The Use of Small Groups in Training

Robert Gosling

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429922664
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book describes the experiences of the Family Discussion Bureau in setting up short residential training courses for social case workers. It discusses that a psychiatrist can use small group methods as a vehicle for making institutional personnel from the penal system receptive to new ideas.

THE TRAINING OF GENERAL PRACTITIONERS

by ROBERT GOSLING and PIERRE TURQUET

INTRODUCTION

This paper is based on experiences gained in a post-graduate training scheme for general practitioners in the psychological aspects of their work. The training scheme was started by Dr. Michael Balint at the Tavistock Clinic in 1951 and since its inception almost 250 family doctors have now taken part in it for longer or shorter periods.

Since 1958, between sixty and eighty doctors have been attending simultaneously in small, weekly seminars. Each seminar consists of from eight to twelve family doctors and one or two, or occasionally three, staff members of the Clinic, one functioning as the leader and the others as participant observers. At any one time there have usually been about seven such seminars meeting each week during the university terms. Their method of working is illustrated in the verbatim account of a session to be found in the Appendix (p. 114). An evaluation of the results has been published elsewhere (Balint, et al., 1966).

For some time now our practice has been to try to keep a new seminar fairly constant in its composition for an initial period of at least two years so that time is allowed for those in it to get to know each other, to learn how safe it is to discuss matters freely, and to try out some new approaches when the old ones have been shown to be inadequate. After two years those wishing to continue the training have been invited to form new seminars in which they meet new colleagues, both general practitioners and psychiatrists, so that they are exposed to a greater variety of approaches and interacting personalities. At the present time, about half the doctors beginning the training scheme stay in it for as long as four years.

In addition to the training seminars for beginners and for those who have attended for more than two years, there is also an ongoing seminar available for those family doctors who want to maintain a more or less permanent contact of this sort with the Clinic if they are to keep up the standard of their work. It recognises that there may be a need on the part of the doctor for constant support if he is to carry the more chronically or recurrently disturbed members of his practice. It provides the doctors with some kind of ‘maintenance dose’ and has now been in existence for thirteen years; there is a slow turnover in its membership, but a few of its foundation members are still attending.

In addition to the seminars, a two year course of lectures on personality development, symptom formation and family dynamics is offered when the demand requires it; it is made available, however, only to those doctors who have already exposed themselves to a working seminar for at least two years.

Since 1958 regular staff meetings have been held for those psychiatrists and psychologists engaged in this kind of training whether as leaders of seminars or participant observers. These meetings have been concerned with the technical problems inherent in this kind of training and with the various methods used for trying to solve them. This paper owes a great deal to these staff meetings and hence to our colleagues who have taken part in them; to them we gratefully acknowledge our debt. While we make no claim to have made a comprehensive survey of all the problems met with, we hope we have highlighted the major ones and have offered a constructive approach to them.

Our debt to both Balint as the pioneer of this training scheme for general practitioners, and to Bion for his seminal work on groups is both great and, we trust, apparent. Without their work this paper could not have been written in the way it has. In addition we have made considerable use of the theories of object relations developed by Melanie Klein.

The aim of our general practitioner training scheme is first and foremost to assist a professional person, the general practitioner, in his work with people; to help him understand the plethora of personal relationships which constitutes his practice, whether of a patient within a family or at work or in some other social setting, or of a patient with himself; to help him come to grips with the patient as a person. Our aim is to help the general practitioner to acquire an increased skill in his professional participation in all these personal relationships; by the word “skill” furthermore we mean an awareness of and a flexibility in the use of the current and ongoing doctor-patient transaction. This increased skill has two components: the one is an increased sensitivity through exposure to interpersonal experiences and an increased freedom to perceive them in the parties involved; the other is an increased understanding of these interpersonal experiences. It is in connection with this increased sensitivity that our seminars differ from the usual academic kind in much the same way as a discussion group on sexual relations differs from a seminar concerned with sexual biology.

