The Challenge for Group Psychotherapy

Group Analysis and the Insights of the Analyst, Part 1

The present paper is based on experiences with group analysis used as an adjunct to individual analysis.

The groups studied were open groups; of no more than six patients; fairly homogeneous as to diagnoses, mostly anxiety, compulsion, and character neuroses; of both sexes; mostly middle and upper socioeconomic classes, age nineteen to forty-five. They consisted as a rule of patients with a history of long psychoanalysis, often with two or more successive analysts. In my analysis, and mostly also in previous analyses, they were at a stage of long-lasting resistance (stagnation). This was true for both psychoanalysis or analytic psychotherapy. The group sessions lasted one and a half hours. Rare “alternate” sessions (without the analyst) also were used. The group sessions took place once every week with some patients and once every two weeks with others. The individual sessions took place two to three times a week.

The introduction of such infrequent sessions of group analysis in addition to the otherwise unchanged individual analysis proved to be of great value in overcoming the resistant unproductive stage of the analytic process. In no instance was this process disturbed or damaged by the introduction of group sessions. It was obvious that this result depended on the right preparation of the patient as well as on the tactics of the analyst and on the proper selection of cases.

Experience with group analysis has in general strongly confirmed the basic theses of individual psychoanalysis by offering new kinds of evidence. By placing the patient in action in a special social setting, both the analyst and the patient himself are offered directly observable evidences of his transference, projections, and fixations. His responses to a variety of interpretations of the same phenomena are shown, and a setting is created onto which not just the transference to one parental figure (the analyst) but to a group of figures (family) is easily projected. As the patient observes a variety of transferences to the analyst in other patients, the analysis of his own transference neurosis is facilitated. One reason group analysis is particularly advisable for patients who have been in individual analysis for a long time is the difficulty in the analysis and resolution of their transference neurosis.

In the group, the patient’s distortions of other subjects’ thoughts and emotions are often more clearly perceived by the other group members and sometimes by the subject himself—and not by the analyst alone. The analyst can quickly realize when the patient’s responses to love, kindness, hostility, praise, submission, aggression, etc., vary from his descriptions in the private session. Analysis of the reasons for these discrepancies is fruitful.

On the other hand, individual analysis contains important elements not duplicated by group analysis and does not, in my opinion, change much by combination with group analysis. However, the addition of group sessions does permit the use of novel material in the individual session: the directly observable reactions of the patient to the other people, his acting out, and his dreams related to the group situation. It counteracts to an extent the deplorable stalemate of a “double life” observable in long-lasting treatments: progress in self-knowledge during the analytic sessions without any application of that knowledge outside the office. Furthermore, in the group both the analyst and the patient have a number of common experiences, which subtly influence their relationship and again supply novel material for the analysis.

This is not the place to discuss the fine points of the selection of patients for group analysis, of the proper timing for it, or the individual method of persuasion. One factor only should be stressed: we must avoid giving the patient the impression that he is being “dumped” into a group because the analyst has become tired of him or has lost hope in the success of individual analysis. On the other hand, the analyst must be pretty sure that these are not precisely his motives.

The chosen role of the analyst in the group was even less directive than in individual therapy. The differences were also characterized by a change of costume (a white jacket was worn in individual analysis only), of setting (cigarettes and candies on the table), and the presence of a tape recorded on many occasions. A new group that was “frozen” was often started by the analyst describing very frankly his own thoughts and emotions at the moment. It is not suggested here that this is a proper setting for other forms of group therapy or combined therapy.

The emerging phenomena of transference and countertransference, of projections, of over-identification, etc., were analyzed by the patient himself or by the other group members on the spot or became the subject of analysis in individual therapy. The emotions and situations that occurred in the group were not forced upon the patient in the individual sessions to the disadvantage of other material. Some patients rarely referred to them at all. However, even in these cases the influence of the group experiences was evident. It showed itself in shaken resistances, revised insights and infantile images, shifts of interest, and new reality testing. Sometimes the analyst referred to group experiences as a good illustration to what the patient was saying. The most important insights were those into the existence of positive and negative transferences.
It is clear that this method fills one great gap of individual analysis: the analyst is not at the mercy of the patient’s version of his human interrelationships. He becomes an actual witness, free to formulate his own view of the events and compare it with that of the patient.

In my groups there is often another witness: the tape recorder.

This is used for therapeutic purposes in three ways: (1) A patient at his own or the analyst’s suggestion listens to a whole group session once more in order to relive it and to check on his impressions of others or his own actual behavior. (2) The patient may catch up with a session he missed. (3) The analyst can supervise his own behavior and analyze it, if necessary.

“Group Dreams” as Evidence of Insights into Transference to Groups
Occasionally a dream was analyzed by the group, followed by analysis of the reasons for different interpretations by different group members. The interpretations by these members, well versed in dream analysis, were often so patently wrong that the analyst had to intervene. At the same time, however, his alertness toward the relativity of his own interpretations was stimulated by his “fellow analysts.” The dreams frequently dealt with group problems, especially in those patients who had problems with groups in life. A few examples may illustrate this.

