The Challenge for Group Psychotherapy

Psychoanalysis in Groups, Part 3

Having gone this far, I would like to elaborate a bit more on the alternate session, mainly to answer some of the more-frequently-asked questions.

When in the course of treatment does the group start having alternate sessions? As far as I am concerned, the first regular group session can be followed immediately by the first alternate session. If the therapist thinks they patients are “too sick” to gather by themselves, he may wait until he feels more secure. And I believe that if patients are well enough to function outside of a hospital and to be engaged in some sort of life outside of group, there is little reason for exaggerated fear that gathering with fellow patients will lead to some kind of disaster. I think it is worth repeating that therapeutic groups have always in my experience set their own limits and, if left to their own devices, will be able to control their acting out. Of course, if the therapist himself acts out and unconsciously encourages the group to do so, the problem becomes quite different. Irrationality can be infectious. But if the therapist can transmit his conviction that acting out retards therapy and demonstrate its resistive character, the extent to which the group goes along with him will not differ radically between regular and alternate sessions.

Another question which puzzles many is how the therapist can do his job when the patients know so much more about what is going on than he does. The answer is that the therapist knows more than they do, not necessarily every detail, but more of the psychopathology and has more of a conscious plan for working through. Besides, the alternate meeting is part of a continuum. It does not exist in a vacuum, nor is it isolated from the regular session. If anything of moment happens in an alternate session, it is bound to come up at some regular session. But more importantly, the alternate meeting is there to help the patient, to get him to understand the nature of, let us say, the repetition compulsion, the all-pervading quality of transference, to raise questions about how he can resolve his frustration and to bring these problems back to the regular session until he can function more appropriately on his own.

New “facts” as such are not necessary to convince the analyst that they exist. I did not need confirmation, for example, that the provocateur I described earlier had a father problem. What I did need was sufficient repetition of his provocations in varied enough form, so that he and the group could see it. And this the alternate meeting helped us all to get.

Another common question is: Is it necessary to hold alternate meetings in the homes of members? No, of course not. I do, however, think it is desirable. Some of my groups cannot afford the extra time alternate evening meetings take, and so must meet in my office. There is, of course, nothing we can do about these reality matters, if, for example, a member has a night job. But if these concessions are made, the therapist should be fully aware that certain drawbacks will be present. These meetings simply will not be as free, in breadth, depth, or relaxation. If, for one reason or another, they must be held in the analyst’s office, I suggest that they be held after and not before the regular session. In the prior session there is a strong tendency for many to withhold until the therapist arrives. I had one such experience with a patient who was generally accepted by the group and myself as being a hard and conscientious worker for his own therapy and that of others. We tended to forgive his temper tantrums when others, in his opinion, talked too much, as being part of his particular problem.

This group had switched their alternate meetings from members’ houses to prior sessions in my office. I had not noticed that whenever I entered the room for the regular session, this patient (let us call him Max) was always launched on some discussion or other, until one day, one of the women in the group took the bull by the horns and accused him of a plot. She pointed out that he was always very active with the other members of the group, flattering them with his attention and offers of help and sympathy, right up until two minutes to one, when the regular session was scheduled to begin. Then, suddenly, as if a bell had been rung, he switched the subject to himself, and continued on it, as I entered and seated myself.

Max, naturally, denied any such plot, and, since none of the others had noticed this method of operation, he stood more or less group supported, and his accuser was seen as a projector. What happened thereafter, however, was most interesting. It was not too important to check on whether Max continued his maneuver. It was much more important to see that once the modus operandi had been exposed, all the other members thought it such a splendid idea, you couldn’t get anyone to discuss anything more personal than the weather before the magic hour of one. Gradually members started drifting in later and later to the presession, so they could start talking later and later. All attempts to analyze this, though interesting, did not solve the reality situation of the waste of the presession. I ended switching the presession to a postsession with a full explanation of the reason for doing so and the expressed hope that meetings soon would be held again in members’ homes. That summer, when I was on vacation, the meetings were resumed at the homes of patients, and postsessions in my office were never asked for again by that particular group.

