks. Four days ago my laptop was swiped from under my nose WHILE I WAS TYPING outside a cafe. That’ll teach me to leave the farm . . . I only just now found your message. It was nice to be reminded of the group and life before laptop. I have no problem with you using material relating to me from the group sessions. My ego would have been bruised if I hadn’t made it in there at all (assuming I’d found out), though my role as a mother-fixated, under-dressed accessory in key jangle-gate isn’t much to speak of. Can’t you bung in a chapter all about me? Please? Pretty please? Just think how therapeutic it would be for me. How much I’d learn, how much the world would learn. I’m joking, sort of . . . During what was a difficult period for me, the feast of communication I was privy to in group was such a marked contrast to ‘normal life’, at least my normal life now in which some of my most profound exchanges are with pigs and kittens. The comfort of group, the regular reminders that life is good and complex and surprising and funny and it’s all thanks to other absurd people like me. I’m sorry I wasn’t in touch sooner after leaving – if you would kindly relay that to anyone in the group who gives a monkey’s. I found the leaving process very therapeutic and uplifting in its own right and I remained silent partly on account of the sense of closure I felt at the end. Anyway, I have thought often of everyone, of Sonia

18  Conclusion and the last word  471

in hi-definition and her keys and Leanne intoning ‘It is what it is’ and Mel whose mix tape was such a cracker. Is Hilda also still with you? And you, in all your kindly brilliance, tuning in for the juicy bits. I hope you are very well and have been enjoying writing the book. You helped me – you and group analysis, the undisputed king of therapeutic methods. I am in good shape more or less, ruddier, unmedicated, having weathered all manner of stuff at the farm since I left the group at the end of 2010. I have mostly been working hard, at least by my standards, looking after livestock and artists. Still teaching and drawing. Single since the break-up I probably bored you all senseless with, but meeting lots of interesting people and wondering if some kind of functional relationship might be possible. Fondest Wishes to you and everyone in the group. 6 Thank you so much for your email. It was lovely to hear from you. I’m doing well but think of you all in the group and miss you. I learned so much from everyone in the group and particularly you John. I feel it was a privilege to be part of the group and to learn from you and the other members. My learning continues even after I have left and I often think of your wise words and wonderful stories. My private practice is doing very well, we have a lovely room in a building in the heart of town. We are working hard to build up the practice and are getting a lot of referrals. We are about to set up a group which we are calling a recovery group which I hope to run with one of my colleagues. The NHS continues to be difficult and I think this is going to continue to be the case. It may be that I have to sadly think of leaving. My love to everyone in the group that knows me and Best wishes 7 I just finish reading. It is beautifully written as it was beautifully conducted by you. Thank you for bringing me back to a very meaningful group time. My mother, as I told you, is struggling for her health this year and we were very near to ‘the end’ many times, as just a week ago, so it feels like I’m still part of this ‘crying group’, aren’t we all? Many Hugs and Good wishes. 8 I appreciate you for asking my permission. I appreciate you for putting a lot of effort writing this book. It is very important. I give you my permission and I wish you success with this book.

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Note 1 ‘The common zone’ is a term we owe to Foulkes. It is introduced in Chapter 1 page 38 and is defined and put to use in Chapter 4 page 124 and elsewhere in the text.

Bibliography Adshead, G. (2015). Strangers and Angels: A Response to John Schlapobersky’s Foulkes Lecture. Group Analysis 48: 433–446. Bollas, C. (1987). The Shadow of the Object: Psychoanalysis of the Unthought Known. London, Free Associations Press. Bollas, C. (1990). Creativity and Psychoanalysis. In C. Bollas, The Mystery of Things. London, Routledge, pp. 167–180. Reissued in M. Gerard Fromm (Ed.), The Spirit That Impels: Play Creativity and Psychoanalysis. London, Karnac, pp. 3–20. Bollas, C. (1993). Being a Character: Psychoanalysis and Self-Experience. London, Routledge. Bosse, H. (2000). Von der Couch zum Kreis. Wandlungen des Übertragunbgsverständnis­ ses auf dem Weg zu einer gruppenanalytischen Theorie und Praxis. In Gruppenanalyse. Zeitschrift für gruppenanalytische Psychotherapie, Beratung und Supervision, 10 (1): 49–66. Brooks, F. (2009). The Othering of Silence in Groups. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Brown, D. (1994; 2000). Self-Development Through Subjective Interaction: A Fresh Look at Ego Training in Action. In D. Brown and L. Zinkin (Eds.), The Psyche and the Social World. Routledge, London. Reissued 2000, Jessica Kingsley, London. Republished in J. Maratos (Ed.), (2006), Resonance and Reciprocity: Collected Papers of Denis Brown. London, Routledge, pp. 107–123. Cox, M. (1978). Structuring the Therapeutic Process: Compromise with Chaos. Oxford, Pergamon. Reissued by London, Jessica Kingsley, 1993. Cox, M., and Theilgaard, A. (1987). Mutative Metaphors in Psychotherapy: The Aeolian Mode. London, Jessica Kingsley. Cox, M. & Theilgaard, A. (1994). Shakespeare as Prompter: The Amending Imagination and the Therapeutic Process. London, Jessica Kingsley. Faust, D. G. (1988). The Creation of Confederate Nationalism: Ideology and Identity in the Civil War South. Baton Rouge, Louisiana State University Press. Faust, D. G. (1996). Mothers of Invention: Women of the Slaveholding South in the American Civil War. New York, Vintage Books. Foulkes, S. H., and Anthony, E. J. (1957/1965). Group Psychotherapy: The Psychoanalytic Approach. London, Penguin. Reissued London, Karnac, 1984. Gans, J. (2010). Difficult Topics in Group Psychotherapy: My Journey From Shame to Courage. London, Karnac. Greene, L. R. (2012). Group Therapist as Social Scientist, With Special Reference to the Psychodynamically Oriented Psychotherapist. American Psychologist. Advance online publication. doi: 10, 1037 / aoo29147 Haddock, R. (1992). Silence in the Matrix in Group Psychotherapy. Theory Paper for Qualification. Institute of Group Analysis, London. Levens, M. (2011). Are Words Important in Group Analysis? An Exploration of the Consequences of Verbal Articulation. MSc dissertation. Institute of Group Analysis, London/ Birkbeck College, University of London.

18  Conclusion and the last word  473 Mies, T. (2015). Some Notes about a Responsive Phenomenology. A Response to John Schlapobersky: ‘On Making a Home Amongst Strangers’. Group Analysis 48: 455–464. Ormont, L., and Furgeri, L. B. (2001). The Technique of Group Treatment: The Collected Papers of Louis Ormont. New York, Psychosocial Press. Pines, M. (2015). Collected Papers. London, Routledge (In press). Prinsley, A. (2013). Nightingales of the South: Female Nursing and Transforming Gender Roles in the Confederacy During the Civil War. Dissertation, Department of History, University College London. Schlapobersky, J. (2015). On Making A Home Amongst Strangers: The Paradox of Group Psychotherapy. 39th Foulkes Lecture. Group Analysis, 48 (4): 406–432. Singer, S., Rev. (1990). Singer Daily Prayer Book. United Hebrew Congregations. London, Singer Prayer Book Publication Committee. Spotnitz, H. (1961). The Couch and the Circle: A Story of Group Psychotherapy. New York, Alfred A. Knopf, Inc. Reissued Literary Licensing (LCC) 2012. Tyerman, S. (2012). Watching the Body in the Group. Theory Paper for Qualification. Institute of Group Analysis, London. Verebes-Weiss, J. (2011). Capacity to Be in a Group: Small Group Psychotherapy in a Forensic Therapeutic Community for People With Dangerous and Severe Personality Disorder. Theory Paper for Qualification. Institute of Group Analysis, London. Von Fraunhofer N. (2008). What’s in It for Me? The Development From Immature to Mature Dependence in Groups. Group Analysis 41 (3): 278–290. Wainstein, S. (2013). An Exploration of Intimacy in Group Analytic Psychotherapy. MSc dissertation. Institute of Group Analysis, London/Birkbeck College University of London. Weegman, M. (2001). Working Intersubjectively: What Does It Mean for Theory and Therapy? Group Analysis 34: 515–530. Reissued In E. Hopper and H. Weinberg (Eds.), (2011), The Social Unconscious in Persons, Groups and Societies. Vol. 1: Mainly Theory. London, Karnac, pp. 133–154. Wilson, P. (2005). Breaking Down the Walls: Group Analysis in a Prison. Group Analysis 38 (3): 358–370. Winnicott, D. (1951, 1978). Transitional Objects and Transitional Phenomena. In D. W. Winnicott, Through Pediatrics to Psycho-Analysis. London, Hogarth Press, pp. 229–242. Reissued in D. W. Winnicott, Playing and Reality. Harmondsworth, Penguin, pp. 1–34. Winnicott, D. (1963, 1985). Communicating and Not Communicating Leading to a Study of Certain Opposites. In D. W. Winnicott, The Maturational Process and the Facilitating Environment. London, Hogarth Press, pp. 182–183. Wojciechowska, E. (1993). The Group as Transformational Object: Fusion, Transition, Transformation. Theory Paper, Institute of Group Analysis, London. Wotton, L. (2011). Expecting the Unexpected: A Source of Change in Analytic Groups. Group Analysis 44 (3): 315–327. Wotton, L. (2012). Between The Notes: A Musical Understanding of Change in Group Analysis. Group Analysis 46 (1): 48–60. Wotton, L. (2015). Improvising a Home Amongst Strangers. A response to John Schlapobersky’s Foulkes Lecture. Group Analysis 48: 447–454. Wright, K. (2009). Mirroring and Attunement: Self-Realizations in Psychoanalysis and Art. London and New York, Routledge.

