The Challenge for Group Psychotherapy

Theoretical Foundations of Group Psychotherapy—I, Part 1

Any theory of psychotherapy must be contingent upon a theory of personality and the etiology of emotional illness. Analytic group psychotherapy subscribes to the psychoanalytic view that the psychoneuroses, in the broad sense, originate in the early years and even months of life as a result of conflict between the instinctual drives and the limitation imposed upon their gratification by the outside world as represented by up-bringers. The initial purely physiological frustrations help to bring about a dawning awareness of self, and then, as the ego functions gradually mature, true psychological conflict begins. Conflict between the infant’s libidinal strivings for love and his aggressive drive for autonomy soon complicates the struggle. These conflicts culminate in a relatively adaptive or maladaptive resolution by the end of the oedipal period.

Meanwhile, part of the personality aligns itself with the forces of repression. In a series of projections and introjections which occur before the ego functions of perception and comprehension have matured, the infant identifies with what he experiences as the forbidding parental attitudes. A gradient in the ego is formed (Freud, 1921), which initiates the rudiments of a superego.

As the ego develops, its most common way of coping with the unacceptable drives is to relegate them to unawareness together with their attendant anxiety and primitive fantasies. Split off from the rest of the ego in this way, they maintain their archaic character and cannot mature with the rest of the personality. For the same reason they are exempt from correction by simple experience (Fenichel, 1941).

But the infantile drives do not disappear. They continue to produce inner tensions at each level of psychosexual development. These remain unconscious but bring about renewed strivings for satisfaction and release. The still-infantile ego must continue to keep them out of awareness by finding new coping mechanisms (defenses).

Furthermore, the compromises of the infantile ego are seldom adequate, so that new defenses must be added from time to time. As the child grows older, the original defenses are reformulated in terms of his developing ego functions and of the changing circumstances of his environment. As this happens, the unconscious fantasies are also modified. For example, the early oral fears of annihilation may become, during the anal period, the fear of being controlled, and later, in the phallic phase, of castration. If these early problems are poorly resolved, those of the oedipal period will be difficult indeed to overcome. From then on, a great deal of energy is required to maintain whatever precarious neurotic balance the individual has achieved. He comes for help when that balance is severely threatened.

Basic Psychoanalytic Concepts that Apply to Group Behavior
Thirty years of experience have established the theoretical foundations for employing the conceptual framework of psychoanalysis and, consequently, its basic therapeutic principles in group psychotherapy. Freud&’;s statement that “individual and group psychology are one and the same” (1921) is amply confirmed by patients in therapy groups. The same cardinal features of personality can be demonstrated in the group behavior of every member. In the group the patients strive to satisfy their needs, including their anachronistic and conflictual tendencies, through their relationships with the other members as well as with the therapist. The several members provide a variety of targets and also actively stimulate a great many dormant needs. In the unfolding interaction, the infantile conflicts of all are repeated rather than remembered. Transference resistance abounds and the group becomes a highly potent therapeutic milieu. Like a theater in the round, it provides a dramatic presentation of the insistent and insidious way in which the past intrudes itself into the present. The therapist must help the members gradually to translate these transferences into terms of the past (Freud, 1914), in order that they may become free to respond realistically to others in the present. The group gives him the advantage of a wealth of audiovisual and experiential evidence to facilitate this task.

At first glance it might seem that the enormous complexities of the interconnecting transference processes together with the requirements of the group setting itself would seriously interfere with the very personal and rigorous psychoanalytic process. Nevertheless, experience has proved otherwise. The members can and do profitably share in one another’s analytic experience. The reason is simple—all the members share the same basic drives and the same mental structure, albeit in different proportions. They have lived through the same epigenetic phases and experienced analogous conflicts at each level of development. The fact that each member has resolved his conflicts in terms of his particular capacities and the special circumstances of his personal experience merely serves to enrich their communication and to provide opportunity for acquiring wider horizons while arriving at more complete personal differentiation.