In Anna’s case three dreams showed successive stages of her groping with her problems. In her profession as a social worker she was considerably hampered by her complexes in speaking before groups of people. When she and the others noticed she had the same difficulty in group therapy, she recognized the similarity of these current feelings with those of childhood – daily experiences at the dinner table, which highlighted her entire situation at home. Her mother, a rejecting figure, engaged in lively conversations with her brother about personal matters while Anna would never open her mouth, convinced that no one could possibly be interested in what she had to say. In her first dream, after entering the group, she was seated during a banquet with a number of elderly ladies, while all her friends were at another table. When she tried to move over to their table she was stopped by a waiter who said that this table was reserved for important people only. In a later dream she was with a group of boys in the analyst’s office. One boy cried and the analyst took him on his lap and kissed him. Anna was surprised and envious; she felt left out. However, in the next sequence she was alone with the analyst, he took her on his lap, kissed her and she liked it very much. But then her mother appeared, angry and with a black face. In a subsequent dream she was again in the analyst’s office. Here, the analyst attended to another patient while she was still there. She was slightly annoyed. Then, the analyst conducted an art class. There was a discussion on what is “subjective.” She wanted to be helpful and suggested that four oil paintings should be given to those who have none. The analyst replied that Anna would get none because she already had a drawing. In reaction, Anna thought: “Despite the fact that this is just, I still feel cheated.”

In capsule form our interpretations, given in this case in the individual sessions, were as follows: In the first dream she was forbidden to be on equal terms with people toward whom she felt friendly. In the second dream, the analyst could only love a boy, her brother, and the following oedipal wish fulfillment was punished by mother. In the third dream everybody got something (love) from the analyst; the fact that she got a little bit, too, did not meet her demands. Despite her frequent complaints about her mother, it was the love of her father which she missed more. The parents did not talk to each other for twenty years.

Sam was another patient who suffered from impotency and was struggling with tremendous sex taboos. He dreamed of a party at which a woman was telling a joke and groping for a word. He promptly supplied the word “shitless!” Everybody laughed gaily, but his brother and a few other people were slightly shocked. The next sequence of the dream was a flashback to the twelfth year of age and yielded an important withheld sex memory.

Ted was an extremely rigid personality whose neurotic system since his third year of age centered on repressing love in order to remain independent. He recalled a dream about a female figure made up of a swarm of bees, which was trying to pull him into her mouth in order to destroy him. This seemed like a perfect image of transference of a parental figure to entire groups.

It is well known that one of the most useful and frequent events in group analysis is the recognition of the patients’ own projections and their confrontation with reality. Thus a forty-year-old man, who because of impotence as well as shyness had never had sexual intercourse and whose sex fantasies were all of the child-and-mother type, exclaimed after listening to the desperate complaints of an obsessive-compulsive pretty young lady who was in tears: “I cannot understand myself! There you are practically breaking down in front of me and yet I continue seeing you as I see women in general: superior, knowing all about sex and absolutely sure of themselves.”

I had the opportunity to analyze many dreams of three group therapists. One, who felt quite secure as an analyst, had a “group dream” in which there was a suspicious emphasis that a friend. a senior analyst, had remnants of a castration complex while he, the dreamer, had none. The other two, who most of the time were thinking obsessively about their groups, never had a “group dream,” although one dreamed often about single members of his group.

One of these, however, found himself in his dreams often in the middle of smaller and larger groups, always hostile and frightening. These groups did not consist of patients. This reflected his typical projections to people in real life as well as the nature of his negative, hostile, and defensive countertransference in the therapeutic group.

Group Therapy as a Tool to Sharpen the Insights of they Analyst
Besides the “supervision” of the analyst by the group members functioning as fellow analysts there are three ways in which the analyst can use the method described here for self-supervision: (1) the direct observation of the patients and of himself in the group; (2) the analysis of patients’ experiences in the group during subsequent individual sessions; and (3) listening to the recordings made during the group sessions and individual sessions—soon after they were taken and again months or years later, when the final outcome of the therapy is known.

Certain mental attitudes are necessary in this self-supervision. We must break out frequent analytic inertia and become conscious of our mental predictions of each patient’s reactions, which we are constantly making automatically and most subconsciously. It is bad indeed if we develop such a degree of inertia that we are not making any such predictions at all. In such cases we must force ourselves to make them consciously, so that we clearly formulate in our mind a hypothesis regarding the unconscious of each patient.

In group sessions there are sometimes moments when the analyst must frankly admit to himself that he is surprised by the patient’s behavior or utterances. In such cases he has obviously made false predictions, otherwise there would be no surprise. In such situations we must fight any tendency to find easy and cheap excuses for these errors of judgment and must take them very seriously. They call for urgent self-analysis of the causes and motivations of the false predictions. At times these may prove almost trivial; at other times they may involve important insights, often concerning countertransference.

To give but one very superficially described example of such surprising behavior: A patient with compulsive homosexuality as his outstanding symptom agreed to join the group under the condition that he would not mention his homosexuality. Yet his first words to the group were: “My problem is that I am an homosexual.” Although the analyst was well aware of the patient’s ambivalences, he was nevertheless surprised. The patient, too, spontaneously expressed his surprise about this behavior during the subsequent individual sessions. This false mental prediction was the subject of analysis and self-analysis. The latter revealed that by his confession the patient was protesting against his guilt feeling. Originally this guilt feeling about homosexuality was so strong that it created an obstacle in the beginning of analysis. The analyst did a rather good job of reducing this guilt but in the further course of analysis unnecessarily continued minimizing it. This was motivated by subconscious over-identification with the patient, caused by the sexual guilt feelings that the analyst himself had retained from the time when he was the patient’s age. Thus, the analyst subconsciously helped in repressing slightly these guilt feelings, which in the special social situation of the group broke out in the form of a protest: “I am a homosexual, so what?”

But the patient’s reactions are not always so dramatically surprising. Much more often one can diagnose one’s false predictions only if one asks oneself repeatedly: “Now, frankly, would you have predicted what has happened right now?” Or if one forces oneself to predict: “In this developing situation I predict that patient will react in the following way.”