The Challenge for Group Psychotherapy

Mental Health Groups: An Intensive, Low-Cost Treatment Method, Part 2

It is also explained that the patient’s progress in treatment may be hampered, even completely thwarted, by his becoming superficial in therapy through avoidance of the requested efforts, by “acting out,” by consciously presenting a false front to the group, or by engaging in actions within the group that are attempts to gratify himself yet conceal his real feelings. For instance, a patient may try discourage a new member from continuing in the group instead of expressing his hostility directly toward the therapist.
Patients are encouraged to translate insights, gradually gained, into real-life experience by applying them constructively, first in the group and then in their day-by-day battles against the old neurotic behavior patterns. For instance, patients who unconsciously have reacted to each interpersonal situation as fearful, helpless, and guilty children might then gradually assert themselves in a more appropriate manner.

No definite sequence of procedures or phases of progress are applicable to the group as a whole. Such techniques as “going around,” whereby a patient expresses his feelings and phantasies toward each of the other group members,1 dream interpretation, directiveness or nondirectiveness of the therapist, and others appear constantly in the group. Analytic as well as reeducative aspects of treatment are always present in the group process. Furthermore, a greater understanding of the therapeutic procedure is demanded from mental health group members so that the time might be used more advantageously.

The emotional reactions of the therapist are utilized as a helpful instrument for detection of the patient’s various unconscious and semiconscious motivations, such as attempts to control or manipulate the therapist, make him angry, or humor him.

The therapist has to exercise considerable firmness with those patients who tend to waste valuable group time by monopolistic attitudes or long-winded speeches or by acting out their hostility and competitiveness. Such behavior is cut short by focusing on the underlying motivation of the patient. Careful attention must be given to asocial behavior and attitudes and their likely consequences to the patient.

In this connection, a reflection on the treatment of psychopaths by the Mental Health Group method is in order. As is to be expected, work with such persons has proved to be most troublesome and unpleasant, although quite interesting. Certainly, individuals with the most severe forms of psychopathy are not likely to come for treatment. However, there are many forms and types of psychopathic personalities, and eleven such cases have been treated over a longer period in these groups. In addition, a greater number of such patients dropped out after a short time in group therapy. Each one of the longer-term psychopathic patients made some progress in one or several areas, even though their true aim in coming to therapy was to become more successful in their psychopathy rather than to move in the opposite direction toward a truly desirable goal. Since they have never sufficiently developed a healthy, mature conscience (as contrasted to the superego of the neurotic) they—in a good number of cases—may appear as admirably fearless, free, and authoritative to the guilt-ridden, inhibited, and anxious neurotic group members. Persons who are not psychopaths themselves do not recognize that most psychopaths derive great pleasure from their asocial, destructive, and sadistic actions. Since it is the therapist’s job to gradually elucidate the psychopathic, exploitative, destructive, and ultimately self-destructive patterns, the psychopathic patients will almost invariably, sooner or later, attempt to undermine the therapeutic group work and in direct or devious ways, or both, try to destroy the position of the therapist and to discredit him. This is particularly true when their attempts to exploit the therapist are thwarted by him. Over the years, quite a number of neurotic patients were induced by psychopaths to leave the groups or were otherwise damaged by them. As a consequence, the writers consider it preferable not to include psychopaths in mental health groups, even though such treatment, when properly conducted, is more effective for them than individual therapy alone.

The following enumeration of some prevalent psychopathic traits may help the therapist and the group members to identify such individuals with greater ease.2 The psychopathic personality has not developed the mature conscience characteristic of a healthy and responsible individual. The psychopath does not feel guilty about his asocial and destructive actions, which stem from those specific psychological areas wherein his psychopathy has developed. This is in contrast to the psychological structure of the neurotic personality, whose infantile superego makes him feel far too guilty for actions as well as conscious and unconscious strivings that the conscience of a healthy individual finds acceptable. Traits listed may appear in varied combinations and degrees of intensity in any particular psychopathic personality.

The psychopath:

  • Lives for immediate gratification; schemes for further self-indulgence.