This brings me to my last reason for sponsoring the concept of the alternate session as strongly as I do. It gives a continuity to the group life which most patients have missed in their own lives. During the long summer vacations, the struggle for realistic communication can still proceed. Life does not or need not stop just because· the therapist goes away. This is especially necessary for the patient who literally thinks he dies when his analyst is gone. This type of patient will still suffer, but there is a chance of mitigating that pain when it can be discussed with the group in a relationship which already has a base of operation without the therapist. In the same way, the alternate meeting can be an important part of any short-term group therapy plan. In short-term therapy different levels of results can be hoped for or expected, but the idea of continuity and the possibility of holding the group together for a while longer through the alternate meeting plan can be very comforting to people who dread the end of help.

At present I provide regular weekly sessions for one and one-half hours with the analyst, alternate meetings once or twice a week without the therapist for two or three hours at a time, and selected individual sessions for three-quarters of an hour. This program provides for the exploration of peer and vertical vectors and shows the optimal usefulness of each procedural variation in the therapeutic fields of operation.

Combined Therapy
Some might say my stand on the alternate meeting is a far cry from traditional psychoanalysis. They might say the same about my attitude toward combined therapy, that is, the routine treatment of a patient in group and simultaneous individual analysis. My stand on this question is quite simple. I am neither for nor against combined therapy. What I am against is its routine use, except where absolutely necessary. There are certain things one must do “routinely,” but I don’t think combined therapy is one of them. There are many patients I have treated who did not need individual therapy at all, others have had to have combined therapy throughout their group experience, and still others have not been able to take the group experience at all. Here, once again, a pet theory of the therapist can be a hollow one when placed against the needs of a particular patient. The need of the particular patient at a particular time should determine whether or not combined therapy is indicated. It is as simple as that.

I seldom use regularly scheduled private sessions in addition to the group, except as indicated below.

Some patients need the one-to-one experience with the maternal surrogate in the person of the analyst before they can join and interact with their siblings and peers. Others cannot avail themselves of the dyadic relationship with the therapist until they have had a liberating experience with their peers.

The group therapist who provides regular individual sessions has too little regard for the therapeutic effectiveness of treatment in a group. Individual hours are often promoted not out of the patients’ real needs but out of the therapist’s countertransference. Individual sessions are frequently rationalized as necessary in order to precipitate a transference neurosis as a step toward working it through, but such a requirement is unusual. For as resistances are analyzed in the group, preoedipal and nonverbal reactions emerge and can be resolved in the group setting.

Some group therapists provide individual hours on the assumption that if a patient is silent in the group or avoids a dyadic relationship with the analyst, he needs individual sessions to resolve one-to-one problems in the vertical vector. But it is a misunderstanding of group therapy to think that dyadic relationships do not exist in group interaction. One-to-one ties and connections develop in the group both in the horizontal and hierarchical vectors.

The regular use of individual hours often leads to an increase in resistance. Often the patient, certain of his routine and private access to the analyst, does not show in the group his responses to other members but saves them for exposure to the therapist alone. This leads to indirection and deviousness rather than a working through to more straightforward responses. It also prevents the members from getting more immediate understanding of their mutually provocative behavior. It blocks reality testing and a detailed on-the-spot and vigorous mutual investigation.

The belief that all patients at all times need combined treatment obscures differences among patients. It obscures the uniqueness of a patient’s behavior in one context and another. It confuses the special value to the individual of the regular and the alternate sessions. It muddies the differences of the members. It might be more relevant for the therapist to ask himself with each patient why he wants to offer private sessions just now. Would individual hours facilitate treatment at this point? Can the analyst accomplish the same ends in the group setting? Would individual sessions promote the patient’s resistance?

The patient may ask for individual hours in order to avoid participation in the group. Or he may misuse the group in order not to relate to the analyst. Or he may exhibit destructive behavior at group sessions and constructive behavior in individual interviews. Or the reverse may take place. Or he may resist telling the group what has taken place in individual treatment. Or the therapist’s fear of the projected dangers of group members’ interaction may lead the group to fall apart.

There are certain patients who ask for individual sessions, whose requests have to be denied and analyzed. Among these are regressed psychotics in preoedipal attachment to a prior individual therapist or to the group analyst himself. The same caution needs to be exercised with the borderline psychotics. Others wish to control or seduce the therapist or to isolate him from the rest of the group. Such a maneuver may not be discovered until the analyst has seen the patient individually.

