Listening with the Fourth Ear

Unconscious Dynamics in Analytic Group Psychotherapy

Leonard Horwitz

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429915710
• Subtopic: Education in Psychology
• Index: Psychology

There are multiple meanings to the term 'group-as-a-whole' and all have a contribution. This book emphasizes that the therapist ideally listens with the fourth ear, not only attending to the latent communication of each individual, but also listening for the shared theme of the whole group. Ferreting out the underlying theme that the entire group is dealing with, the common group tension, provides a valuable opportunity for each individual to change the underlying issues that impair his or her relationships. In addition, the author provides a wide ranging coverage of theoretical, clinical, and training issues. These include a clarification of the confusing, but all-important conception of projective identification as well as a contribution to the understanding of the similarities and differences between group and individual psychotherapy. He presents a special perspective on why groups are particularly indicated in dealing with narcissistic pathology and also explores the effect of the therapist's narcissism on his patients. Finally, he emphasizes that therapists' participation as members of experiential groups is an essential part of their training.

PART I

HISTORICAL

The first four chapters summarize the background and main thesis of the book to the effect that an especially useful model for the group treatment of individuals is not only to respond to each individual’s life issues and conflicts but therapists should also strive to integrate dynamics of the group with the struggles of the individual. One model for doing this is an inductive, group centered approach derived, but different from, the early Tavistock model. This section will present the historical context in which the inductive group centered model developed and will also attempt to describe a variety of group-as-a-whole models.

Chapter One is devoted to the contrast between the early British and American approaches to group treatment depicting how the American method has gradually moved in the direction of incorporating some of the group-as-a-whole thinking that had originated in Britain in the 1940s. Chapter Two presents an historical survey of a variety of group centered theories and methods, both the early pioneering contributions as well as the more recent developments. In Chapter Three, the main critiques of group centered thinking are presented and evaluated. Finally Chapter Four consists of the forty year history of the group psychotherapy program at the Menninger Clinic which includes the story in some detail of how the resistance to group psychotherapy was gradually overcome in a psychoanalytic institution which at first was not receptive to this modality. Also I relate how my thinking developed from my initial exposure to the early Tavistock model and my reasons for modifying it in an effort to make it more patient friendly and helpful.

This historical section constitutes both the history of how the field of group psychotherapy moved gradually to accepting some form of group-as-a-whole thinking and intervening. In the United States, in particular, an individualistic approach took root early and was gradually replaced by a variety of models in which individual and group dynamics became integrated.

CHAPTER ONE

The American and British perspectives

Ever since psychotherapists began treating patients in groups, they have had to face the issue of understanding the dynamic forces that are set in motion, as well as the challenging problem of how to use those forces to therapeutic advantage. The controversy in this field has not been whether group dynamics exist in psychotherapy groups but rather to what extent they can be exploited therapeutically. Attitudes have varied from Bion’s contention that the group therapist’s major task is to attend to the group’s basic assumptions as opposed to Slavson’s (1957) quite different view that any effort to work with the dynamics of the group-as-a-whole will lead to a variety of anti-therapeutic effects. This debate was waged rather heatedly in the late 1950s and early 1960s. Now, however, the debate has shifted to how best to integrate the dynamics of the group with strategies of individual intervention. In order to appreciate the evolution from the individualistic to the group centered approach, one must contrast the philosophies of the two groups, the American and the British, separated by an ocean and a common language, as G. B. Shaw once quipped.

The American scene

Beginning in the 1940s which marked the first organized steps of group psychotherapy internationally, there have been two major loci of activity, the United States and Great Britain. The indisputably dominant American figure for over a quarter of a century was S. R. Slavson, founder of the American Group Psychotherapy Association. The mentor of many who later became leaders on the American scene, he was quite forceful, if not dogmatic, in asserting an individualistic point of view as the proper model of group psychotherapy. He addressed the issue in a 1957 article entitled “Are There Group Dynamics in Therapy Groups?” and answered this question with a resounding “No!” He differentiated therapy groups from a wide variety of other groups, contending that the former do not have a “common group goal”. Groups other than therapy groups show a “synergy” in which individuals give up a portion of their egos to encourage a group ego, while therapy groups avoid doing this. Although there may be a group-wide reaction or a contagion effect in a group, said Slavson, the therapist is always focused on individual differences in these reactions, the individual character patterns, the quantity and kind of affect, as well as the source of the reaction.

Thus, even though Slavson acknowledged a number of dynamic forces in all groups, including mutual induction, intensification, and identification, he believed that the pivotal difference between psychotherapy groups and ordinary groups is that the former seek to uncover intrapsychic determinants within each member; hence, any emphasis on the similarities among members based on group dynamic considerations is anti-therapeutic. In fact, says Slavson, group dynamics should be nipped in the bud, analyzed, and explored before a group pattern or group effect begins to set in. He equates these dynamics with homogenization, artificial uniformity and submersion of individual differences, with the result that individual problems cannot be thoroughly communicated—and worked through. Slavson (1964) decried any evidence of the group acting as a unit: “The therapist has to deal here with a mass reaction rather than with an individual, a situation fraught with difficulties and even danger. The therapist must always be on the alert against unanimity of any sort in the therapy group, for unanimity in groups is derived from hostility against the therapist” (p. 386).

