The Challenge for Group Psychotherapy

Psychoanalysis in Groups, Part 2

If a patient persists in remaining silent, the analyst may leave him alone, refusing to indulge his silent provocation, and let the frustration build until he speaks because he must speak or burst. In other instances the therapist may struggle to analyze a resistive silence or simply encourage the patient to speak. Those patients with weaker egos should be helped toward verbalization. Of these, the analyst may, at first, ask directly for a dream or a fantasy, hopeful that the symbolic nature of the communication will serve as a defense against the anxiety of self-revelation. Failing that, and only as a last resort, the patient will be urged to discuss immediate or current problems of his life outside the group. With notable exceptions, most patients are too prone to compulsively recite and review their current difficulties or case histories, and it is just this form of resistance that successful group therapy tries to discourage.

The recounting of dreams, fantasies, and reveries and free association to these unconscious productions and tentative interpretations are among the first devices used to stimulate group interaction and to establish group rapport. The next step is to encourage free association of members to each other. Until recently I used a technique I called “going around.” Here a single member was asked to free associate to each other member of the group. Eventually, as patients became more sophisticated and appreciative of the power this artificially centered position gave them, I noticed that there was never enough time, and before I knew it, each “going around” took up most of the regular session, naturally causing extreme frustration to some other members of the group. Today I use the device only rarely. And when I do, I encourage immediate responses to the member “going around.” I feel the same effect can be realized by promoting the free flow of interaction which inevitably gives rise to free association concerning group members and by constantly referring other free associations back to group members and familial antecedents. Let me give an example of how this might work and go hand in hand with other phases of analytic pursuit. Peter complained that he couldn’t trust women. He free associated to his mother and sister who were “always ready to jump on him.” Kay, a group member asked, “Does anyone here remind you of your mother or sister?” Peter answered, “Yes, Jane. You’re like a tight spring,” he tells Jane. “I’m afraid you’ll suddenly uncoil and snap at me.

What are you afraid of? Do you, any time you’re approached, feel you’re going to be raped?”

Jane resented the association and the interference. She refused to accept any of it as valid for her, insisting that it revealed nothing but Peter’s own projection. But that night she had a dream which uncovered her obsessional fear and concomitant wish to erotic contact with the father. At succeeding sessions the deeper intricacies of erotic interest in and fear of the father were elaborated and working through begun through analyzing her interaction with the men in the group. This one example illustrates the use of basic psychoanalytic techniques—free association, the use of dream material, the subsequent uncovering of repressed material, of transference and working through—all brought about by interaction within the group.

Analysis of Resistance and Transference
The analysis of resistance is also greatly facilitated by the group setting and the group process. For example, as patients interact, the person rigidly blocked in erotic, transferentiaI interest in the analyst, is helped to insight by the other members of the group, who are quick to assert their own special investment in the authority figure, while at the same time resenting the lack of attention being given them by the therapist or their peers. The commonly seen resistances or acting out of a missionary spirit, martyrdom, scapegoatism, etc., are among others most easily exposed in the group for the neurotic commitments we know them to be. Another form of resistance, not so easily available for direct study in individual analysis but glaringly obvious in the group situation, is voyeurism in its more socially acceptable form of ” living through others.” The injustice collector, the consistent diagnoser of other peoples’ ills, the judgment dispenser, the hider in historical detail, all these and many other resistive manifestations are clarified in group interaction and are made available as they become familiar and characteristic operations of the individual.

The analysis of transference, closely allied to the analysis of resistance, is one of the most important and productive aspects of psychoanalysis in groups. The projection of parental and sibling images onto other group members are phenomena requiring exhaustive study, and the analysis of this transferential process is the largest single area of concentration of this particular method except working through. Under the analyst’s guidance, patients discover the extent to which they invest one another with early familiar qualities. In the group setting, where a member may not only project a significant historical figure onto the analyst, but may also single out members of the group for the same purpose, the field for transference, in formation and in working through, is appreciably extended.

At first the analyst stresses certain truisms about the transference phenomenon.