  • Is self-indulgent to the point of stupidity. (A former clinical term for the psychopath was “moral imbecile.”)
  • Will engage without hesitation in such gratification regardless of how much suffering it may bring to others.
  • Will exploit others without hesitation when it seems advantageous to him and will rationalize such actions. (The guilt-ridden neurotic person easily falls victim to the psychopath.)
  • Finds meaning in the words “gratitude,” “loyalty,” and “duty” only if they refer to “obligations” of other persons to him.
  • Will always present a false front to cover those areas where his psychopathy is dominant. Often he is charming and appears to be sincere.
  • Will say anything in complete disregard of truth if it furthers his goals and creates a good image of himself. Many are quite well-spoken.
  • Is convinced—or at least very hopeful—that his psychopathic acts will go unpunished.
  • Will try to get sympathy when in trouble or endangered, but will return to his old patterns as soon as he feels safe.
  • Will ward off any criticism either by attacking those who might realize or reveal the truth about him or by various forms of seeming acquiescence.
  • Projects onto others his own psychopathy and selfishness.
  • Is almost incapable of changing, has a marked inability to learn from his mistakes and no desire to direct any effort toward socially constructive goals.
  • Makes himself far more vulnerable to destruction than most people without realizing it.
  • May well bring about his own eventual downfall due to his inner patterns and outward actions.

Many therapists nowadays speak of “gestalt of the group” and “group mind” as something above and beyond the individuals present in the group. They attempt to deal therapeutically with the group as a whole in a global approach.

The writers’ contention, however, is that those trends in a particular group which give the appearance of a “group mind” are actually resistance. As the transferences are examined, the resistive motivations of each group member causing such conformity become apparent. Any neurotic submergence of the individual in the group must be analyzed and attacked by the therapist until it is resolved.

Psychoanalysts are quite capable of accurately describing the existing relationships in the basic group, namely, the family, without referring to terms such as “gestalt,” “group mind,” and others. The use of such terms is therefore both unnecessary and misleading.

The writers find that the patient’s cooperation can counter some of the resistive and repressive forces that constantly tend to destroy the constructive aims of therapy. The following techniques would be unnecessary in individual analysis, where the patient is seen a number of times each week. However, they are helpful—to a limited extent—in the Mental Health Groups, since the patient sees the therapist only once weekly.

In an effort to prevent the patient’s insights from slipping away, the therapist explains to him, at appropriate occasions and in the simplest possible terms, his particular neurotic patterns. The patient is encouraged to remember these formulations and, on occasions, to reinforce the insights by writing them down. For instance, an anxiety-ridden patient who unconsciously had to assume the role of his dictatorial, “lecturing” father was thus able to maintain the cognizance of this behavior pattern and therefore avoid some of its pitfalls.

In other instances, where a group member is approaching awareness of a certain problem area—for example, hidden hostility, fear of abandonment, a need to malign threatening figures—he is encouraged to search, even between sessions, for associations and feelings, particularly those stemming from childhood experiences. Patients are told that this remembrance of insights acquired and the focusing on problem areas must not become mere intellectual exercises but should involve real feelings. Such suggestions, which are merely at the conscious level, are most often followed only halfheartedly by the patients and are, most certainly, not equivalent in value to the traditional psychoanalytic techniques. However, these attempts diminish some of the confusion and distortion into which the neurotic patient regresses between sessions. He is given something to hold onto outside the therapeutic situation that may help him to deal more realistically with threatening environmental situations.

Initially, this technique was applied only with the patients of two groups in order to determine whether it would bring about noticeable therapeutic advantages. Results showed better integration and cohesiveness within these groups, and in less than a year, the technique was applied in all Mental Health Groups.

The therapist’s communications with the patients are in simple, non-technical language, always expressed on their level of understanding and referring to their own dynamics and their own imagery as evidenced in their dreams and phantasies.

As each patient is constantly made aware of his emotional reaction to each group situation, he gradually arrives at a better understanding of both outer reality and his own true feelings.

Just as it was the social world of the patient’s childhood environment that originally gave rise to and became imbued with his fears, suffering, and emotional imprisonment, it is now the social experience of the therapy group that helps him to enlarge his awareness of reality and to gain greater emotional freedom and depth.