Certain group-determined variations of behavior were recognized by Freud (1921). Since then social science research has more fully illuminated the nature of groups and group behavior. The present- day group therapist is provided with a profound understanding of the milieu in which he works. Awareness of the therapeutic or anti-therapeutic potential of the ongoing group dynamics broadens his perspective; comprehension of the group as a dynamic entity puts a new dimension of force at his disposal. But, in my judgment group dynamics are complementary to the analytic process. They neither conflict with it, vitiate it, nor replace it. The major therapeutic thrust remains the analysis of transference and resistance in their new group costumes.

The therapeutic task is, therefore, the same in group therapy as it is in individual psychoanalysis. It consists in an attempt to reunite the excluded tendencies of each member with his total personality to the end that a redistribution of energy will occur which will bring about basic structural change. In the group the principal technique for reaching this goal remains the analysis of transference and resistance. The task is feasible because the infantile tendencies continue unconsciously to motivate the patients so that the neurotic conflicts reappear, as they began, in relationships with other people—in this case, the group members. These constitute the transferences. Because of their inappropriateness, they are identifiable in the group in spite of the fact that the member-to-member interaction is largely subjective. The therapist, on the other hand, adheres strictly to the analytic attitude of concerned neutrality because it helps transference come into clearest focus. He, therefore, analyzes but does not respond to the patients’ communications. Because the cognitive shift which his “translations” bring about are meaningful only in an emotional context, he makes them at moments of intense impact. The group is a superb provider of such occasions. The fact that he cannot be completely anonymous in the face-to-face situation with a number of patients does not interfere with the analytic process; the compulsion to repeat the original conflict is too strong to give way so easily.

The intragroup transferences convey the patients’ resistance to uncovering the infantile drives. Analyzing the resistance is, of course, the first order of business. In his task of bringing what was repressed back into awareness, the group therapist uses the usual clues (preconscious derivatives), which appear in quantity among the intragroup relationships. The uncovering process is sometimes even more frightening to the patients than it is in individual treatment, and at such times they tighten up their defenses accordingly. That is how the defenses become the resistance in the treatment situation. Their fear of exposing themselves to the group must always be dealt with sooner or later. The sensitive group therapist takes into consideration the patients’ need to keep their self-esteem with their fellow members. He may do this by the way he words his comments but he must be firm and persistent in combating the resistance, nevertheless. More often than not, the group members contribute substantially to carrying out this function. It is much easier for them to perceive transference and resistance in others than in themselves and they call attention to it. Having done so, they are better prepared to gain insight into their own neurotic behavior.

As in individual psychoanalysis, established security measures are not easy to give up no matter how costly they have become. Sometimes, changed behavior follows directly upon insight, but it is likely to be temporary. Working through is therefore as necessary as it is in individual treatment. In stubborn cases the patients’ identity may be completely caught up in their neurotic behavior; often their neurotic suffering itself is grounded in masochistic gratification; and most patients cherish an unconscious hope that by paying the neurotic price they will regain paradise lost (i.e., the state of primary narcissism) by finding the perfect relationship and will fulfill their omnipotent fantasies to boot. These deeply rooted causes of resistance to real change become exacerbated when the goal seems within reach. They must be thoroughly analyzed before basic character change can be achieved.

Factors in Group Therapy that Require Modifications in Psychoanalytic Method
The inclusion of the members in the treatment situation does not change the basic principle of analyzing transference and resistance, but it does require some modifications of the techniques which implement it. Moreover, the structure of the group setting itself necessitates certain changes in procedure for the purpose of providing the best conditions for the therapeutic task (Fenichel, 1945).

There are at least two major consequences of working therapeutically with several patients at the same time. The more obvious of these differences is the preclusion of free association; the more significant concerns the development and handling of the transference.

The technique that was designed to gain rapid access to primary process is manifestly impracticable in the group. The question has been raised as to whether any method which does not use this valuable tool can be considered psychoanalysis (Kubie, 1958). But group psychotherapists have long since reached a consensus that “the group produces its own equivalent of free association in the spontaneous flow of communications among its members” (Foulkes, 1964). So many preconscious derivatives appear in the interaction that if the sensitive therapist listens for what his patients, individually or as a group, are struggling to communicate, he will learn much more about their latent feelings and motivation than he can handle in any one session. Moreover, the rapid shifting of defenses tends to put the members off guard to a certain degree so that they unwittingly permit more preconscious derivatives to filter into their conversations. There are also many points during the sessions at which true free associations may be elicited, as for example when a contradiction or an inappropriate or disproportional emotion is recognized.