He explains that all of us carry a heritage out of childhood which impels us to endow the present with old forms, that we see ourselves and others in terms of our own circumscribed experiences, that this attributes to others qualities they may not actually possess and results in the distorted relationships which lead to the pain and self-defeat of all neuroses and that therapeutic help, if not cure, can be measured by the extent to which these distortions can be revised in the patient himself and tolerated when directed toward him by others. Patients are alerted to the general qualities of the transference reaction—such as irrelevance, compulsion, repetition, irrationality, overcompensation, etc., so that they can learn to spot these transferential reactions as they occur in themselves and others.

As I said before, I believe the discovery, analysis, and working through of transference to be the most important work of psychoanalysis in groups, since transference repeatedly interferes with the patient’s true estimate of reality and since by its nature it must pervade every area of the patient’s life. In the group it is possible to study this phenomenon in all its myriad mutations and to demonstrate over and over again its repetitive and all-pervading qualities. Once the patient has been alerted to these general qualities of transference, he is ready to observe and analyze its manifestations in interaction. Since, as we all know, the transferential response is unconscious, we must expect considerable resistance to its recognition. Here again the group can be of great help. Since there is a great variety of interaction, the endless calling of attention to transference need not become a mechanical bore. So, we are in a position to remind the patient time and again when he is reacting to a mask which exists largely in his mind, when his reactions are illogical, unreasonable, absurd, or at least archaic and when he exhibits affective disturbances or anxiety, extreme irritability, depression, fearfulness, or even panic and terror.

Other qualities of transference are more easily observable in group than in other treatment situations. Here we can see how rigid are the transferential patterns, how excessive, how helpless is the person in their grip, and see how inhibiting they are to projector and object alike. By examples and illustrative material presented at the moment of occurrence, the analyst repeatedly verifies these identifying features of transference, using every opportunity possible to clarify the particular response in terms of the present reality and the possible historical background of the response.

Sometimes transference is so rigidly fixed in the character structure that a patient projects the same distortions on everyone around him, no matter how different the other personalities. These patients are easy enough to diagnose: they are often psychotic. But they are much more difficult to treat. Here again the group can be of immeasurable help, by provoking less threatening versions of the transference in the form of less-menacing peer personalities. Every group will contain some such less-threatening figures and allow the emergence of penumbral variations of response which, later on, may make it possible to reach the core transference problem with the therapist.

For example, a patient rigidly fixed in transference gives a complicated historical picture of a powerful, inimical family of parents and siblings. In individual analysis the patient may project onto the therapist at one time or another all these images. It is not always possible in the individual analytic situation to pursue these multiple, volatile responses. Certainly it is not always possible to differentiate the source of the particular projection. In group, the situation is reversed. “You are my sister, brother, father, mother, aunt, or uncle,” the patient may say at one time or another to analyst and group members. Or he may say to each one, “You are my mother; everyone is like my mother.” In either case, his response remains the same. And the group is bound to respond compulsively as well as spontaneously to these irrational investments, dealing with them in the less-threatening peer interaction, until the rigidity of response is worked through to more flexible and realistic alternatives. At this point it is easier for the therapist to start to deal with the thematic or central transference, which is usually centered on him. Since this is usually a reproduction of a relationship to a more significant parent or authority figure with whom the patient was most ambivalently and affectively bound, it must also of necessity pose the greatest threat to the defenses of the patient. With the groundwork for this laid beforehand in interaction and analysis of peer relationships, penumbral transferences, etc., the threat is no longer so great. Now, hopefully, the door has been opened to tackling a core problem which would have been too painful to approach earlier or more directly.

In group, when transference is evoked, the patient is asked for both the immediate provocation, so that the validity of his response can be evaluated, and for the possible historical background for the response itself and for his estimate of the quality of that response. Thus the searching for historical data and for the releasing of this data becomes not an obsessional maneuver to evade reality, but rather a search specifically focused on clarification of the transference as an opening door to reality. I believe that the therapist who can concentrate early in treatment on the analysis of transference can shorten the duration of treatment considerably and can more reasonably expect that the benefits gained from treatment will last.

I would like to cite here one example of this process, which highlights the totally different responses exhibited to me by a patient when in individual analysis and when transferred to a group. In thirty preliminary sessions, Joe and I got on famously. Joe was brilliant, serene, and exceptionally friendly; he made rapid progress. There seemed to be no obvious resistances. He interpreted a dream, and I would add some additional points. These Joe would accept and perhaps add some modifications which seemed entirely appropriate to both of us.