With such aims our problem in a seminar is one of so conducting it that there is little or no denying or evading of the emotional welter in which the general practitioner is living his professional life. This implies that the opportunities for learning that our seminar provides should be largely of an experiential kind. It is not our aim therefore to organise a course of ex-cathedra pronouncements about human emotions as they are expressed in relationships, but rather to help the general practitioner to experience and recognise the full range of his own emotional involvement (or lack of it) as well as to experience the reactions of the other members of the group to his reporting of his cases. The correct dosage of this experiential component is one of our central problems; and by “correct” we mean finding the dose that, while small enough to be acceptable to the general practitioner and to the rest of the seminar, is yet large enough to keep the group on the stretch.

Experiential though our seminars are, this does not mean that they do not contain an important element of direct teaching. Teaching does go on, but the seminar is a genuine situation of educare, i.e., of helping the general practitioner to draw on his emotional experiences of his patients so that these can be examined and hence can become part of his professional understanding and skill. Thus our seminars are an example of learning through experience, in itself an essential aspect of acquiring insight, and therefore part of the model for the doctor-patient relationship which will be discussed below. How the leader of the seminar is experienced by the group is of prime importance; how the leader behaves and what he says to the general practitioner can have more effect than what he says about a case. In all this we are much helped by the general practitioners’ need to learn: they come to us aware of a lack in their medical education and oppressed by a sense of inadequacy in how to look after an important section of their practice. This is the vis à tergo.

The group setting has three important implications for the building of our training programme. First, there is a need to define clearly the seminar’s primary task. Vagueness on this point can only lead to a failure to achieve our aims as it will facilitate the emergence of group processes that are inherently inimical to learning and hence to the achievement of these aims. Second, the leader of the seminar must embody the primary task; what he says and does must exemplify it, and therefore his role needs close study and definition. Third, because of the experiential element, the leader’s relationship with the other members of the seminar acquires the status of a “model” for the general practitioners in their relationship with their patients. The following sections will be devoted to considering these implications.

THE PRIMARY TASK OF THE SEMINAR

In attempting to define the primary task of the seminar—its work task—two considerations were operative, each related to a need encountered as we listened to the general practitioners reporting on their work situation.

1. The need for the reporting general practitioner to maintain an appropriate psychological distance between himself and his patients. When this distance has been lost, he needs to externalise his experiences with his patients to reconstitute the relationship between himself and them. It is not unusual in our seminars for the reporting doctor to enact the patient he is reporting, and this can be taken as an indication of the degree to which he is lost in his case. For example, a doctor says “No” to all the suggestions and remarks made to him by his colleagues in the seminar, so revealing how he has become the patient he was reporting who said “No” to all the advice he offered her. Or again, the woman doctor who described how a woman patient would not allow any discussion of her relationship with her husband and who likewise refused to let the seminar examine her relationship with themselves. The patient sometimes exercises a regressive influence on the doctor so that he becomes emotionally over-involved. With the help of the seminar the doctor can recover distance and can re-emerge from an unconscious identification with his patient into a more reality based relationship. A few general practitioners have left during the early stages of our seminars because of their fears of being caught up in these regressive moves and of our inability to provide quick solutions to the problems they brought; they felt left too long enmeshed in their involvements.

The contrary situation also occurs when the general practitioner sets too great a distance between himself and his patient. For example, he prefaces his report to the seminar with the remark “I could never get on with him”, or “Though they have been on my list for some time and she has brought the children and he seems to have been off sick quite a lot, I really don’t know them.”

Whatever the psychological distance, however, the patient is always present, influencing the doctor as he reports. In its work the group has to take this fact into account and the task of the seminar leader is to persuade its members to discover in what way the patient’s influence is being expressed and to distinguish the patient’s influence from that of the reporting doctor’s own needs and distorting tendencies. This is indeed a most difficult task for all concerned.