Acknowledgements:  Extract from Gans (2010), Difficult Topics in Group Psychotherapy: My Journey From Shame to Courage, reproduced with permission from Jerome Gans.

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Index

Note: Italicized page numbers indicate a figure or table on the corresponding page. abuse 6, 35, 43, 85, 120, 137 – 8, 140, 144, 160, 175 – 6, 179, 180 – 2, 190, 193 – 4, 240, 294, 323, 332, 334, 442 acoustic resonance see resonance activity groups 203 – 4 adjourning see five-phase progression in group theory Adlam, J. 397 Adshead, G. xxxv, 11, 15, 173 – 5, 194, 460 Agazarian, Y.: auxiliary ego 141; classification of dysfunction 44; Foulkes’s influence on 162 – 3; leadership activity 202; recognition of Foulkes’s resonance 225, 251 – 3; sub-grouping 213 – 14, 412; systemic concepts 114; systemscentred therapy (SCT) 213 – 14; theory of group development 88, 109 agency: in forensic work 174; of group 287, 330, 357; key factor in therapy groups 63, 90, 93, 115, 255, 279, 462; mutative agency of metaphor 151, 394, 425, 449; in writing of Sartre 90 alcohol abuse 362 Alexander, F: corrective recapitulation family experience 60, 67; relational shift, with Ferenczi and Balint 372 – 3 alpha males 352 American Group Psychotherapy Association 43, 87, 188 – 9, 211 amplification as a process dynamic 247, 256, 262 – 3

angel metaphor: couples therapy 428 – 31; group therapy 431 – 6; individual therapy 425 – 8, 427 anniversary effects in group therapy 108, 213; see also death concerns Ansell, J. 189 Anthony, E. J. xi, xxvii – xxxiii, 9, 13 – 18, 39, 40, 45, 48, 51, 52, 79, 112, 119, 127, 148, 162, 165, 209, 223 – 5, 229, 234, 247, 249 – 53, 255 – 6, 301, 322 – 3, 326, 328, 335 – 6, 363 – 6, 366, 367, 370 – 1 anti-group: in group therapy 15, 71, 98 – 9, 294, 302, 306, 377, 395; in group theory and development 85 – 7, 92; in institutions 172; Nitsun’s contribution 94 – 5; in society 15 anti-social sexuality 175 – 7 anxiety, primary 95, 115, 377, 394, 412, 463; existential 463; signal 275 archaic/primordial domain/level 285 – 6, 325 – 6, 333 – 4, 360 Arlo, C. xxxiv, 67, 81, 220, 412, 454 Arnold, M. 155, 397 – 8 assessment of change: AGPA 10; Dick 166, 167, 168, 165 – 7; evidence based practice 10; Lorentzen 168 – 70; NIHCE 9; Schlapobersky 186, 190 – 4; Yalom 8 – 9, 64 attachment theory 46, 363, 364, 405 attendance pattern 229 – 32 authority: as the basis for clinical interventions 228; in Bion’s basic assumptions 207; conductor’s authority with external boundary

476 Index events illustrated 103 – 4; with internal boundary events illustrated 309; of conductor/convenor 301; in dynamic administration 237 – 8, 305, 306, 308, 316; in Foulkes’s ‘crescendo/decrescendo’ 128, 159, 306; further illustrations 241 – 3; in group-analytic developmental theory 96, 97, 98 – 9; in past developmental theory 87 – 9 Auden, W.H. 42, 397, 418 – 420 auxiliary ego 39, 40, 71, 76, 81, 140 – 4, 286, 394, 410 – 12, 461 avoided state (Ezriel) 86 – 7 Bakhtin, M. 13 – 14, 115 Balint, M. 125 – 7, 363, 367, 372 – 3 see also object relations Bamber, H. xi, 21, 178 see also Helen Bamber Foundation Barnes, B. 8 Bartel-Rosing, M. 299 Barwick, N. 39, 40 basic assumptions (Bion) 69, 85, 87 – 8, 205 – 7 basic law of group dynamics (Foulkes) 455 bearing witness 39, 69, 81, 178 – 9 belonging, state of 39, 63, 64, 66, 69, 90 – 3, 103, 117, 181, 275, 336, 341, 357, 374, 387, 393 – 9, 403, 405 – 6, 409; see also coherence in groups; cohesion in groups; longing and belonging Bennis, W.G. 63, 86 – 8 Behr, H. 39, 40, 52, 60, 210, 237, 237 – 8, 301, 303, 306, 414 Berger, M. 39, 40, 55, 255 Berger, P. 397 – 8, 415 Berman, A. 39, 40, 253 B-Group of the British Psychoanalytic Society 363 Bion, W. 19, 63; attacks on linking 76; basic assumptions 86 – 8, 109, 119, 203, 205 – 7, 423 Bipolar disorder 77, 193, 410 Birkbeck College University of London xi, xxxiv, 20 Bledin, K. 8, 92, 397 block groups 10, 160, 167, 184 – 6, 186 Bollas, C. 32, 66, 326; gathering of the self 420, 427; metaphor, mnemic and symbolic objects 32, 66, 326, 421;

shadow of the object 364 – 5, 396, 424 – 5; transference 359, 364 – 5, 370, 373; transformation 147, 424 Bosse, H. 460 boundary: events 75, 81, 96, 99, 103 – 4, 212, 228 – 9, 233, 234, 308 – 9, 319; external 308; of group as a whole 206, 208, 210, 245; internal 309; transgressive 348, 405 – 9 Boswood, B. xi Bowlby, J. 364 brain-injured soldiers 12 British Psychoanalytic Society xxix, 363, 367 British School of Object Relations see object relations Broadmoor Hospital 160, 173 – 5 Brooks, F. 8, 32, 136, 280, 463 brothers in group 6 – 7, 70, 77 – 9, 107, 360 Brown, D. xxxi, 437 – 8; ego training in action, self development, intersubjective validation 39, 40, 96, 126, 247 – 8, 420 – 4, 423; internal boundaries of group 309; metapsychology 126, 207, 248; psychosomatics 182 – 4; resonance and reciprocity 253 – 4 Brown, S. 92 Buber, M. 1, 8, 12 – 14, 59, 63; see also Millard, P. Bunyan, J. 84 Burman, E. 8 Burrow, T. 209, 212 Camille Claudel (film) 145 caretakers, care for 345, 349 Cassirer, E. 8, 12 categories of need amongst people in group therapy 42 – 3, 43, 188 – 90, 190 Centre for Group Studies (CGS) 212, 460 Chalkley, J. 419 children and adolescents: Anthony on Hiroshima survivors xxix; Anthony on resiliency and vulnerability factors xxx; Anthony on psychiatric care of xxviii – xxix; early development of language 404; groups for 2, 16; in group therapy 399; helplessness of 348 – 9; in writing of Erikson 370; in writing of Jennings 399, 400; in writing