Suspicious as it might sound, there seemed to be no stumbling blocks. The whole relationship was simply too unneurotic, and I began to wonder why Joe was in therapy at all. I suggested that he join a group, so that we might have a chance to explore certain areas of his personality which individual analysis had not revealed. Joe agreed. I was not able to detect any lack of enthusiasm toward my suggestion. But at the very first group session, Joe exhibited his first sign of negative transference. He was a changed man. Our harmonious relationship, his warm appreciation of what I had done for him, his eager willingness to act reasonably, all vanished. Now, at this very first meeting, he challenged everything I said. He used his fine intellect and keen intuition to analyze all his fellow group members, unconsciously managing to forestall or to belittle any contribution I might dare to make. Whereas in the prior private sessions we had had easy interchanges, in the group he would hardly allow me to open my mouth. He interrupted, he anticipated and predicted—often accurately enough—everything I was about to say. I let this go on for some time. In fact I let it go on until the group began to notice his compulsive behavior and began calling it to his attention. Joe could hardly believe his ears, and finally he turned to me for confirmation. I remarked then on the sharp contrast between Joe’s friendliness in our individual sessions and his truculence toward me in the group. This time Joe was surprised and embarrassed. But he could see that what I said was true. And, almost immediately, he could allow repressed memories, which had not seemed appropriate in the individual situation, to come into consciousness. In subsequent sessions, Joe recalled with what pontifical dignity and Victorian strictness his father had held court at the dining room table when Joe was a child; how one had to tiptoe about the house when his father was napping; how he was not allowed to speak unless spoken to in his father’s presence. His rage mounted as Joe recalled other indignities reaching back into early childhood as, for example, that his father could visit with his mother while she was taking a bath, while he, Joe was excluded. As time went on, Joe’s field of insight widened. He began to realize that he could relate freely and well with one person—so long as that contact was self-limited and circumscribed. He then was able to recall that he could always talk with his mother when he was alone with her but that she was not too often available to him for any extended periods. In a group, however, he felt driven to excel, to be the genius of the living room. In other words he discovered that in every social gathering, he habitually recreated the family milieu and automatically strove to become its guiding intellect. The group suggested and Joe agreed that what he was acting out was his father’s role and that probably he had often fantasied as a child that he would one day successfully challenge his father in everything he said and did. Joe was then able to see how consistently he had been acting out this unconscious fantasy in his business and social life, to his own self-defeat; because, though he was relatively successful in both areas, he was far from reaching his full potential, a fact that had brought him into therapy. Now the group had given him the chance to act out the fantasy in a situation where it could really be explored in depth.

It was then made clear that when Joe was in a one-to-one relationship of limited commitment, as he had had with me, he could reproduce the pleasantries of his relationship with his mother. But that when I was in the group, I became his father and the group his family. From this insight we were able to proceed more deeply into his oedipal conflict, his intense attachment to his mother, his repressed rivalry with his father and his compulsive replacement of his father in the regenerated family. Obviously, Joe’s transfer to a group revived old family ghosts who would have appeared in individual analysis with difficulty but who had been almost immediately and spontaneously evoked in a group situation. What’s more they had been evoked with such undeniable drama and concreteness that insight had to be experienced by anyone not desperately ill. The group setting proved just as concretely helpful in the working through of his transferences. And what held true in Joe’s case has been observable in many other cases that heretofore were held to be “unanalyzable.” As his father transference to me was worked through with me, I again became the preoedipal mother from whom he was ultimately able to separate himself.

As the foregoing indicates I am still committed to the practice of psychoanalysis in groups with the modifications which necessarily must come with the change in setting. I believe that human behavior is largely determined by original provocation and the formation of early distortions. I do not believe that man functions accidentally, as a consequence of impulsivity or imagination that is totally self-generated and unrelated to causality or etiology. I believe rather, that a patient’s behavior, his illness, and his health are also largely consequences of his history and that transference in the present is the repetition compulsion of an earlier relationship, which can be worked through, so that there is a gradual but radical displacement of the negative history in the course of treatment. The group analyst need not avoid or reject spontaneity, inspiration, choice, or accident. But neither does he give up trying to discover, at every turn, the patient’s motivation, the original causes of his pathology, the development, and the laws that govern its present operation. While in early treatment, he allows spontaneous interaction to build up. He also consciously and expertly enters into the therapeutic relationship, always with the aim of facilitating freedom from compulsion by dispelling projective illusions.