The generalized and nondiscriminative use of individual sessions parallel to group therapy tends to make treatment too leader-centered. The therapist’s anxiety over the projected dangers of group interaction and acting out leads him inappropriately to provide too many overprotective individual hours. He invests group members with a helplessness and aggressivity that demand individual attention. As a result patients are infantilized and subverted in their wholesome need to use their own resources in working through to a more maturating giving and taking with one another. Accordingly, I suggest only occasional rather than regular individual hours, when their use is appropriate and realistically necessary. Such sessions should be group-centered, and the patient should be encouraged to tell the group what transpired in the individual meeting.

For many passive dependent patients, unless there is peer interaction, therapy does not take place. This has taught me in conducting individual analysis to promote the patients’ interaction with other persons outside the therapeutic situation as well as in the treatment setting. Of course, with patients who are terrified of closeness, such deep anxiety proscribes interaction except in very small doses, built up slowly as treatment proceeds. Even these isolated individuals make no progress until they are drawn into interactional experience. Patients who are very passive, inactive, schizoid, or character-disordered profit enormously from the promotion of peer interaction with other group members.
I treat the patient in the group setting. Where transference involvement with me is intense, individual private sessions may deepen the pathology. There are specific indications for providing adjunctive individual hours in certain circumstances and at certain times in the course of treatment.

Psychoanalysis in groups does not exclude individual sessions where they are indicated. Each patient’s treatment begins in individual sessions, and he is free to return to them, if they are in his interest. My concern is that the patient not be forced into an entrenchment of a transference neurosis or psychosis. His dependence on the group operates against such a hazard. I see the dangerous entrenchment of the preoedipal attachment all too often. Most of my patients come to me from overextended transference neurosis or psychosis to one or more individual analysts. One such came to me quite psychotic after eighteen years of individual treatment in the service of the id, not the ego. Group therapy frees the patient from his regressed dependence upon the mother invested in the analyst.
There have been some attempts to be discriminating in the selection or rejection of particular diagnostic categories of patients for combined therapy. However, in the hands of different therapists the varieties of patients include the whole range of diagnostic possibilities. The criteria for selection, it appears, are not explicit. The problem remains unsolved. We need more adequate clinical experience and research.

It is possible, however, to be a bit more specific with regard to those patients who would benefit from associated individual sessions, where there is little danger of entrenching regression. Such patients have fairly intact egos. They are not prepsychotic or psychotic. For them, regression is in the service of the ego. Others who benefit from associated individual sessions are the oldest or nearly the oldest siblings in a large family who in childhood were prematurely forced to assume surrogate parental roles with the birth of each new sibling as the actual parents abdicated their parental responsibilities. Such patients may need individual sessions before they relinquish their compulsive mothering and fathering of group members, individual sessions in which they have the experience of being children in fantasy. Still other patients who may require individual hours are those who are in a sudden panic or severe depression, those who are unable to express their basic problems, silent members, severe sadomasochists, patients who act out, and those who remain too long on a resistive plateau in the group without forward movement.

Orthodoxy Versus Unorthodoxy
All of this is a far cry from traditional psychoanalysis. But I believe that Freud himself was farsighted enough to know that certain changes in form and technique would have to be made as society changed. One of the good things about psychoanalysis is that in many instances it has been able to adapt to cultural change so that it could make some contribution in terms of the society in which it operated. Where it has not, where it has remained rigid or flown off into irrationality, psychoanalysis has become the butt of humorists and a scapegoat for the bitter, the skeptical, and the disillusioned.

There are those who behave and write as if Freud were responsible for all the ills of the present world. There are those who take the equally unreasonable position that if one would just psychoanalyze everyone in the world, there would be no problems, no wars, no famines, no disasters—natural or man-made. And there are those diehards who would tell you that to strike out one word of Freudian text or change one iota of original analytic dogma would be tantamount to treason if not heresy.

Although I am not one to run away from a good fight, I believe many of these battles are unworthy of us. To take extreme positions for one form of treatment as against or totally excluding any other, and to hold that extreme position at all costs, does a disservice to patient, therapist, and discipline alike. I am content to be connected with a behavioral field that is flexible enough to meet the challenges presented by our rapidly changing society. This society is moving more and more toward group orientations, which presents a particular dilemma for modern man. His struggle to adjust to complex organizational demands and yet retain some measure of his individuality and his agony as he finds himself enmeshed in increasingly threatening clashes between Goliaths are bound to have their effects on the emotional problems presented in therapy today. And, with such massive group pressures, where the individual feels more an more confused, anxious, helpless, and hopeless, it seems to me only natural that the therapist should propose and the patient accept group therapy as one logical means of dealing with personal problems as placed against the new reality of group demands.