Index 477 of Pines 400, 402 – 3; in writing of Winnicott 150, 395 – 6, 400, 401 child sexual abuse, female adult survivors 180 – 2 see also abuse Cilasun, J. 220 classical theory in psychoanalysis 126, 326, 363, 366, 365, 372, 463 Clews, M. 451 – 2 clinically focused writing 7 – 8 clinically relevant evidence (Lorentzen) 170 clinical practice in group therapy: in Adshead 173 – 5; in Agazarian and Gans 88; in Behr and Hearst 237; in Brown 420 – 4, 182 – 4; and content 278, 281, 282; in Cox and Theilgaard 69, 131, 455; in Foulkes’s early work in Exeter, Northfield and London 14 – 15; in Frankfurt’s early social theory 10; in Friedman 44, 91; in Frosh 15, 373, 460; in Gans 34, 469; in Kennard, Roberts and Winter 49, 50; in key group-analytic principles 39, 222, 233, 255; in Kleinberg 8; and leadership 316; in Mies 14; in Nitsun 94; and philosophy derived from Buber and between Goldstein and Cassirer 12; process 247 – 50, 251; in Schermer and Pines 8; in Schlapobersky 179 – 80; in Spotnitz and Ormont 212; of structure 236; in Urlić 8, 184, 204; in Woods 175 – 7; in Yalom 87 – 8 closed groups 10, 158, 161, 169, 239, 312 cognitive therapy 202 Cohen, D. 12 Cohen P. 7, 108, 189, 213, 220, 460 coherence in groups 37, 39, 40, 46, 52, 79, 90, 96, 97, 98, 179, 211, 226, 229, 239 – 40, 275, 313, 316, 316 – 17, 325, 398, 412, 462; see also longing and belonging cohesion in groups 36 – 7, 39, 40, 46, 52, 79, 88, 90, 97, 170, 202, 211, 226, 229, 239 – 40, 265, 275, 313, 316, 316 – 17, 318, 325, 348, 451, 462 combined group 162, 186, 187 common zone: and binding metaphors of transformative experience 437; defined 124, 151; and dreams 381; and Foulksian domains of

group 39, 40; illustrated in current domain 153 – 5; and interchange of experience 270 – 1; and intersubjective validation 437; and longing and belonging 38; and making a home amongst strangers 460; reviewed in literature 38; and speech forms 117; and subjects and figurations of discourse 271, 275; and transference 378; and visible group 232; and Vygotsky’s zone of proximal development 14; where aliens become allies 453 communication: in the ‘autistic’ language of the symptom 48; and boundary events in group 308; and common zone 39; communicating absence in group 451; communicating silence 140; and context in language and musicality 8, 31; in descriptive and unconscious resonance 266; and discourse 280; discourse theory analysing formal structure of 146, 146 – 8; in dreamtelling 91; in dynamic administration 237 – 8; Foulkes’s four levels as domains of communication 288, 328 – 35, 343; and four domains of group 40; generative and emotional communication in Modern psychoanalysis 212; in Foulkes and Anthony’s descriptive table, ‘the Rosetta stone’ 366; in foundation and dynamic matrix 52; in gesture 72, 401; in horizontal and vertical perspective of group 94; and interpretation 447, 449; and I – thou relationship 63; Levens’s critique of Foulkes’s emphasis on the verbal 393, 402, 450; in limbic resonance 253; linking communication in group 319; and location 452; modelling by conductor 319; monologue, dialogue and discourse xxxi, 64, 90, 112 – 34; non-verbal, pre-verbal and verbal 32, 139, 280 – 1, 281; original and current formulation 339; phatic forms 401 – 2; resistance as blocked communication 75; resonance as unconscious communication of affect 225, 252; serial monologue

478 Index as group’s first form of 100; and silence 135 – 6; silence as a transference communication in therapy 150; in simple and complex resonance 266; symptoms as unconscious communication 381; transference as emotional communication in psychoanalysis 373; and translation 446 – 7, 455; twelve modes of communication in Foulkes and Anthony 335 – 38; working with communication in groups 338 – 45, 339 – 40, 341, 343, 344 complex PTSD 241, 425 – 8, 432 complex resonance 265 – 6; see also resonance complex transference 371, 376, 375 – 6, 378 – 82 compulsion 436 – 7 condenser as a process dynamic: defined 38, 249, 251, 255 – 6, 247; illustrated 260 – 3, 267 – 8, 334, 318 conductor: advice to 303, 303 – 4; Anthony on xxx, xxxi, 322 – 3; authority see authority; basic principles and leadership 39; Behr and Hearst on 237 – 8, 301; capabilities of 11; composition most enduring contribution 11, 43, 225, 236, 236, 238 – 9; contrasted with leadership in other models 200 – 18; as convenor 304, 307, 307 – 8; as convenor, therapist and group member 304; Cox on 40; crescendo and decrescendo 244, 304; cultivating cohesion and coherence 46; defined 32, 37; and dynamic administration 237 – 8, 301, 304, 307 – 11; Foulkes on 4, 128, 159; framing moments of consequence in process 259; and free floating discussion 75, 112 – 34; as group member 306, 311 – 12, 312; illness of 151; illustrations 228 – 32; inside and outside the group 37; integrated responsibilities of 312 – 22, 313 – 14, 315, 316, 318, 319, 320; interpretation by 232; intervention by 248; location, translation, interpretation 48, 441 – 5; main forms of intervention

49 – 50, 50; and managing silent and spoken communication 147; map for 222; and model of three 181, 236, 243 – 4; and narrative content 278, 281, 282; overview 31, 301 – 3; person and resources of 35, 301 – 24; as pilot of Tardis 53; prevailing identity and responsibilities 313; primary job of 7; process dynamics and 247, 259, 275; as prompter in narrative failure 38; resonance as conductor 268; role of 48 – 9, 296, 301 – 2; role functions of 222; SALT-GAP study and 168 – 70; and the setting 308; and structural dynamics/ principles 225, 235 – 6; subjectivity of 34, 225, 302; summary 462 – 3; therapeutic challenges of 281 – 3, 282; therapeutic direction 60; as therapist 305, 309, 309 – 11; three-person psychology 127; transference domain and 305, 311, 375, 376, 382; turning monologue into dialogue and dialogue into discourse 49, 90, 112 – 34; turning relational into reflective and reflective into reparative experience 48, 60, 90; turning thematic and narrative analysis into therapy 281, 281, 282; unique term for leadership 301; and the voice of the symbol 278; at work with principles and dynamics 243 – 4 content dimension: discourse theory and 279 – 80; illustrations 289 – 96, 295, 296; language, imagery and thematic development 288 – 96, 295, 296; narrative and thematic analysis 286 – 7; narrative/narrative encounter 283 – 6; non-verbal communication 280 – 1, 281; overview 224, 225, 278 – 9; stories, narration and reparative symbols 296 – 9; therapeutic challenges of conductor 281 – 3, 282 convenor, conductor as 304, 307, 307 – 8 core complex, defined 177 corrective emotional experience: in Alexander 67; in Arlo 67; in Foulkes 128, 305 – 6; in Schlapobersky’s reparative

Index 479 dimension 77 – 80; in Scott Rutan, Stone and Shay 214 countertransference 2, 126, 302, 326, 311, 359, 368, 369, 370, 373, 374, 375, 376, 378 couples psychotherapy and couples groups 36, 73, 248, 428 – 31 Cox, M. 69, 131, 173, 402, 455 crescendo/decrescendo in conductor’s role 128, 159, 210, 304 – 5, 322 – 3, 357, 378 ‘crying group’ 345 – 57, 354 – 6, 357 cultural field: defined by Winnicott 150, 393 – 5; and longing and belonging 396 culture and identity in group therapy 92 current domain 226, 285, 320, 329, 329 – 30, 338, 342 – 4, 343, 345, 360, 444, 454, 462 – 3 Dangerous and Severe Personality Disorder Programme (DSPD) 173 death concerns 173 – 5, 177 – 80, 348 – 53, 354, 355, 357, 357, 379, 401, 410, 418, 426; see also anniversary effects deductive and inductive group theory 85 – 7, 95, 207 de Maré, P. 14, 39, 61, 115, 234, 255 dependency in group therapy: as basic assumption (Bion) 207; qualities of (von Fraunhofer) 63 – 4, 91 depression and group therapy 43, 73, 164 – 8, 193, 241, 364, 420 – 1; illustrations of depression treated in therapeutic groups 73, 77, 104, 129, 151, 294, 298, 306, 332, 420 – 8, 425 depth psychology 34, 96, 226, 361 descriptive resonance see resonance dialogue: between patient and analyst 126; conductor’s work with 49; in consolidation phase of therapy groups 31; defined in group therapy 112 – 13; developmental 84; development tasks in group 97; emergent 64; engagement, authority, intimacy, change, termination 96 – 7; in forensic psychotherapy 174; formative 47; in free-floating discussion 39, 40; gestural 403; hostile 121, 386;