Equally vehement in their attack on group dynamics were Wolf and Schwartz (1962) who crusaded forcefully to eliminate the heresy of thinking about the group as a unified entity. Because much of the work on the study of the dynamics of groups at that time was conducted by social psychologists under the leadership of Kurt Lewin and his students, the above writers were concerned with the wholesale transfer to psychotherapy groups of concepts derived from the study of non-clinical groups, thus engendering superficial thinking and a neglect of unconscious motivations. Like Slavson, they were afraid that conceptualizing the group as operating in a unitary fashion would lead to a neglect of individual differences, to a demand for conformity on the part of the members, and to an expectation that the patients would become submissive to the leader’s wish for homogeneity. In general, Schwartz and Wolf established a dichotomy between treating the group and treating the individual, and believed that the two modes of thinking were incompatible.

These anti-group centered points of view were extremely influential on the American scene in the 1950s and the 1960s, but they were by no means representative of all American group psychotherapists. In fact, several leading writers of that period expressed views considerably different from those of Slayson and his followers. Thus Redl (1949) emphasized both the phenomena group contagion and role suction and Semrad and Arsenian (1951) proposed the similar concept of billet. They believed that an individual’s behavior in a group setting cannot be understood fully by reference only to individual dynamics, and that the emotional currents within a group often pressed patients into relatively atypical roles. Durkin (1964) joined this debate and displayed an unusual degree of openness to group dynamic concepts, in particular the view that the cohesiveness or the attractiveness of a group to its members should be an essential part of every group therapist’s thinking. Whitaker and Lieberman (1964) produced the first systematic theory in the United States which recognized the unitary functioning of the group in what they termed the “group focal conflict” or the commonly held wish or motive countered by a defense.

Saul Sheidlinger (1968) attempted to steer a middle course between the anti-group dynamicists and those writers such as Bion (1961), whom he believed were exclusively preoccupied with group phenomena at the expense of individual personality factors. Scheidlinger has consistently been interested in various group dynamic elements, such as group climate, group structure, and norms, but he has equally been opposed to any characterization of the group that smacks of “group mind”:

Group members can maintain shared or common fantasies; they can even act in unison in response to group occurrences, such as the entry of a new member or the absence of the leader. And yet, this need not mean that the group as a group now has a certain fantasy or acts in a certain manner ... Shared fantasies are far from being the same in each individual ... A group can possess observable characteristics, can be perceived and related to as a whole, but this makes it a social and psychological reality, not a physical reality; it does not indicate a “group mind”. (1968, p. 8)

Although the major early contributors, Bion, Ezriel, and Foulkes, had different technical perspectives, they were all definitely in a group centered camp which emphasized the importance of group dynamic properties and, to a greater or lesser extent, used the concept of unitary functioning. Depending on one’s perspective, these British writers were either too enamored about group commonalities or had an important insight into how groups function, as I believe. Although most writers would agree that shared fantasies are not the same as identical fantasies, Scheidlinger appears to believe that Bion’s “group mentality” opens the possibility of a belief in the fallacy of each patient marching in lock-step. The challenge the American raises is how to utilize the observed commonalities for therapeutic purposes while at the same time respecting the individual differences of each member.

The British scene

In contrast to the Amercan emphasis on an intra-individual approach, some have described the British as “caught up in a group illusion” or, as I prefer to believe, they were influential in facilitating a significant shift toward integrating individual and group dynamics. It appears that American group psychotherapy has gradually begun to incorporate some of the significant contributions of our British colleagues as we have moved from Slavson’s individual emphasis to incorporating a group dynamic or group centered approach. How and why the British adopted a group centered stance so much earlier than the Americans is an interesting phenomenon. An important development was that many leading British psychiatrists and psychoanalysts were assembled during World War II at the Northfield Hospital (Trist, 1985) where they collaborated on applying group methods. ln the treatment of psychiatric casualties of the war, this unique collaboration undoubtedly contributed to their thinking about group methods.

The contrast between the British and American contributions will be briefly outlined here and a more detailed description as well as my evaluative comments will be given in the next chapter. The single most important contributor to group psychology theory, whose influence has been felt universally by all group scholars, is Wilfred R. Bion. Social psychologists associated with Kurt Lewin’s Survey Research Center studied Bion’s writings for insights into the more regressed levels of group functioning. To a greater or lesser extent, the work of the Tavistock Institute of Human Relations, the group relations conferences sponsored by the A. K. Rice Institute, and the sensitivity training programs sponsored by the National Training Laboratories used Bion’s views regarding the basic assumption life in groups and the way these forces obstruct or facilitate the primary task of a work group. Although Bion interrupted his work with groups prematurely and did not write extensively about the application of his ideas to psychotherapy groups following the publication of his major work in 1959, many of his theoretical notions were adopted by the group psychotherapists at the Tavistock Clinic where his ideas were translated into a specific model of group psychotherapy.