We must remember that Freud and his original followers developed their one-to-one psychoanalytic techniques at a time when the individual still saw himself as the hub and center of the universe. Today we in psychoanalysis in groups still consider the individual as the center of treatment but we also feel that the group is a realistic, pertinent setting for the resolution of those personal problems in the context of our society today.

The conflicts of the human condition—life and death, good and evil, success and failure, love and hate, male and female, work and play, conformity and individuality—are, alas, eternal. But history has proven that the circumstances of each new age highlight one or another of these conflicts, creating distortion in all of them and so affecting the values and behavior of the individual. We live in an age where widely differing ideologies are confronting each other. Their ultimate clash might mean catastrophe for all of us. During the present standoff, the pressures toward conformity have become so overwhelming that the individual has become submerged and, to some extent, dehumanized.

Psychoanalysis in groups is just a drop in the bucket against this trend, but I believe it can be one of the last strongholds where the uniqueness of the individual can be preserved. At least my experience with psychoanalysis in groups has shown me that, in successful treatment, as each individual interacts more constructively with his fellow group members, his fears of individual and group pressures both inside and outside the group are lessened. And, as this constructive process continues, each individual in the group increases his capacity for positive fulfillment, personal responsibility and more humanized and creative adaptations.

Three decades in the practice of psychoanalysis in groups has influenced my views on psychoanalytic theory and practice and brought about modifications of my individual analytic techniques.

The therapeutic group more easily challenges the therapist in a way the individual patient has greater difficulty in doing. The group promotes the expression of free association and affect toward patients and therapist. The individual patient’s caution in exposing attitudes and affect directed toward the therapist tends to feed his grandiosity and sense of omnipotence, a dangerous hazard for the individual therapist. The knowledge of the isolated patient’s reserve has led me in individual analysis to encourage the patient more strongly to present all his mixed thoughts, associations, fantasies, dreams, and feelings about others in his life and about me.

One of the ways group members develop better egos is derived from their alternating roles of helper and helped. It is almost impossible for the patient in individual analysis to help the therapist. But aware of the value of this experience in psychoanalysis in groups, I have spoken to patients in individual analysis about the value to them of helping in treatment by valuing their dreams, their associations, their interpretations, as a great help to me in facilitating my understanding of them.

Psychoanalysis in groups has made me more aware of my own transferences and counter-transferences, largely through listening to patients’ perceptions of me, their criticism and corrective suggestions. While a part of their observations was distorted and transferential, another part was always in some degree appropriate. So the practice of group therapy has led me to be more self-examining and self-critical in both group and individual analysis, more attentive and regardful of what each patient has to say of me, not only in terms of his distortions but in terms of his valid estimate of my behavior.

Psychoanalysis in groups with its greater activity has enabled me better to understand ego psychology and given fresh direction to my practice of individual analysis. The observation of patients’ social behavior has impressed me with their need for activity, for ego activity, not just ego support. In individual treatment, therefore, I ask the patient to take action, not just to talk, think, or feel but to do. I ask him what he plans to do in reality with this or that insight. The analyst is often a poor example just sitting, thinking, and feeling. He, too, needs to do more, to take appropriate action, make appropriate interventions without acting out.

Psychoanalysis in groups has led me to question the necessity of total frustration of the patient’s archaic needs. Freud questioned the wisdom of such absolutism without the benefit of experience in group therapy. An analyst, practiced in psychoanalysis in groups, took a patient’s hand in the group situation, because not to have done so would have been a traumatic repetition of her father’s silence and rejection of her. The therapist could have taken the same action in individual treatment. Here then a gratification of an archaic longing was seen as an immediate therapeutic necessity. But the analyst needs to be discriminating. I would not, for example, take the hand of an asthmatic patient of .mine, because her aim in pleading for this was to control me.