2. The need of the doctor to accept regression on the part of his ill patients as a necessary part of recovery and healing, but without falling into the temptation to gratify his own omnipotent needs by keeping the patient ill and dependent. “Paternalism” is a common defence amongst general practitioners against the anxiety provoked in them by their patients’ illnesses and is expressed in the general practitioner’s tendency to take matters into his own hands and hence off the patient’s shoulders. For example, when a doctor found a patient of his ill and alone at home, a married woman whose husband was a commercial traveller and was out of town, he carried her off bodily in his car to the local hospital.

To these two considerations must be added two further facts. First, our seminars are for training and not for therapy. The pressure in a seminar to convert it into a therapeutic group is often great; so the choice of the work task must help the leader to resist this demand. Secondly, as the discussions take place in the setting of a group the seminar is liable to be overwhelmed by an upsurge of group processes that increase the regressive tendencies already present in the individual general practitioners.

The primary task of our seminars has therefore been made the examination of the doctor-patient relationship and the transactions it contains. We have been fortified in this choice by the point made by Szasz (1964), namely, that Freud came to formulate his revolutionary concept of the transference while listening to Breuer recounting his perplexity and distress in his attempts to treat Anna O. This patient’s erotic tie to Breuer after he had dispelled her hysterical symptomatology frightened him out of his capacity to think. It was Freud, who having no personal relationship with Anna O., could therefore contemplate Breuer’s struggle with his impulses with some objectivity and who divined that the patient’s erotic tie belonged more to an imaginary figure of her inner world than to Breuer himself. Thus the therapeutic task was divided up between the therapeutic agent, Breuer, and the therapeutic observer, Freud. No one can read of Breuer’s distress in trying to treat this famous patient, of his wife’s jealousy and his subsequent dropping of the patient to go on a second honeymoon with his wife, without envying Freud his advantageous position. Though we cannot all be Freuds, his role in this trio may be assumed from time to time, provided we can also facilitate the assumption of Breuer’s role by somebody else. In our seminars the role of Breuer is assumed by the reporting doctor.

A similar situation exists of course in psychoanalytic supervision where the trainee recounts a “case” to his supervisor. New views about the case come from two sources: first from the trainee himself as he regards the case again in his telling of it, as he externalises what has been unacknowledged and faces what has been dissembled; secondly, from the supervisor as he catches sight of the material for the first time from his own particular external vantage point. In this context a ‘case’ refers not to a fiction about a patient but to the live doctor-patient relationship which both supervisor and trainee are watching and examining jointly. In the supervision session the supervisor has the advantage of freshness to the case and of standing outside it.

We would suggest that in our seminars, by taking the doctor-patient relationship as our focus, we are initiating a process anala-gous to the Breuer-Freud and supervisor-trainee transactions and are helping the reporting doctor to acquire a measure of psychological distance from the engagement of himself and his patient together in treatment. Our aim is to enable the general practitioner to internalise the patient, his complaint, illness and suffering, in such a way that the patient can be remembered, experienced and thought about, but never to the extent that the doctor either becomes lost in the patient or must defensively keep the patient at a great distance.

A third party is thus introduced into the dyad of the treating doctor and his patient, namely, the observing doctor. In the working of a seminar when a ‘case’ is reported the doctor concerned is in part the doctor who participated in a relationship with the patient and in part, by the existence of the seminar and with the help of his colleagues, the doctor who is external to the dyad and who observes it. The doctor is thus invited to take part in a three-body transaction, the three bodies being: the patient, the participating part of the doctor, and the observing part of the doctor. In so far as the triad corresponds to the triangular Oedipal situation, curiosity and initiative are stimulated and the doctors are drawn on, magnet like, to explore internal and external worlds and to attempt creative solutions. Furthermore, this three-body situation to some extent counteracts the regressive forces that abound in the patient-doctor dyad.