Gradually he helps supplement the technique of spontaneous interaction with an encouragement to strive for conscious, methodical sifting and planning of verbalized responses in the best personal and mutual interests of the members of the group. This is always a process of intense struggle for the patient struggle with his own transference reactions when they cannot be justified or condoned, when insight without acting on it cannot be tolerated, when character change must replace explaining, and when self and group discipline demands personal reconstruction. This struggle is how I see “working through.” And, like all other struggles taking place in psychoanalysis, it runs throughout the course of treatment. When termination is near, however, it takes precedence over the other phases, and in group is a generally rewarding phenomenon. When the other members begin to remark with pleasure on the changes in attitude we know that the patient is on the way to termination.

One test of readiness for discharge is the patient’s ability to analyze and dispose of his own transferences by choosing more realistic alternatives and his ability to recognize situations where formerly he might have reacted in transference and instead of acting out verbally his lateral transferences to other patients to respond more appropriately.

The Rose of the Therapist
All this calls for considerable skill on the part of the therapist. His role is complicated, much more complicated than that of the individual analyst. And therefore it is also one of the most controversial topics of discussion among group therapists. There are some who see him as the most important patient in the group, participating on every level as the patient participates. Others liken him to the conductor of an orchestra or the director of a play. Others see him as a “leader” or conversely as a silent figure who represents leaderlessness and whose object is to build up the ultimate in frustration among group members.

My view of the group therapist is much more conservative, conventional if you will. I believe the group therapist should be first and foremost a well-trained psychoanalyst. He should be trained in the principles of individual psychoanalysis, and then later specifically for psychoanalysis in groups. He must have self-understanding and a capacity for empathy. These should be enhanced by study so that these endowments are under his conscious control and cease to be a source of wonder to him or to others. But above all I believe he should have the ability to scrutinize and work through his own transferences and counter-transferences. This is why he needs a thorough individual analysis and in addition a sustained heterogeneous group analytic experience. I am a firm believer in postgraduate workshops where the young and not-so-young therapists focus their attention on and continue to resolve their transferences and counter-transferences to their patients.

I hold this point of view not only to protect the patient, which is our therapeutic responsibility, but also to protect the therapist himself. If he is really doing his job in the group, he must expect constant efforts to manipulate him; he cannot afford to be discouraged or thrown off balance by the intensity of interpersonal feeling which occasionally develops in meetings. He must even encourage the most timid to react to him, and he must support the angry or loving patient who will test him to the utmost. He must be strong enough to lead and to exercise control where control is in the patients’ interest. He must be strong enough to acknowledge his errors and secure enough to relinquish the initiative to the group or to a patient as the situation of the moment demands, without feeling that his authority is being threatened. He must be able to control any tendency to play the proselytizing missionary or arbitrary dictator. He must remind himself at all times that the meaning of the interaction within the group is the significant focus of his attention and the jumping-off point for all analysis, and that, therefore, he must regard the patients in his group as partners in the analytic pursuit, while at the same time maintaining the reality position of the guiding expert—a position he can neither relinquish nor misuse if he abides by the reality principle established by the tenets of psychoanalysis.

This is by no means an easy position to maintain at all times and in all situations. Nevertheless a conscious attempt should be made to find ways of doing so. I think there are two ways, among others, for the conscientious therapist to accomplish this. In the first place, it is of paramount importance that he check continually on the possibility of his own counter-transferences interfering with his relationship to the patient. He must also look for ways to build the self-confidence and ego strength of his patients, so that the dependency on the authority is steadily decreased, and material which must be repressed or hidden from that authority is released.

The Alternate Session
It was in the service of this last principle that I introduced the formal concept of the alternate session, and my conviction as to its importance, theoretically and practically in any group therapy plan, has grown stronger with the passing years.

The alternate session, as I have indicated, is a scheduled meeting of a therapeutic group without the therapist being present. These sessions alternate with the regular sessions when, of course, the therapist is always present.