illustrations with monologue and discourse in vignettes 33 – 5, 36 – 7; introduction 14; in language of group 90, 93; Plato’s 49; reflective 116; in relational dimension 68 – 9; reparative 35, 119, 371; resolving 141; as speech form in language of group 2, 20, 32; with survivors of abuse 181; therapeutic 268; in transference domain 377; in 2-person psychology 115 differentiation phase in early group theory 88; in group-analytic theory 98 – 100; illustrated 105 – 6, 123; in Modern psychoanalysis 213; in slow-open groups 160 – 1 discourse: as advanced form of communication 48 – 9, 64; and chain reaction 130, 288; and common zone 124, 437; in conductor’s map 222; and content dimension 279 – 80; and conversational exchange 69; and current domain 153; in cycle of group’s development phases 313; defined in group therapy 113 – 16; and depth psychology 226; and dimension of content 279 – 80; and discourse theory/ analysis 146, 146, 148, 310; in free-floating discussion 39, 40; goal of monologue and dialogue in group therapy 100; in group therapy 112 – 13, 114 – 16, 122 – 5; historical 287; illustrated 119, 121, 123, 386, 431 – 3, 435; illustrations with monologue and dialogue in vignettes 33 – 5, 36 – 7; and imagery 279, 288; and leadership 315; and location 294, 452; and mature dependence 64; and musical key 452; progression 372; promoted by conductor 305, 310, 442 – 3; and relational field 116, 404, 409; and resonance 344; round the circle 35; and semantic/relational elements 125; and silence 148; social 402; as speech form in group’s language 2, 20, 32, 90, 93, 284; and thematic development 287; therapeutic 268; and three-dimensional model 226, 233; in 3-person psychology 115;

480 Index towards theory of 128 – 32; and transference 362, 377; universe of 403 – 4; widening 371; within silence 148 – 9; as work of a chorus 113 discrepancies of need 270 – 1 disillusionment 104, 252, 377, 383 – 4 dissociation as false solution 109; avoidant 257 – 8; in ‘crying group’ 346, 349 – 51; general dissociative state 258 – 60; illustrated 256 – 9; in projective mirroring 270; sexual 231; at ‘6 degrees below zero’ 336 dominant internal objects 437 Dover Beach (Arnold) 397 dramatic play 399 dreaded state 87 dreams: and angels 427; condenser 255 – 6; daydreams 75, 93; dreams of the night 93; Friedman’s three uses of dreams in groups  –  informative, formative, transformative 63, 91, 93, 382; illustrations of work with dreams in groups 75, 121 – 2, 130 – 1, 320 – 2, 380 – 2, 386 – 8, 406 – 9; meaning-making 62; oedipal problems in dream 406 – 9; and other imaginative constructs 226; in primordial domain 339; in PTSD 426; prophetic 47; as source of metaphor in groups 38; and symbolic register 395 – 6 dreamtelling in Friedman, R. 63, 91, 93, 382 drugs 137, 362, 264, 428 – 31 Durkin, H. 63, 88 dynamic administration: and authority 229; Behr and Hearst; and boundary events 228, 224; conductor’s convening role 39, 304, 307 – 8; conductor’s role function mapped against group’s domains 320, 341; conflicts in literature 306; in construction of group 235, 237, 237 – 8; and crescendo/decrescendo 128; defined 237 – 8; external 308; internal 309; in phases of group’s cycle of development 313; primacy of 223; and setting 308; and silences 150; and structural interventions 224 dynamics of change 325 – 7

early development of group analysis 14 – 15 ego training in action 420, 423, 423 – 4 Einhorn, S. 189, 220 embodiment-projection-role (EPR) 399, 400 emotion: against self 42; in anniversary effects 108; attunement 257; carried in stories 314; childhood 422; communication 212 – 13, 373, 450; of conductor 134, 127, 210, 302; corrective 67, 128, 305 – 6; debasing 437; depressed 421; development 37; dissociated see dissociation; dreamtelling 91; early 294, 406; of family life 3; gratitude 40; grief and loss 401, 421 – 2; growth 155, 257; healing 140; injured 242, 290; levels of 75; limited 107; love and hate 315; in matrix 52, 181; measured 383; mirroring 121; model of three 127; mood and tone 399; musicality 31; new and new language 127; overwhelmed 423; owned 408; painful 311; in parataxic distortions 406; primordial 268; projective identification 44; rage 80; range 7; recognised, hidden, available 44, 136, 140, 143; reparation 66; repeated in group 46; resolving 138 – 9, 422; resonance 252 – 3, 256 – 7, 259; seat of 47, 113; shame see shame; shared 118, 140; site in body 183; at six degrees below zero 336; source emotion 80; spoken 230; support 177; on terminaton 100; texture 396; transference 361, 372, 374 – 5; translation 447; truthful 293; valency 120, 254; vulnerable 351 empty spaces 84, 136, 415, 451 – 2 endings and beginnings 93, 100, 106 – 8, 226, 308 engagement: depth of 61; disengagement 100; first and last 161, 270, 345; in group 51; mirroring 268; narrative failure 139; nurturing in therapeutic community 172; of conductor 1, 128; poor 194; preverbal 213; promotion 172; spoken/unspoken 139, 146; stage or phase in group

Index 481 88, 93, 96 – 7, 98 – 101; illustrations 102 – 3, 117, 137 – 8, 169; terms of 65, 87, 228; with primordial themes 131; with self in monologue 33; with unspoken 227; words of 278; environment and object mother 326, 396, 463 envy 42, 96, 123 – 5, 132, 258, 338, 340, 345, 347 – 8, 349, 354, 357, 410, 412 Ernst, S. 189 European Group Analytic Training Institutes Network (EGATIN) 460 evidence-based practice 9 – 10, 466 – 7 exchange see reciprocity exclusion criteria in group therapy 44 exclusion dynamics in relation disorders 44; see also Friedman, R. experiential groups xi, 86, 236 – 7, 288, 296, 304, 312, 329, 345 external boundary events 308 – 9 Ezriel, H. 86 – 7, 205 – 7 Fairbairn, W.R.D. 63, 91, 367, 405 see also object relations; return of the repressed false self 395 fast-open group 163 fathers and therapeutic work with paternal issues in groups: 143, 246; abusive 35, 119, 333 – 4; author as father to vignettes 456 – 7; authority of conductor as father 103 – 4, 308, 329; Daedalus and Icarus 418 – 19; dying 106 – 8; good 119 – 21, 152, 243, 257; horizontal transference in group 73, 231, 261 – 2, 360; killed 425; killed in dream 121 – 2, 340; in literature of whole object transference 211, 339, 360, 377; in model of three 246; negative transference 383 – 4; negligent 388; omnipotent 322, 349; playboy 428 – 31; provocative triggers 294; remote and persecutory 152; resolving transference 142 – 4, 294, 378 – 82, 386 – 8, 456 – 7; in role 400; safe 36, 77; unavailable 242; underrepresented symbolic father 456 – 7; vertical transference in group 152, 243; violent 289 – 91 Feld, B. 81

female survivors of child sexual abuse 180 – 2 fight/flight as basic assumption in groups 88, 206, 207 figurations 14; defined 37, 345; dynamic 101; of holding-containment and exploration-play 326; and mirroring 270 – 1; and mutative metaphors 226; and process and content 283; recognition of 318; regenerative 109; and sources of meaning 333; and structure and process 224, 280; subjects, themes and figurations in ‘the crying group’ 345 – 57, 354 – 6, 357; triangular 91 – 4; unexpected 108 finding a voice 179 five-phase progression in group theory: forming, storming, norming, performing, adjourning 86 – 7 flashbacks 253, 425 – 7, 432 – 3 focal conflict theory 63, 89, 93 – 4, 125 forensic psychotherapy 7 – 8, 15, 160, 171 – 7 formative approach to dreams see Friedman forming see five-phase progression in group theory Foulkes biography: early work in UK 14 – 15; group-analytic ‘turn’ 16; according to successors 16 – 19; according to Anthony 322 – 3; Socrates and psychotherapy 17; publications 14, 159, 161 – 3, 247, 251 – 2 Foulkes’s innovations: crescendo/decrescendo in therapeutic activity: 128, 159, 306 common zone: 14, 38, 124, 151 conductor: as leader defined 301 – 5; cautionary points in practice 303; debate on Foulksian leadership 306 – 7; 3 role functions of conductor 312 critique: 17 – 19, 250, 306 – 7, 402, 446, 450 four levels of group: summarised 328 – 334; originating account as 12 levels 335 – 6, illustrated 336 – 8; revised as domains 334 – 5, clinical applications of 4 domains 338 – 358; original and current formulation 339 – 40, 341