Dreams in Mental Health Groups. The actual presentation and analysis of dreams occupy a relatively small portion of the mental health group sessions. Yet, dreams are most important in this type of group work. After a patient tells his dreams, he is advised to speak about the feelings experienced In them as well as to relate any associations. The patient’s understanding of his dream is aided by the associations, feelings, and interpretations of the other group members.

The therapist will utilize dreams to make the patient aware of the problem areas to which he must pay attention at each particular stage of his psychoanalysis. Constant parallels are made in the group between the defensive and neurotic behavior of a patient and his dreams. Furthermore, defenses and emotional reactions of the various patients are often compared, and similar, identical, or opposite patterns are pointed out. In this context, it is important to realize that the dreams of psychopaths often require a diametrically opposite interpretation to the dreams of neurotics. For instance, the same dream that would show progress by the neurotic may very well mean a status quo or even a hardening of his asocial tendencies by a psychopath.

Orthodox psychoanalysts who practice only individual analysis have expressed the fear that a premature interpretation of strongly repressed dream material by fellow group members would cause, in some instances, intolerable anxiety in a patient. The writers have not witnessed any such situation that could not be handled adequately. More often than not, it is sufficient simply to show no reaction to the correct but “dangerous” dream interpretation or, when appropriate, to probe its meaning for the “interpreting patient” rather than for the dreamer.

We know that at the beginning of therapy dream material is often quite repressed and strongly symbolized; e.g., patients may dream of animals, trucks, etc., which threaten them. As therapy progresses, dreams become clearer, and significant human images take the place. It has been noted that this process is often more accelerated in mental health groups than if the patient would only come for one individual session per week.

Because of the importance of dreams in analysis, and in view of the limited and severe conditions under which effective therapeutic service must be rendered in the Mental Health Groups, therapists who want to engage in this form of therapy must be skilled in the proper handling of dreams.

Transferences in Mental Health Groups. Transferences often take a different course in the Mental Health Groups, where there is far less individual contact with the analyst yet longer contact among group members. Even with the analyst’s constant warm, positive attitude, more patients, particularly those of the same sex as the therapist, persists in projecting manifold negative feelings upon him. These hostile feelings are expressed in innumerable overt as well as covert forms. The so-called “positive transference” toward the therapist is less apt to develop to any intense degree, and, in many instances, it cannot be counted on as a prime tool in working through existing resistances. Transferences of the patient toward other members appear even more pronounced than in other forms of group therapy. Transference reactions such as withdrawal or acting out are more intense in this kind of group.

Freud has termed any therapeutic approach as psychoanalytic when it makes use of the transference. If this is the determinating factor, then analytic group work may be called the psychoanalytic therapy par excellence. The transferences of the group members toward each other and toward the therapist become the chief vehicle by which the emotional problems are worked through. Therefore, great attention has to be given to establish a group composition that allows emergence of a variety of significant transference relationships.

The transference relationships are allowed to develop and are elicited within the interaction during the group session. Focusing on the transference involvements, the therapist asks the patients to associate to the feelings presently experienced. Those associations are to recent as well as to childhood experiences, especially within the original family constellation. This procedure brings out the significance of the transference reaction, where it originated, how it has been reinforced, and the present need to maintain the defensive and resistive behavior patterns.

Free Associations. Associations in group therapy differ greatly from those in individual sessions. Often they are more emotionally charged because of the strong stimuli of group interaction. Such emotional responses may lead directly to the upsurge and revelation of repressed childhood material and traumas, often manifested in the dreams of the patients. This, of course, is far more therapeutically desirable than a more intellectual and sterile description of childhood history without affect.

There is frequently the danger that a patient may not verbalize his associations because much activity is occurring at the particular time. This can be used by his resistance and result in the loss of significant analytic material. Such an occurrence must not be taken lightly by the therapist, perhaps consoling himself with the hope that the lost affect will eventually become manifest again. In the Mental Health Groups, the therapists were most attentive in their efforts to prevent such a loss, which, in practice, is a difficult task. They attempted to observe the reactions of all group members and at the end of the session asked for unexpressed feelings. Of course, the longer sessions provide the Mental Health Group members with increased opportunity for self-expression.