The aggressive evaluation and criticism of one another that goes on in group therapy is in part an acting out but also a genuine, relevant estimate of each other that is very insightful. Its critical quality demands of the observed and observer a movement and change toward a more realistic adaptation. It has taught me to be less neutral in my role as analyst. It has made me more challenging than I used to be. I am not neutral with regard to the patients’ pathology. I do not accept his resistance, his distortions. I keep questioning his commitment to outmoded ways of thinking, feeling, and acting. I do not accept his rationalizations. I pursue his latent motivations more actively. I am equally assertive in promoting the necessity for him to be as questioning and challenging with regard to everything I say and do.

Group experience has demonstrated to me the value of the presence of peers in the horizontal vector. In the individual analytic setting only the vertical vector is present, and peer relationships are usually not experienced. Accordingly, the patient works through his relationship with authority, the father and mother invested on the therapist in the hierarchical vector. Sibling relationships tend to be neglected. Therefore, in individual treatment I am much more alert to the patient’s relationship to his siblings and his peers beyond his dyadic involvement with me. This means that I pay more attention to his contacts with his fellows apart from his oedipal and preoedipal engagement with me. This leads to a working through of his vertical relationship with me and to freedom from overly long regression.

The need to attenuate the hierarchical vector, to remove the patient from his parents and their surrogates in or out of the therapeutic milieu, is facilitated by putting the patient in a therapeutic group of peers. In individual analysis, when the patient has worked through his oedipal and preoedipal transferences, the therapist is experienced more in the horizontal vector as a peer, a dyad in which sibling relationships emerge and are worked through.

Psychoanalysis in groups has led to a more refined understanding of family life, of how the patient invests members of a group with counterparts of mother, father, and siblings, and of how he relates to a stranger to the family in the group member who is not so invested. This experience has led me more and more in individual analysis to explore the patients’ relationships not only with his primal and current families but with his professional and work associates, colleagues, friends and enemies alike, as well as strangers.

My group experience has taught me to be less the parent who induces preoedipal regression and more the authority and peer who gives and takes, who will not incorporate or be incorporated, who pursues the security of the patients’ primary trust in me to the end that he develop his own autonomy.

Questions of Regression
The recovery of patients in psychoanalysis in groups has led me in individual treatment to demand less regression, to use face-to-face sessions more and the couch less. It has taught me not to frustrate the patient too much. It has taught me to be more discriminating about regression. It is necessary for some patients to regress in order to survive. This is regression in the service of the ego, as with the borderline behavior of adolescents who behave in novel and bizarre ways as a defense against becoming quite psychotic. It is not unlike psychologically determined fainting. Some regression, however, is in the service of the id, or in the service of the id and the ego. For example, a psychotic episode is preferable to certain death. And paranoid grandiosity as a means of survival is not a bad defense in the face of the gas chambers of a concentration camp. Acting out against authority, challenging the father or the analyst is often in the service of the ego. The aggression expressed by group members has led me to be more challenging and provocative of individual patients. Perhaps more patients would be more analyzable if therapists did not insist on such deep regression. My group experience has taught me to be less interested in the depth of regression and more interested in helping the patient to see and accept reality.

This raises the question of the nondiscriminative necessity for regression, for the development of a transference neurosis which may turn out to be a transference psychosis. That is, the trip into the preoedipal experience is not always necessary in therapy. It may, in fact, be contraindicated—as with psychotics and some borderlines, who are already too severely regressed.

For some time analysts have been preoccupied with what harm the parents did the patient. More lately analysts have attended to their own transferential and counter-transferential roles in misusing the patient. My group experience has taught me to reconsider this focus. Group members bring out what is done by the neurotic child in the patient, his provocative role. Group interaction clarifies not only what has been done to the patient but by him as well. We observe, for example, how a female member intrudes whenever another patient and I interact, in order to exclude her sibling and have the mother in me to herself. Behavior is interactive: bilateral, triadic, quadratic, etc. The child psychiatrist tends to view the mother as hurtful to the child. But the mother does this in part because the father rejects her for her involvement with the child. This kind of triangular reenactment in group therapy illustrates the importance of understanding behavior in its multilaterality in individual analysis and recognizing that the behavior of two persons changes with the addition of a third person, a fourth, etc. In individual analysis, therefore, I look for the unseen third or fourth member in the manifest dyad of the patient and therapist. For example, a male patient, who in his transference neurosis experiences me as his mother and tries to escape me as he does all women, would take flight largely because the father is present in absentia, a castrated appen