482 Index free-floating discussion: defined and illustrated 112 – 134; and Freud’s free association 126 – 128; and language of group 114 – 6, 114; illustrated 116 – 125 group-analytic model: 221 – 2, 222; applied as psychotherapy 227 group-analytic situation: 45, 75; from ‘leader of’ to ‘leader in’ group 159 group-specific factors: introduced 247, 249, 249 – 50; revised as process dynamics defining terms and illustrations 251 – 263 group’s three dimensions defined 223 – 6; structure 235; process 247; content 278 interpretation: 447 – 8, 448 – 450 influence: 18, 162 – 3 location: 13, 440 – 1, 444 – 5 norms and normative resolution: ‘basic law’ 455 – 57 social unconscious 13, 15, 92, 228, 294, 297, 368, 433 – 4, 446 three therapeutic principles: location, translation, interpretation 440, 444 transference: discovered in groups 360 – 1; the ‘T’ and ‘t’ situations 364 – 6, 366, 370 – 1, linking group analysis and psychoanalysis in The Rosetta Stone 365, 366, linking transference and process dynamics 368 – 70 translation: 445 – 6, 446 – 7, 446 types of groups: terms and definitions 162 underlying conception of self 455 vertical and horizontal relations in group 86, 92, 159, 370 – 1, 376 – 8, 378 see also common zone; communication/communication domains; location, translation, interpretation forms of play 399 – 403, 400 Freedom From Torture agency 177 free-floating discussion: ‘crying group’ 345 – 57, 354 – 6, 357; development of 127 – 8; discourse theory 280; free association as 46; language of the group 112, 116; speech and silence in psychotherapy

147 – 8; speech forms in 131 – 2; spontaneous mood of the group 75 Freud, A. 18, 140 – 1, 363, 367, 464 Freud, S.: conductor and 303, 305; definitions of transference 371 – 3; hypnotherapy 373; introduction 11 – 12; love and work 41 – 2; mourning and melancholia 422; recognition of transference 361; signal anxiety 275; talking cure 126 – 7 Friedman, M. 12 Friedman, R. xxxiv, xxxv, xxxvi, 8, 15, 81, 109, 156, 189, 414; indications for optimal therapy 44, 53; integrative approach 441; relation disorders (exclusion, scapegoating) 44, 228; three uses of dreams in groups 63, 91, 115, 382 Frosh, S. xxiii, xxxiv – v, 15, 20, 373, 460, fusion through joining to belonging 90 – 1 gaps in field of group psychotherapy 16 gaps in text 464 gender 8 gestural communication 31, 71, 399, 400, 401 – 3; conductor’s illustrated 407 – 8; empathic 423 Gill, M. 303 Goldstein, K. 8, 12, 16, 166 Gordon, J. 8, 15 Graham, R. 132 Grendon Hospital 161, 173 Grief in group therapy: 106 – 8, 258 – 60, 401; see also mourning group-analytic model: applications of model in 10 clinical studies 154 – 94; basic developmental schemata 88 including: anti-group 92, 94 – 6, development of culture and identity 92, 94, focal conflict theory 89, 93, from dyadic to triadic dynamics 91, 93 – 4, fusion, reciprocity and maturity 90 – 1, 93, intimacy agency and belonging 90, 93, language of group  –  monologue dialogue and discourse 90, 93, 112 – 34, three dimensions of group therapy  –  relational, reflective reparative 90, 93, 59 – 83, three uses of dreams  –  informative, formative, transformative 91,

Index 483 93 – 4; clinically focussed literature 7 – 8; concluding summary of model 459 – 64; evaluated 7, 9 – 10, 164 – 9, 186 – 94; exposition of model 221 – 2, 223 – 34, 227; group analytic ‘turn’ 16; heuristic learning 2 – 4; history of model in Frankfurt 12 – 14; indications and contra-indications 43 – 5; introduced 1 – 7; journey of 462; key principles 31 – 2, 37 – 41, 39; methods and methodology 467; opening illustrations 5 – 6, 33 – 7; preparation for 45; range of groupanalytic groups: block 10, 158, 160, 184 – 6; closed 10, 19, 158, 161, 169, 239, 312; combined 162; conjoint 162; homogeneous 19, 45 – 6, 158, 160, 161 – 3, 171 – 84, 200 – 2, 205, 227, 236, 238 – 40; mixed 19, 44, 46, 158 – 9, 160 – 71, 182, 185 – 94, 227, 238, 262; once-weekly 10, 158, 160, 162 – 3, 164 – 9, 187; open 19, 161; slowopen 19, 101, 108, 158, 160 – 3, 185 – 94, 231, 236, 239 – 41, 312, 460; twice-weekly 10, 42, 77, 123, 128, 137, 141, 158, 160, 162 – 3, 165, 184 – 5, 187 – 94; re-making of meaning 38 – 40, 39; therapeutic techniques/operational principles 49 – 51, 50; vision and clinical method 46 – 7; visible and invisible group 232 – 3, 233; Group Analytic Practice 162, 188 Group-Analytic Society 15, 21, 53 group-analytic ‘turn’ 16 group composition 241 see also principles of similarity and difference group defences 87, 394, 463 – 4 group development see personal and group development group member, conductor as 306, 311 – 12, 312 group psychotherapy: aims and vocabulary, categories of need 42 – 3, 43; conceptual frame differentiating methods, models and applications 200 – 5; illustrations of 67 – 79; Interpersonal 208 – 9; Groupanalytic 209 – 11, mutative metaphors 80 – 1, overview 59 – 62,

61; Modern psychoanalysis in USA 212 – 13; Psychoanalytic in USA 211 – 12; range of models 205 – 13; Systems Centred Therapy for Groups 213 – 14; Tavistock and Bion 205 – 7; therapeutic factors 64 – 5; three-dimensional model defined 65 – 7; tripartite division 62 – 5, 64 group-specific factors 225, 247, 249 – 51, 251; see also process dynamics Haddock, R. 136 – 7, 146, 147, 220, 463 hallucinations 431 – 4 Hayes, C. 182 – 4 Hearst, L. 17, 39, 40, 45, 52, 54, 60, 210, 237, 237 – 8, 301, 303, 306, 414 Heine, H. 139 Helen Bamber Foundation 178 Henderson Hospital 161, 171 – 3 heuristic learning 2 – 4 Hillbrand, M. 173 Hobsbawm, E. 397 Holmes, J. 62 – 5, 64 Holocaust xviii, 5 – 6, 12, 105 – 6, 296, 299, 345, 351 – 2, 355, 357, 381 holography 20, 39, 53, 334 – 5, 444, 461 The Homeless Mind (Berger) 397 homogeneous groups 162 Hopper, E.: aggregation/massification 148, 207; basic assumptions 88; deductive theory 85; hope 4; social unconscious 15 horizontal transference 378 – 80, 384 – 6; see also vertical transference Horkheimer’s Institute for Social Research 12 Horowitz, L. 86 – 7 Hutchinson, S. 81, 220, 304, 306, 414 Hyde, K. 8 hypnotherapy 373 I and Thou 12; see also Buber, M. identification, defined 374 ‘I-for-myself’ and ‘I-for-the-other’ (Bakhtin) 14 I-It relationship (Buber) 63 imagery and content dimension 288 – 96, 295, 296 images of survival and transformation 424 – 5 indications and contra-indications for group psychotherapy 43; inclusion

484 Index and exclusion criteria for mixed groups 44 – 5; for homogeneous groups 45 individual psychotherapy 182, 425 – 8, 427 inductive group theory see deductive informative approach to dreams 91; see also Friedman In Memory of Sigmund Freud (Auden) 42 Institute of Group Analysis (IGA) 8, 162, 237, 460, 466 integrated responsibilities of conductor 312 – 22, 313 – 14, 315, 316, 318, 319, 320 intermediate territory 360, 374, 393 – 4 see also Winnicott internal boundary events 309 International Association of Forensic Psychotherapy 15 International Psychoanalytic Association 466 interpersonal model 1, 208 – 9, 208, 305, 361 interpretation concept 226, 441 interpretation overview 447 – 8, 448 – 9, 450; see also location, translation, interpretation intersubjective relationships 65, 76, 89, 183 intersubjective validation 183, 423, 423 – 4, 436 – 7 intimate conversations 34 intimacy phase 63, 90, 99 – 100, 104 – 5 intrapsychic drive psychology 126 introjective identification, defined 375 isolating silence 140 I – Thou relationship (Buber) 63, 90 Jakobson, R. 400, 401 – 2 James, W. 116, 403 – 4 Jennings, S. 399, 400 John Howard Centre 173 Jones, M. 171 journey literature and developmental theory 38, 40, 84 Kane, L. 139, 156 Kennard, D. 8, 49 – 50, 50, 54, 169, 173 key therapeutic agency in groups 63 – 4, 64 Kibel, H. 189 kinship exchange 254