Following World War II, Bion was invited by the Tavistock Clinic to begin “taking groups”, and he pursued an intensive study of work with patient groups as well as study groups of professionals for the next few years. His series of articles on his experiences and formulations were published first in the journal Human Relations between 1949 and 1951 and were assembled subsequently in the book, Experiences in Groups (1961).

According to Bion, groups operate at two levels of functioning, the work group and the basic assumption group. The former consists mainly of conscious, rational, goal-directed activities dictated by the task of the group, while the latter consists of less conscious, more regressed emotional currents that express a primitive “group mentality” and often tend to interfere with the primary task. He believed that the group develops “basic assumptions” as a defense against primitive regressive forces that threaten the group. Bion described the mechanism by which the group becomes caught up in one of the three basic assumptions (dependency, fight-flight, pairing) as the Kleinian concept of projective identification in which members attempt to put parts of their psyches into each of the other members and attempt to influence and manipulate the others into certain desired roles. The therapist’s main tool for perceiving and understanding the group mentality is the “numbing” feeling of being manipulated by the group into certain behavioral responses. This description is not unlike the phenomenon of counter-transference reactions within the analyst that illuminate the patient’s conscious or unconscious attitudes. Bion’s important contribution, however, was his detailed description of the unitary functioning of groups with some suggestions about how to turn these understandings into therapeutic benefit.

Using Bion’s notions of the group mentality, Ezriel (1950) proposed that the group therapist’s interpretive task is to ferret out the underlying common group tension, a conflicting fantasy shared by all group members but experienced in idiosyncratic ways by each member. The conflict consists of a commonly held wish that cannot be openly expressed because it would create excessive anxiety. Ezriel described this conflicted situation as a three-tiered relationship: a wished-for or “desired” relationship, defended against by a “required” relationship, lest a “catastrophic” situation ensue. The therapist’s role is to diagnose both the common group tension as well as the three-tiered relations manifested by each member (a somewhat formidable task!). The general structure of the interpretation offered by the therapist to the group is essentially an explanation of the prevailing common group tension and how each individual is responding to this conflicted situation in his or her own unique, personal way. Here we have the first effort to integrate the commonly shared dynamic force within the group with each individual’s characteristic patterns of dealing with this conflict, that is, an integration of individual and group dynamics.

Foulkes (1975) also endorsed the view that there is a unitary quality to the functioning of a therapeutic group. This idea is embodied in his concept of matrix, which he described as “the common ground of operational relationships, comprising all the interactions of individual group members” (p. 110). He believed that all individual reactions must be understood as a “figure” in relationship to the “ground” of the group-as-a-whole. He also used the metaphor of the individual as a single neuron embedded in the total nervous system which is analogous to the total network of communication within the group. His view of the group functioning holistically is concretized by his recommendation that the group’s productions should be regarded as equivalent to the free associations of a single individual, and that the latent meaning of the communication within a group can best be ascertained by means of this free associative approach.

All three British writers share a common perspective on the functioning of the group-as-a-whole. Bion’s group mentality, Ezriel’s common group tension, and Foulkes’s communicative matrix may differ in detail and specificity, but they share the notion of an all-important group affect—whether it be a commonly shared fantasy, conflict, or simply a shared background—that produces a significant effect on the behavior of each member. These writers also agree that, to intervene accurately and usefully, the group therapist must at some point define and integrate the influence of the group upon the individual. Their contributions will be described in greater detail and then critiqued in the next Chapter.

The current scene

Slowly and imperceptibly the theory and practice of group psychotherapy have increasingly incorporated some kind of group centered thinking. Very early Parloff (1968) predicted a gradual move away from a strictly individualistic and interpersonal approach toward an “integralist” or group centered approach. Evidence of such a transition may be seen in the work of Rutan, Stone, and Shay (2007) and Agazarian (1997), both preceded by the report of the AGPA Task Force on General Systems Theory chaired by Helen Durkin (1982). The present writer has also been an early, active proponent of the group centered approach (Horwitz, 1977).

Group centered thinking is represented by a broad spectrum of theoretical approaches ranging from a circumscribed application to specific developments in a group to a view that group dynamic forces are omnipresent and need to be uncovered by the group therapist. I shall delineate three main points of this spectrum.

The most limited view of group-wide phenomena and their interpretation is that espoused by Yalom and Leszcz (2005). Although recognizing that a group has important system properties, they are opposed in general to what they describe as “mass interpretations”. The pejorative connotation of the term seems to convey their attitude that such interventions unduly emphasize patient–therapist relationships as opposed to peer interactions, and, furthermore, that one may fall into the error of artificially squeezing into the mass interpretation individuals who may not belong there. Therefore, Yalom and Leszcz would restrict their group-wide interpretations mainly to situations wherein the therapist finds it necessary to remove obstacles to the progress of the entire group. Thus, when the entire group is under the influence of some anxiety-laden issue that members are unable to address, or when an anti-therapeutic group norm is beginning to develop, such as the collusion among members to be...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgements
• About the Author
• New International Library of Group Analysis Foreword
• Preface
• Introduction
• Part I: Historical
• Part II: Theoretical
• Part III: Clinical
• Part IV: Training
• Epilogue The value of group-as-a-whole models
• References
• Index