In order to facilitate the group associative process, the therapist sets up a suitable group analytic situation. He opens by asking the members to speak as freely as possible about whatever they are ex-periencing. They usually find it difficult to comply fully, so that the therapist must continue to encourage the fullest and most spontaneous interaction possible. He tries to get them to talk with one another instead of directing most of their comments to him. He avoids answering questions and giving advice. He remains neutral but constant in his concern for what they are trying to express. His choice of interventions makes them increasingly aware of the importance of their latent feelings. In other words, he watches carefully over the group atmosphere in order to facilitate the forward movement of the therapeutic process. In doing so he must maintain a delicate balance between his necessarily more active approach and his willingness to let them take over the interaction insofar as they are able. Most important, he keeps analyzing their resistance to exposing their inner thoughts and feelings. In this way he establishes the best possible situation for carrying out the analytic process in a group.

Differences in the Development of the Transference
Transference behavior is ubiquitous in the interaction. But the architecture of the group gives rise to marked differences in its development which require definite changes in its technical management. The individual psychoanalytic situation was set up to minimize the intrusions of reality and to diminish the patient’s ego functioning. The quiet, undisturbed atmosphere of the analytic chamber, the couch, and the complete anonymity of the therapist all contribute to the heightening of transference to such a point that all the patient’s infantile conflicts are eventually relived through the person of the analyst. This procedure generates powerful tension in the patient-therapist relationship, which is converted into therapeutic leverage. Consequently, transference in individual analysis tends to be thought of as a single entity, an artificial neurosis. It is called the transference neurosis and is usually considered the sine qua non of psychoanalytic treatment.

Manifestly, the conditions of group therapy cannot support such all-consuming one-to-one relationships. The therapist, whose responsibility requires him to keep all the group relationships in his ken, simply cannot handle them. Nor does the situation permit their development. There are too many interruptions. Reality cannot be sufficiently subdued. Members who possess characteristics closer than the therapist’s to the patients’ parental images attract transference reactions to themselves. They also find it easier to displace to their less awesome peers the love or hate meant for the therapist. Moreover, the members react subjectively to one another, so that transference illusions cannot be maintained very long. Instead, frequent changes of transference objects tend to occur, and only one aspect is reenacted with one person at a time, though several may be going on simultaneously. Thus, the manifestations of transference are less concentrated but they are not less intense than those of individual psychoanalysis.

Transference in the group, then, consists of concurrent series of inappropriate reactions toward a variety of persons with whom past attitudes and feelings and behavior are repeated. To view these transference processes as a dividing up of “The Transference” is, it seems to me, a consequence of adhering too strictly to the findings of individual psychoanalysis. Actually, a monolithic transference of this kind has never developed in the therapy group.

Transference processes develop in a unique way in the group. From the beginning, the members turn to one another as well as to the therapist in their unconscious search for infantile gratifications. For this purpose they form a number of neurotic alliances of varying duration and intensity. Those who have complementary needs in any one area will tend to engage in a transferential transaction for mutual satisfaction. Those whose needs are similar may identify with one another. Both forms of relationship will carry resistance. Since any one individual’s transference reactions may be stimulated, headed off, or ignored by other members in accordance with the most urgent immediate concerns of the majority, transference phenomena will necessarily be less continuous than they are in individual psychoanalysis. The individual members bend, in this respect, to the movement of the group as a whole; but in the long run all of their individual conflicts will make themselves felt and become available for analysis. As treatment progresses, the interconnecting transference processes will create a continually shifting network (compare Ezriel, 1950).