Klein, M. and Kleinian 60, 66, 363 – 5, 367, 373, 464 Kleinot, P. 39, 40 Ladden, L. 220 La Muerta (Neruda) 353 language exchange 254 language of the group: clinical illustrations 116 – 25; conclusion 128 – 32; dialogue 112 – 13, 119 – 22; discourse 112 – 13, 114 – 16, 122 – 5; evolution of technique 126 – 8; freefloating discussion 127 – 8; Freud’s talking cure 126 – 7; monologue 112 – 13, 117 – 19; overview 112 – 16, 280, 402; psychological forms and relational field 113 – 14, 115; speech forms 114 – 16 leader activity: conductor 314, 315, 316, 316; goal-directed therapy 202 – 3, 215, 216 Lao Tsu 301 Lavie, J. 8, 12 Lawrence, G. 86, 207, Leszcz, M. 4, 5, 8 – 10, 37, 45, 60, 63 – 5, 67, 71, 87 – 8, 109, 112, 150, 159, 168, 189, 203, 208 – 9, 361 – 2 12 levels of experience in Foulkes and Anthony 328, 335 – 6; illustrated 336 – 8, 341 4 levels of experience in Foulkes: illustrated 329 – 34; as holograms 334; revised to domains 329 Levene, R. 212 – 3, 220 Levens, M. 402, 450 Lewin, K. 12 limbic resonance see resonance Living Human Systems 213; see also Agazarian, Y. location, translation, interpretation: conductor role 441 – 3; critical concerns 450 – 4; empty spaces 451 – 2; introduction 440 – 1; limits to the verbal 450 – 1; location by group members 452 – 4; location of disturbance 452; overview 443 – 8, 444, 446 – 7, 448 – 9, 450; reflections on 454 – 7 location of disturbance principle 223 – 4, 305 location of group’s preoccupations 226 location overview 13, 444 – 5

Index 485 longing and belonging: auxiliary ego 410 – 12; confusion between 405 – 9; embodiment-projectionrole 399; four forms of play 399 – 403, 400; introduction 393 – 4; other people’s pictures 403 – 5; overview 394 – 5; phatic forms of communication 401 – 2; remembered and unremembered histories 398 – 9; reparation 411 – 14; special qualities and 395 – 7; summary 463 – 4; word play and gesture 399 – 403 Lorentzen, S. 88, 168 – 70 maintenance interventions 51 malignant mirroring 122, 385 – 6 Malinowski, B. 400, 401 Maratos, J. 132 Marcus Aurelius 1 Mark, P. 9 massification/aggregation in group therapy 207 massive psychic trauma 177 – 80 Mathiesen, T. 81 matrix in group psychotherapy xxxi, 12, 35, 46 – 8, 51 – 3, 61, 65, 81, 84, 90, 94, 109, 112, 114, 116, 123, 125, 127, 129, 161, 181, 210, 211, 227, 228, 235, 244, 244, 274, 288, 294, 329, 365, 368, 388, 404, 406, 409, 452, 454, 461 maturational problem 235, 330 mature dependency 90 – 1 Maudsley Hospital 18 – 19, 162 Mead, G.H. 14, 31, 399, 400, 403 metaphors: ego training in action 420, 423, 423 – 4; images of survival and transformation 424 – 5; intersubjective validation 423, 423 – 4, 436 – 7; mourning and melancholia 421 – 2; overview 418 – 19; a primitive disaster 422 – 3; in psychotherapy 38, 40; self-generated metaphors 444; suffering and 419 – 21; transference and 463; use in therapy 394; see also angel metaphor methods and models: basic applications 203 – 5; Group-Analytic model 209 – 11, 208, 210; Interpersonal model 208 – 9, 208; leader activity

in 202 – 3, 215, 216; leadership and 201, 201; main models of 205 – 14; Modern psychoanalysis 212 – 13; Psychoanalytic model 211 – 12; role of therapist 214, 214 – 17; System-Centred Therapy for Groups 213 – 14; Tavistock model 1, 69, 205 – 7, 206; therapeutic goals 200 Mies, T. 8, 12, 14, 21, 460 Millard, P. 14, 63 – 4, 90, 357 Millstein, M. J. 53 mirroring as process dynamic: 247 – 8; defined 254 – 5; examples 258 – 9; explorations and applications 269, 269 – 70; as ineffective 274; language of the group 119 – 20, 122; and projective identification 258 – 9; therapeutic competence in 317 mixed groups 44 – 5, 162 mnemic objects 424 – 5, 433; see also Bollas, C. Mojovic, M. 8 Modern analytic model 1, 212 – 13, 373 monologue: dialogue and 33 – 4, 34, 36 – 7; in group therapy 112 – 13, 117 – 19; serial monologue 68, 100, 142; transference domain 377 mothers and therapeutic work with maternal issues in groups: xxviii, 5, 34, 36 – 7, 73 – 9, 99 – 107, 116, 120, 121 – 3, 258, 308; ambivalent 420 – 3; damaging 122; deprived 45; in gratitude 401; lost 422; in making meaning 403 – 4; mother, cow’s milk and calf 77 – 9; mother, madonna, whore 426 – 31; mother of Muses, Mnmosyne 424; motherless 411; mother’s wardrobe 105 – 6; 99, 107, 116, 120, 121, 123, 141, 152, 181, 183 – 4, 211, 241 – 6, 256 – 8, 264 – 5, 268, 272 – 5, 289 – 95, 296 – 9, 308, 337 – 8, 345 – 53, 378 – 80, 387 – 9, 406 – 9, 410 – 11; object and environment mother 326, 396, 463; in play 400, 404 – 5; and survival 5; in transference 339, 336, 375, 377 mourning in group therapy xxxi, 70, 142, 166, 258, 181, 258, 334, 345 – 57, 349, 421 – 2; see also grief

486 Index Mourning and Melancholia (Freud) 396, 421 – 2 muses 424 musicality in groups 8, 31, 52, 302, 463 see also Wotton narcissistic fusion 91 narrative/narrative encounter 283 – 6 Nathan, G. 53 National Health Service (NHS) 158 National Institute for Health and Clinical Excellence (NIHCE) 9 – 10 National Training Laboratories 12 Nazi ascendancy 12 negative transference 376 – 7, 378 Neeld, R. 39, 40, 141 Neruda, P. 353 neuropsychoanalysis 250, 252 Nitsun, M.: anti-group see anti-group; bearing witness 39, 40; clinical writing 8; critique of Foulkes 17, 306, 367; deductive theory 85; early development in group 32, 393; Foulkes’s four levels 339; group as object of desire 339, 393; metapsychology 200; organizational mirror 253; originality 86; strength in numbers 3 Nitzgen, D. 8, 12, 16, 360 – 1, non-verbal communication 280 – 1, 281 norming see five-phase progression norms 88, 176, 308, 455 – 6 Northfield Military Hospital 162 Northfield story 16 – 17 Norton, K. 171 – 3 numbness 294 object mother 396; see also environment mother; longing and belonging object relations: and Balint in object relations bias 126; and Bollas 420, 427; British school of 126, 367; in countertransference 150; and Fairbairn on mature dependency 63, 64, 91, 367; and Foulkes on metapsychology 365 – 70; in groups 205, 368, 369; mature object relations 64, 339; in metapsychology 363; object relations therapy 373 – 4; and return of the repressed 405; in transference 211; in two-body

psychology 326, 365; unthought known 370; whole-object and partobject relations 31, 339 – 40, 360, 377 Oedipal conflict 120, 406 – 9 Ofer, G. 15, 39, 40 once-weekly group 163 once-weekly homogenous groups 171 – 84 once-weekly mixed groups 164 – 9, 166, 167, 168 one-person psychology 113 – 14, 367 open group 51, 161 operational principles 49 – 51, 50 oral tradition of group therapy 16 Ormay, T. 8 Ormont, L. 162 – 3, 212, 310, 367, 460 ‘the-other-for-me’ (Bakhtin) 14 other people’s pictures 403 – 5 outcomes, in group therapy 170 outpatient psychotherapy 44 – 5 outsight, introduced 4, 21, 39; defined 61; discussed 274, 337, 407; illustrated 228, 229, 241, 258, 406; and mirroring 255; and longing and belonging 406 parataxic distortion 405 parent – child relationship 367 part-object relationship 330, 332 paying love forward (Arlo) 67 Peleg, I. 8, 33, 53, 280, performing see five-phase progression Perls, F. 12 personal and group development: commentary on 108 – 9; conductor role 314; critique of linear phases 88 – 94, 89; five key development tasks 101; five-phase progression 86 – 7; four internal connections 100 – 1; group-analytic literature 89, 89 – 92; integration 93 – 4; key phases illustrating 102 – 8; language of the group 90; overview 84 – 6; progressive/regressive dynamics 98 – 100; tasks, movement, and progress 96 – 7, 96 – 7, 97; theories on group development 86 – 8 personal tradition of group therapy 16 Pertagatto, E. and G. 209 phatic forms of communication 401 – 2 Pilgrim’s Progress (Bunyan) 84