Taking the doctor-patient relationship as our focus has a further advantage: it can help to find a useful path of entry into the plethora of facts offered by the patient, facts which are so numerous as to allow a wide range of possible explanations. It can thus become an instrument of work. As a doctor reports a ‘case’ to the seminar, the various and varied symptoms, the past history, together with what has been said in their mutual transactions, a situation easily arises in which anybody’s guess is as good as anyone else’s. The diagnosis may be ‘post-influenzal depression’, ‘the menopause’, ‘the loss of mother two years ago’, ‘the unsatisfactory husband’, ‘a breakdown in an obsessional, over-houseproud woman’ and much else. Some order has to be put into this chaos of jostling possibilities, particularly if anxiety is not to swamp the seminar’s discourse. The need for some order is obvious: both parties to the transaction require the facts to be marshalled. But the question is, along what lines?

A full examination of the doctor-patient relationship with the reporting doctor bringing forward as the discussion proceeds fresh facts directly relevant to the relationship, can secure a new order in the material offered. This new order is not merely a theoretical order external to the patient and his immediate needs nor an order arising from the doctor’s preconceptions about patients in general, but is a live, active ‘here and now’ order that is constantly seeking to express itself and hence will allow for change and development. With this possibility the seminar can eschew the need to secure clarity at all costs or to impose an obsessional, rigid, once-and-for-all, never-to-be-modified order. To the extent that the seminar can maintain some plasticity in its approach, so too may the general practitioner learn to encourage his patients to explore the possibilities of change in their lives.

Whilst this choice of primary task helps our aims, it introduces some problems of its own. Thus the examination may swing too far in the direction of investigating the doctor and his behaviour, with the risk that material personal to the doctor is proffered and therapy of the reporting doctor begins to displace furtherance of his professional competence. In the other direction, too much emphasis on examining the patient may lead to aloof, detached, scientific pronouncements about psychopathology while the events of the doctor-transaction are ignored. To avoid the former error is often easier than to avoid the latter, especially when the case presented includes an organic illness or a ‘classical’ psychiatric syndrome. Intriguing problems of differential diagnosis can then easily be made to obscure recognition of the patient’s emotional conflicts as they are actually being presented and experienced.

Here we have one of the many tightropes the leader has to walk in this kind of work. In addition, he has to guard against the satisfaction of some of his own needs which are subversive to getting work done according to the task we have defined—for example, to have a well-attended group of dependent general practitioners, to be a highly esteemed consultant, to avoid painful issues, or to be taken as the Messiah. Such a dilemma for the leader has its positive aspect, however. It keeps him on his toes, hard at work trying to keep his balance. If he is hard at work, the other members too may be encouraged to do what they can. This prevents the leader from getting stale and the situation arising in which the general practitioners do the work and the leader sits back. It also provides a realistic model for the general practitioners in their work in which active participation of varying kinds is required from both doctor and patient.

THE GROUP DYNAMIC: BASIC ASSUMPTION ACTIVITIES

Small groups working on a primary task, however, frequently get into difficulties which interfere with and even prevent them getting to grips with their avowed aim. In order to understand some of the phenomena we have encountered in our work with general practitioners we wish to refer to Bion’s work with small groups as, in our opinion, it throws much light on the inner working of our seminars. Bion (1961) describes groups as inevitably engaging in two tasks at once: one, the furtherance of the avowed aim of the group, which is realistically conceived and requires of its members their conscious co-operation and the exercise of their intelligence and forbearance; the other, the satisfaction of emotional needs that are obscure and largely unacknowledged by the individual members constituting the group at that particular moment. The group as it is engaged in the first task he calls the work group; the same group as it is engaged in the second task he calls the basic assumption group. In fact both work group and basic assumption group exist at the same time, though at any particular moment one may be more prominent that the other.

The basic assumption group is so called because the perplexing and devious ways the members behave with each other can be comprehended, Bion suggests, on the basis that the members had come together and mad...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Introduction
• The Training of General Practitioners
• Short Residential Courses for Post-Graduate Social Workers
• Staff Training in the Penal System
• Appendix A General Practitioner Seminar at Work