A second change in the form of the transference arises from the fact that reality cannot be drastically reduced and free association is restricted in the group. Defensive aspects of the transference tend to remain in the forefront of the interaction. The emphasis is on the ego rather than on the infantile libidinal and aggressive drives. Under these circumstances, each patient’s ego development will become apparent and will, of course, reflect the transformation through which his libidinal and aggressive drives have passed (A. Freud, 1936). Unavoidably, therefore, the defensive aspects of the patients’ transferences will become the major target of analysis.

On this subject, Ackerman (1954) wrote, “In principle, the structure of the therapy group is less conducive to the unchecked assertion of irrational and egocentrically oriented behavior in the individual than in psychoanalysis.” What he fails to note is that the defenses themselves contain the irrational regressive elements. Though they are intended to ward off the original drives, they regularly betray their presence.

Because of the emphasis on the ego, also, a great many of the transference phenomena in the therapy group consist of character defenses. They may be classed as transference because the behavior represents the solution of infantile conflicts and thus bring the past into the present; but they are habitual modes of behavior and tend to be fixed rather than responsive to a particular object (Fenichel, 1945). Because they bind the anxiety so well they are not usually experienced as ego alien. For this reason they are difficult to deal with in individual analysis (A. Freud, 1936) but respond very well to group treatment. The members quickly react to their stereotyped quality. Although patients whose character resistance is being explored in the group also put up a fight, they yield much more readily to the interpretations of their peers who are less threatening than the therapist. Furthermore, they are forced to come to grips with the group’s consensus which is generally anchored in reality.

The group is also more effective than individual psychoanalysis in dealing with impulsive characters whose transferences become so intensified that the “ego behaves wholly as an infantile ego” (A. Freud, 1936), for the group members provide what the individual analyst cannot. They exert pressure which eventually succeeds in giving impulsive patients pause to think before they plunge into action. This wedge forces them to become aware of the intense anxiety which heretofore they had done away with by acting out. Once they experience anxiety, the other group members provide the emotional support which helps them to endure it. Inner change becomes possible.

Modification in the Management of Transference in Group Therapy
If transference is to be employed as the principal therapeutic instrument, then each manifestation of it must be analyzed separately, for that is how it presents itself in the group. In other words, the group therapist must be responsive to what is actually happening instead of relying on a preconceived concept from another setting. As he observes the many intragroup transference processes shifting rapidly in ever-changing configurations, he must be alert in order to interpret those that bear resistance. He cannot wait, as in individual analysis, for a slow buildup of single structures—the timing of his interventions must be geared to the empirical situation. Secondly, he must learn to select the transference reaction or transaction which is, at the moment, most pertinent both to the group and to the individual engaged in it. Sometimes this requires that he make an interpretation to an individual who at that point seems to epitomize the major group preoccupation, or whose own need is so strong that he must be allowed to determine the group focus. Since any individual’s need is usually responsive to what has been happening in the group, the others are apt to be ready for his contribution. In exceptional cases where the individual is for some reason removed from the group’s orbit, he or they may be in resistance. The therapist must assess the situation and act according to his clinical judgment. At other times the therapist may make his comments to two or more members as a unit or to the group as a whole: Whichever he chooses to do, he will follow through by trying to draw everyone into the discussion. Although the other members may not be openly involved in the particular transaction being explored, they will probably be responding to it inwardly. Eliciting these reactions helps them work it through.

The group therapist also shares his interpretive function with the members. He permits the patients to engage in it freely and often finds them extremely insightful. (It takes one to know one!) But because patients frequently use interpretations to express their own unconscious motivation, and because the therapist alone understands the total picture and is skilled in timing, he must reserve for himself the ultimate management of the interpretive function.

The therapist’s task then is to spot the crucial transference behavior and to analyze it. In doing so he follows the basic principles of psychoanalytic method but adapts them to meet the changed conditions. He finds that in the group the therapeutic process moves in a horizontal rather than a vertical plane. It resembles a plane trip in contrast to the voyage by rail of individual analysis (Fried, 1954). Moreover, because so many transferences occur in rapid succession and tend to overlap, the group therapist will, ipso facto, be more active in dealing with resistance. The pace of the therapeutic process will be faster; its rhythm, more staccato.