Index 487 Pines, M. 8; on Bion 206; biography of Foulkes 8, 367; classification of group therapies 200 – 3; cohesion and coherence 36 – 7, 39, 40, 46, 90, 96, 324 – 6; criteria for selection and exclusion in group therapy 44 – 5; developmental dialogue 84; dynamic administration 237; evolution of group analysis 164; Foulkes and Anthony’s ur-text of group analysis 461; groupanalytic practice 162, 187 – 8; group-analytic psychotherapy summarised 210; group-specific factors 249 – 50; history of group psychotherapy 211; interpretation  –  developments in Foulksian limit 440, 451; and intersubjective therapy 46; language of gesture, mother and child 402 – 3; leadership in group therapy 316; and matrix 52; metapsychology 47, 85, 113, 420; mirroring 39, 225, 248, 254 – 5, 269, 402 – 3; neuropsychoanalysis 252 – 3; outsight 61, 255; play and its forms 40 play: in Bollas’s dialectics of selfexperiencing 427 – 8; children 272, 394; experience that may have no words 393, 459; four forms 399, 400; free play of words at work 115, 248 – 9; with human experience in groups 7; key driver in group’s life 40, 275; as key principle in group therapy 39; lambs 264 – 5; leading to discourse 310; learning to play 85, 144; of levels/domains in group 325; of light and shadow in vignettes 325; newfound vitality in group 332; play as theatre 457; ‘playing God’ 323; playing with dream 406 – 9; role play in Foulkes 224; with sexual symbols 36; transference a ‘play’ on time 364; transitional phenomena 182; ‘transitory’ objects 183; Winnicott 150, 393, 395 – 6; wordplay 38, 130, 399; work or play 250, 462 political conflicts 346 pornography 434 – 5

Portman Clinic 160, 161, 175 – 7 positive intervention principle 179 positive transference 376 – 7, 380 – 2 post-traumatic psychosis 432 principles of similarity and difference in group composition introduced 3, 43; defined 239 – 241, 241; illustrated 265 see also group composition primitive disaster 422 – 3 private psychotherapy practice 185 – 6 problem-solving groups 204 process as a process dynamic in groupanalytic model: basic illustrations 256 – 64; concluding illustration 271 – 5; definitions 251 – 6; explorations and applications 263 – 70, 266, 269; history of terms and current use 249 – 51; groupspecific factors 249 – 51, 251; overview 170, 224, 225 – 6, 247 – 9; transference and 365, 366 process groups see experiential groups progressive dynamics 98 – 100 projection 119, 121 projective domain: overview 285, 332 – 3; transference and 360, 368, 368 – 70, 369 projective identification, defined 374 pro-social therapy 11, 257 psyche and social world 13, 48, 113, 118 psychiatry 14 – 15, 18, 44 – 5, 171, 175, 320, 361, 465 psychoanalysis and transference 363 – 4, 386 – 9 psychoanalytic interactions 62 – 5, 64 psychoanalytic model 211 – 12 psychodynamic model 1, 205 psychosis in group therapy 8, 44, 165, 205, 431 – 4 psycho-educational groups 204 – 5 psychosomatic problems in group therapy 182 – 83 Punter, J. 397 qualities of dependency 63 – 4, 64 range of applications: block groups 184 – 96, 186; definitions 161 – 3; once-weekly homogenous groups 171 – 84; once-weekly mixed groups 164 – 9, 166, 167, 168; overview 158 – 60; slow-open

488 Index vs. time limited 160 – 1; ten studies 160; twice-weekly group psychotherapy 187 – 9, 190 – 4 rape culture in Kosovan-Albanian communities 456 Rafaelson, L. 343 Rayfield, E. 8, 31 Real, constructed and representational 61, 394, 398, 405, 411, 421; see also the symbolic order and reverie reciprocity (exchange) as process dynamic 247, 254 reflective dimension: commentary on 75 – 6; construction in 80; defined 65 – 6; examples of 72 – 4; introduction 3 – 4; overview 60, 61 refugee survivors 177 – 80, 431 – 4 regressive dynamics 98 – 100 relational dimension: commentary 69, 70 – 2; defined 65; example of 68 – 9, 70 – 2; language theory 113; mnemic objects 424 – 5; overview 60, 61, 70; psychological forms and 113 – 14, 115; understanding 12 relational field 12, 39, 40, 53, 61, 113 – 14, 116, 125, 127, 211, 251, 253, 404, 421, 461; see also semantic field re-making of meaning 38 – 40, 39 remembered and unremembered histories 398 – 9 reparative dimension: commentary on 78 – 9; conductor and 310; deconstruction/construction 80 – 1; defined 66 – 7; examples of 77 – 8; introduction 3 – 4, 35; overview 60, 61, 65; summary 411 – 14; symbols 296 – 9 repetition compulsion 405 required state 86 – 7 resilience in adversity 179 – 80 resolving emotions 138 – 9 resonance: acoustic 253; Agazarian’s recognition of Foulkes’s resonance 214, 225 – 6, 251; and amplification 122, 125; in common zone 271; complex form 265, 266; defined 251 – 4; descriptive and unconscious forms 266 – 267; as elementary conveyor of emotion 252 – 3, 461; empathic 253; explorations and applications 263 – 70, 266; Foulkes’s definitions

214, 247, 252; giving rise to dialogue 100; group as resonant arena 240, 318; in group’s language 115; as group-specific factor 249, 250; history of term and current use 249; illustrations of 117, 256 – 8, 332, 344, 351, 384, 407, 412; key/governing factor in process dynamics 40, 251; limbic 253, 433; as linked to transference 368 – 9; and mirroring 34, 250, 254 – 5, 317; missing from Foulkes and Anthony’s account of ‘t’ situation 365; and outsight 255; and parallel process 253; as process dynamic 39, 222, 247, 251, 317; and reciprocity 100, 248; signal/simple form 263 – 4, 266; and valency and countervalency 252, 253, 254, 258 return of the repressed 288, 290, 405, 437 re-traumatisation 253, 433 revenant 424,437 reverie 135, 146,147, 150, 154 – 5, 287, 427, 427 see also symbolic order and real, constructed and representational Ritchie, S. 220 Roberts, J. 8, 49 – 50, 50, 54, 169, 173 Rogers, C. 373 Rosetta stone: reading psychoanalysis and group analysis  –  Foulkes and Anthony 40, 326, 366, 365, 461 Rouchy, J. C. 92 Rutan, J. S. 30, 214, 302, 303 Salm, A.M. 452 sanctuary from fear 179 Sandler, J. 371 – 3 Salzberger-Wittenberg, I. 100 Scanlon, C. 397 Schlapobersky, J. 185 – 8 Schultz-Venrath, U. 8 self-abusing patterns 436 – 7 self-declared need 155 self-denying fusion 91 self-engagement monologue 33 self-experience 427, 427 – 8 semantic field 39, 40, 53, 61, 114 – 16, 116, 125, 127, 129 – 30, 211, 288, 403 – 4, 421, 424 – 5, 461 see also relational field serial monologue 68 – 9