Usually alternate sessions take place in the homes of various members of the group, with the objective of utilizing a still more informal atmosphere, so that interaction and participation is further stimulated. I have rarely given formal rules as to how these alternate sessions are to be conducted. But experience with hundreds of patients has demonstrated that the alternate session usually becomes an extension of the regular session and tends to preserve the tone, form, and quality of the work done when the group is with the therapist.

The alternate session serves many purposes adjunctive to and helpful to the therapeutic picture in both the horizontal and vertical levels. On the horizontal level it emphasizes the important role interaction with one’s peers must play in therapy. Members learn they can disagree with each other and settle their differences without the intervention of the authority. In other words they learn they can stand on their own two feet without running to mama or papa for protection. Many patients feel freer to interact at alternate meetings when transferences to the therapist are less threatening or less repressive. Some report they can experience, see, and define different transferences more easily in these circumstances, and others say that it is largely at the alternate session that they can really feel they are relating to their fellow members. Necessarily, these are also attitudes that need to be worked through. At the alternate meeting the patient has a greater chance to learn how to ask for help from his peers, and conversely he can give help in circumstances he would ordinarily leave to the therapist to handle.

Another important function of the alternate session is that it gives members a chance to compare their behavior in the two climates. Anyone who has had experience in these different settings will tell you this is not a trivial factor in human relatedness. As far as I am concerned, it is one of the reasons I believe tape recordings of analytic sessions or watching through one-way mirrors is unsatisfactory and does not give a true picture of what actually goes on in such meetings. Since, ethically, the patient must be apprised of these mechanical interventions, they are naturally conscious of them, even if they themselves maintain it makes no difference in their behavior. The same contention is almost uniformly expressed by patients in group. Almost to a man they deny there is even the slightest difference in their behavior between one meeting and the other. But continued verbalization usually proves just the opposite. Rarely, the therapist may ask some questions about what happened at an alternate meeting, though I have found that usually this is not necessary and often unwise. The pertinent facts will be disclosed sooner or later. So I find out from one member or another that the patient who praises me to the skies in the regular meeting saves all his complaints about me for the alternate session. The therapist-patient who is a genial colleague at the regular session is an agent provocateur at the alternate, openly inciting the members to revolt against me or to quarreling among themselves. The conventional lady, compulsively conforming, may fantasy all kinds of escapades the mice might indulge in while the cat’s away. The habitually silent member who waits for a chance to be able to get something said at a regular meeting, while the others are not busy vying for my attention or to get their money’s worth, is allowed to speak only at alternate sessions. As I have said, at sometime or other, the “alternate” material is introduced in regular sessions sooner or later. For example, shortly after the war, there was a therapist-patient in one of my groups who wanted to learn about group therapy as well as resolve his neurotic difficulties. He was an older man, experienced in individual psychoanalysis, with emotional problems of his own. In the group was also a younger man who had suffered the horrors of a Nazi concentration camp in his early adolescence. The therapist member was not Jewish and had displayed latent hostility toward me as a father figure, but no feelings tainted with prejudice.

At one regular session the young Jewish man suddenly blurted out, “If anyone calls me ‘dirty Jew,’ I won’t be responsible for what I will do!” Everyone looked rather embarrassed, and he repeated his threat. I did not probe for clarification, because I was not certain how much the accusation had to do with reality and how much was a manifestation of his illness. I was also waiting for more background material. A week later, one of the women was angry with the therapist member and accused him of deliberate taunting. “The way you kept needling Abe at the alternate, always asking him, ‘What would you do now if someone called you dirty Jew’?” The occasion gave all members a chance to discuss their reluctance to be tattletales, though all were angry at the “therapist” member. It gave the latter a chance really to get his teeth into his own transferential disturbance and it gave Abe a chance to ventilate his pent-up violent feelings against those he felt had misused him so horrendously. It would have taken a much longer time for this material to have emerged if the group had met only in regular session. And I wonder sometimes if it would have come out at all. There is no doubt in my mind that for a clearer picture of the dynamics of any given patient the alternate session is invaluable. In the analyst’s absence members develop a relationship to each other on their own where they can learn to assimilate and tolerate their own contradictory feelings, and this fact alone can often motivate a group to stay together as well as to engage each other. This is one reason why I see the alternate session as ego demanding and therefore ego building.

It would seem then that the alternate session would be an accepted part of all group therapy plans. This, however, is far from the case. Many therapists are still extremely fearful that the mem