The Systematic Analysis of Transference in Group Psychotherapy
The question remains as to whether analysis of transference and resistance may be carried out systematically enough in the group setting to bring about the resolution of those infantile conflicts of the members which brought them into treatment in the first place. At first glance the very intricacy of the multitudinous and interconnecting transferences would seem to raise an impossible obstacle to an orderly group analysis. Indeed, reasonable objections have been raised by traditional psychoanalysts on the grounds that such attempts would produce a fruitless “wild analysis,” end in confusion, and in all likelihood, leave untouched large portions of any single member’s problems (Kubie, 1958).

Experience has disproved this concern. The complexities of the group communications can be reduced to manageable proportions. As the therapist concentrates on the continually reintegrating group relationships, a new kind of patterning becomes apparent to him. Each member’s engagement in the interaction process soon begins to reveal a characteristic structure which indicates the nature of his ego development. His major defense system becomes clearly discernible in his repeatedly stimulated transference reactions. In every session there will be a plethora of clues which indicate the state of his id, ego, and superego balance. And there will be others that point to that phase of his development which was most decisive in determining his character defenses. These patterns provide a guideline for a coherent and systematic analysis. As the character of each individual’s ego is thus illumined in the total network of the intragroup transferences, it stands out like a figure on a ground, enabling the therapist to streamline his interpretations and to follow them through systematically. They will be directed to the basic conflicts, and the temptation to do a lot of analytic wandering around is avoided. Examination of the protocols over an extensive period of years shows that the major aspects of each member’s transference repertoire come to light in the course of the group process; they are explored and given ample opportunity to be worked through. Moreover, the protocols regularly show changes in dreams, attitudes, and behavior, which are expectable in terms of the insights achieved; and they are followed by the appearance of new preconscious material in the communications
(Durkin, 1964).

Since systematic analysis and working through go hand in hand, it must be noted that working through, too, has its distinctive features in group therapy. The therapist must pay attention to the “ground” as well as to the “figure.” From the standpoint of the individual, therefore, it follows a zigzag course. His neurotic patterns of behavior are explored in all their variations in ever-changing contexts as they occur in relation to other members. Experience has warranted the assumption that the conflict which is being repeated by anyone member at a given moment will reactivate unresolved aspects of the same conflict in the other members. Therefore, once a transference has been identified, the therapist follows through by eliciting the associations, reactions, and memories of the entire membership instead of exploring its ramifications only with the individual immediately involved. During this process of group elaboration, transference is consistently checked against reality, and the total process is sharpened to a fine point because of the combined effect of the therapist’s neutrality and the members’ subjective reactions.

Working through together in this way enhances the group spirit. The members keep motivating one another to find out how their outmoded and now troublesome ways of relating came into being to meet childhood exigencies that no longer exist except in fantasy.

Sometimes, when a patient talks about a relationship with which he is having difficulty on the outside, the members try to be helpful but fail because he is unwittingly trying to ward off its infantile implications. After a while they get discouraged and join him in resistance. But this is usually dissolved very quickly as soon as it can be demonstrated that the pertinent conflict is simultaneously being reenacted in one or another of his group relationships. The discovery of the connection between the there and the here, the then and the now, brings with it surprise and excitement to all group members. There usually follows a renewed spontaneous and lively interchange among the members, who become progressively involved with one another as they pursue their search and share their experiences. The historical vector becomes extremely meaningful in this way and is kept in close relation to the current situation with excellent therapeutic effect.

But there is more. The nature of the group process itself provides a means of unifying the overall group analytic work. The continuous dynamic restructuring within the total network of communication provides clues to the changing emotional preoccupation of the group as a whole. Dealing with it as such may cut through many individual interpretations. Moreover a formidable source of emotional power is created by the convergence of so many physiological and psychological drives in constant interaction (Ezriel, 1950). It is as if they form a matrix (Foulkes, 1964) out of which a new dimension of the group analytic process is born. Its impact on the membership is strong. The therapeutic leverage of such dynamic group interaction is at least comparable to that of the transference neurosis as it functions in individual psychoanalysis.