Index 489 setting and convenor 308 sexual abuse illustration 333 – 4 sexuality in group therapy 336 – 8, 260, 263, 434 – 5 Sharp, M. 132 Shepard, H.A. 87 – 8 Sherbersky, H. 303 shame 42, 85, 176; illustrations in group therapy 35, 74, 104, 124, 143, 181 – 3, 263, 337, 385, 430 – 5, 437 short-term and long-term group analytic psychotherapy randomized controlled trial (SALT-GAP) 168 – 70 siblings 285, 321, 339, 363, 379, 454 signal resonance 263 – 4 silence 135 – 157, 279, 287, 312, 317, 318 – 9, 319, 320 – 322, 441, 459 see also brothers; sisters Simon, P. 144 simple transference 375 – 6 sisters in group 7, 77, 289, 330 – 1, 360, 378, 384 – 7 see also brothers; siblings ‘six degrees below zero’ (Foulkes and Anthony) 336 – 8 Skynner, R. 17 – 19, 88, 114, 213 slow-open group 160 – 1, 162 – 3, 312 Smail, D. 419 small-group psychotherapy 16, 171 – 3, 251 social theory 10, 11 – 14, 13 social unconscious: 13, 228, 294, 297, 368, 433 – 4; in Foulkes and Anthony 21, 446; in Hopper and Weinberg 15 The Sound of Silence (Simon) 144 source emotion 80 ‘space capsule’ of the ‘normals’ 287 speech and silence in psychotherapy: conclusion 151 – 5; discourse 148 – 9; forms 114 – 16, 131 – 2; free-floating discussion 147 – 8; human experience of 145 – 7, 146; overview 135; resolving emotions 138 – 9; silence in psychotherapy 135 – 8; symbolic order 150 – 1; the unspeakable 140 – 7; the unspoken 139 – 40 Spotnitz, H. 460 splitting 140 – 1, 142 – 4 spoken language forms 399 spontaneity 49, 115, 303, 446 springing the trap metaphor 155

‘stand-alone’ therapy 160 Stern, D. 403 Stern, D. B. 67, 402 Stone, W. 30, 204, 214, 220, 252 – 3, 302 – 3 storming in five-phase progression 86 – 7, 88 Stacey, R. 8, 28, 52, 90, 400 Strachey, J. 371 – 2 structure dimension of group-analytic model: authority and meaning 228 – 32; dynamic administration 237, 237 – 8; examples of 241 – 3; overview 224, 235 – 7, 245, 236; principles of construction and selection 238 – 40, 241, 244 – 6; therapeutic vs. experiential groups 236 – 7, 236 suffering and metaphors 419 – 21 symbolic order 150, symbolisation process 116, 403 System-Centred Therapy for Groups (SCT) 213 – 14 Systemic models 1, 200 Tavistock model 1, 69, 205 – 7, 206, 361 Taylor, P. 81 termination phase 106 – 8 thematic development 286 – 7, 288 – 96, 295, 296 therapeutic alliance: basis of 45, 165, 376; factors 64 – 5; group process and 170, 236; individualized 87, 237 therapeutic community 14, 161, 171 – 2, 304 therapeutic techniques 49 – 51, 50, 310 therapeutic vs. experiential groups 236 – 7, 236 therapist conductor as 305, 309, 309 – 11 three domains of meaning 360 three-person psychology 113 – 14, 115, 127, 367 three-phase rotation 88 three-Rs of group-analytic psychotherapy see reflective dimension; relational dimension; reparative dimension three uses of dreams in groups 91, 382; see also Friedman the timed in group psychotherapy 47 time limited application 160 – 1 torture 425 – 8, 427

490 Index transference domain: clinical problems in group-analytic psychotherapy 360 – 3; complex transference 375 – 6, 378 – 82; conductor and 305, 311, 375, 376; countertransference and 172, 369, 376, 378; current definitions 374 – 5; current literature on 373 – 4; differentiations 370 – 7; dreams, illustrations 339 – 40, 380 – 2, 387 – 8; emerging identity 285; in groups 364 – 5; horizontal transference 378 – 80, 384 – 6; monologue, dialogue, and discourse 377; mutative metaphors 463; negative 99, 376 – 8, 383 – 4; object-relations theory 365 – 70, 368, 369; overview 330 – 1, 359 – 60; positive transference 376 – 7, 380 – 2; process dynamics 365, 366; projective domain 360, 368, 368 – 70, 369; psychoanalysis and 363 – 4, 386 – 9; restricted and extended definitions 371 – 4; simple and complex 375 – 6; structure, process and content 377; theory and practice 360 – 3; three domains of meaning 360; transference object 120; ‘T-situation’ 370, 370 – 1; vertical transference 378 – 82 transformative approach to dreams 91; see also Friedman, R. transgressive sexuality 405 transitory vs. transitional objects 183 – 4 transitional objects 183, 184; see also intermediate territory translation concept 226, 441, 445 – 6, 446 – 7; see also location, translation, interpretation trauma in group therapy 164, 178 traumatic loss and violence example 68 – 9 Traumatic Stress Clinic at University College Hospital London 178 traumatised asylum seekers 68 – 70, 425 – 8, 431 – 4 ‘T-situation’ 370, 370 – 1 Tucker, S. 11, 39, 455 – 6 Tuckwell, B. 88 Turquet, P.M. 207 twice-weekly group psychotherapy 187 – 9, 190 – 4 twice-weekly slow-open group 163 two-person psychology 113 – 14, 367

unconscious: 13, 46 – 7, 121, 128, 406; angels 425 – 7; anti-group 95; anxieties 394, 463; Bion in basic assumptions 207; childhood emotions 422; circular exchange in groups 368 – 9, 463; collective in Foulkes 249; communication 381; condenser 261; conflict 80; construction 285; Cox 174; defences 139; distortions 363; domains of meaning 328 – 35, 344 – 5, 444; dreamtelling 91; dynamics 201, 203, 297; Fairbairn’s return of the repressed 405, 424; fear 86, 377; Foulksian levels 124, 335 – 8; group behavior/dynamics 233, 243; group-analytic model 210; holograms 334 – 5; interpretation through conductor’s dream 321 – 2; language 48, 127; large group 304; makeup/character 409; meaning of disturbance 228; mind 381, 426; mind of conductor 302; primordial 338, 344; projective 340, 366; projective identification defined 374; psychosomatics 183; repetition compulsion 420, 437; repressed 366, 446; resistance 249; resolutions 326; resonance 225 – 6, 252 – 3, 265 – 8, 322; restrictions 87; restrictive solutions 89; shared 36, 115, 453; small and median group 315, 317; symptoms 222; transference 343, 361; translation 232, 305, 319, 320, 445, 446, 450; ultimate experiences of horror 433 – 4; visible and invisible group 339 uni-linear progression 89 unreachable misery 78 – 9 the unspeakable 139 – 147 the unspoken 139 – 40 valency as process dynamic : examples of 256 – 8; explorations and applications 263 – 8, 266; language of the group 119 – 20; overview 254; see also Bion, W. validation 352 – 3 Verebes-Weiss, J. 8, 32, 173, 280, 463 vertical transference 378 – 80 see also horizontal transference

Index 491 visible/invisible group 232 – 3, 233 voice therapy 15 von Fraunhofer, N. 39, 63 – 4, 64 Wainstein, S. 4, 8, 32, 54, 280, 463 weathering in groups 31, 52 – 3, 461 Weegman, M. 8, 17, 32, 52, 84, 86, 159, 365 – 7, 420 Weinberg, H. 15, 92, 299, Whitaker, D. S. 63, 150, 89, 125, 150, 159 whole-object transference 330, 332, 338 Wilson, P. 397, 463 Winter, D. 8, 49 – 50, 50, 54, 169, 173 Winnicott, D.W. 32; anti-social tendency 176; containment 211; corrective emotional experience 67; facilitating environment of group 364; forms of play 400; game of hide and seek 418; hate in countertransference 373; idiom, metaphor and intermediate territory 398; intermediate territory/ transitional domain 65, 147, 150, 182, 280, 393, 424; longing and belonging 399; object and environment mother 326, 393, 396;

object relations theory 363, 367, 373; representational world 398 – 9; symbolic makeup of cultural field 396; transference in intermediate territory 374; transitional objects and their derivatives 395, 403, 398 – 9, 424; see also object relations word play and gesture 399 – 403 World War I 12, 14 World War II xxviii – xxxi; 5, 7, 11, 162, 290, 296 – 7, 367 Wotton, L. 8, 31 – 2, 38, 39, 52, 53, 275, 280, 400, 441, 463 Wright, K. 14, 32, 400, 403, 463 Yalom, I. 4, 5, 8 – 10, 37, 60, 63 – 5, 67, 71, 87 – 8, 109, 112, 150, 159, 203, 208 – 9 Young, J. 173 Zeizel, E. 213, 220 zone of communication (Foulkes) 124 – 5 zone of proximal development (Vygotsky) 14 Zulueta, F. 8, 15