Theoretical Considerations. The authors have been exposed to widely diversified experiences in psychotherapy and psychoanalysis, including different forms of group psychotherapy, which have increased significantly their understanding of the functioning of the human psyche. As has been stressed in the Foreword of this book, it is felt that group psychotherapy can make a most meaningful contribution to the improvement and refinement of psychoanalytic theory and technique. In this era, healthy examination and valuable discussion reevaluate the original dogmas and tenets of traditional psychoanalysis.

Freud was a genius in clinical observation, but he was forced to work as a pioneer in almost unexplored territory and his attempts at theory had to be largely speculative.
Even though Freud’s structural theory represents an advance over his topographical theory, it still fails to present a workable and factual framework to sufficiently explain the interaction of psychological forces. Most certainly his many followers added notable corrections and improvements in later writings but, by and large, they were not able to free themselves to a desirable degree from what they had been taught. As with the adherents of other psychological schools, their observations are frequently limited by their concentrating on a somewhat restricted number of elements and thus ignoring and disregarding other essential factors necessary for an understanding of greater depth and scope. An even greater danger exists—particularly for overly intellectualized therapists—that they read into a patient’s psyche concepts ingrained by their specific professional education which do not truly exist within the particular individual.

Group psychotherapists today have the benefit of some eighty years of psychoanalytic experimentation. They must, of necessity, have gained a thorough-going knowledge of the many psychic injuries that can afflict a patient in his early and subsequent years and of the many ways in which the human psyche reacts and defends itself against these traumas, anxieties, and conflicts; such as how the members within a family may attempt to exploit, seduce, manipulate, or destroy one another. As a rule, these psychological determinants will become more crystallized and visible in group psychotherapy than in individual psychoanalysis due to the presence of a variety of personalities of both sexes. The necessary regressions are fostered and can be far better understood as they reveal a variety of projections upon the other group members and the therapist at the same time. This phenomenon cannot occur in individual analysis as dramatically and with such clear-cut simultaneous separation of the different transferences. The distorted masks of each patient’s early images are cast upon the other members and we view as many plays as there are patients in the group.

Thus group psychotherapy is singularly useful to the attentive and open-minded observer since he can test, enlarge and improve his psychoanalytic concepts and techniques by scrutinizing the interplay of the complex traumatic forces, specific to each individual, which brought about emotional disturbance. Careful and skillful psychoanalytic work in the group will unravel to a significant extent and in an impressive majority of cases, the child’s world that operates within each patient and gradually remedy at least some of the damage.

The psychological forces and mechanisms as perceived by the authors will be presented in the form of “working hypotheses” in the next publication of the International Institute for Mental Health Research. These hypotheses have the advantage of providing a useful and verifiable base for further theoretical formulations, which, in turn, result in psychotherapeutic techniques more in accordance with psychological reality. The hypotheses also attempt to bring about fuller understanding of dreams in terms of their content, levels, the interplay of negative and constructive forces and their evaluation during treatment.

Finally, the authors would like to express a few words about the results in mental health groups. Although standards of evaluating results are usually highly subjective, some objectivity has been obtained in the present study through preparation of detailed comparison charts. In evaluating therapeutic progress, it must be remembered that many of the patients in these groups were clinically difficult cases such as severely damaged neurotics and ambulatory psychotics. Results in working through the patient’s problems seemed very satisfactory for about one-third of the patients, satisfactory for about one-half, and somewhat less satisfactory for one-sixth even though they made progress in some areas. (Good results were also reported by the junior staff members who were trained in this method.) Progress was roughly proportionate to the effort made by the patient. An important task of the therapist, therefore, is to enable patients—even those with little motivation—to cooperate with the procedure.

The method of mental health groups proves convincingly that most ambulatory patients can be helped to a significant degree at minimal cost if they are willing to give the necessary cooperation.

It is the authors’ conclusion that the intensive treatment done in such mental health groups can offer a most hopeful solution to the most pressing problem in the field of mental health: effective treatment at low cost.

de Schill, S. (1959), Mental Health Groups: An Effective Form of Low-Cost Psychoanalytic Therapy. New York: American Mental Health Foundation.