Applications of Group Analysis for the Twenty-First Century

Applications

Jason Maratos

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429910890
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The Institute of Group Analysis (IGA) celebrates forty years from its foundation with the publication of these two volumes. The first volume aims to publicise the foundations of group analysis (with the earliest papers of Foulkes) as well as the most influential theoretical contributions by pillars of modern group analysis, such as Pines, Brown, and Hopper. The reader will be able to see the development of Group Analysis, form an opinion about the trajectory that it follows, and judge which way the tradition of openness and creative integration of diverse theoretical contributions will lead in the twenty-first century. The second volume focuses on the numerous fields of work that use group analytic principles. Workers in the field of forensic psychotherapy would now consider a great omission if they did not use some form of group analytic intervention, as would professionals dealing with those who manifest personality disorders or different age groups, such as adolescents. Group analysis has made significant contribution to organisational work, to feminism and anti-discrimination (including anti-racism) as well as in education.

PART I

FORENSIC PSYCHOTHERAPY

CHAPTER ONE

Let the treatment fit the crime: forensic group psychotherapy^*

Estela V. Welldon

I’m deeply indebted to the Group-Analytic Society for inviting me to be this year’s Foulkes Lecturer. It is a great honour, and it acknowledges my work with groups. I am first and foremost a clinician. For over thirty years I have spent my professional career trying to find a treatment that fits the problems of patients in the field of forensic psychotherapy. In preparation for this lecture, I read again some of Foulkes’s work and his autobiographical notes and I recognised some of my own sense of discovery and excitement in my efforts to apply group analysis to patients with social and sexual disturbances. For example, Foulkes wrote:

I forged my method and technique through trial and error, but above all by thinking about my experiences, as I still do. The practice of group analytic psychotherapy (in the change of human altogether) is the experimental situation in which theories are continuously put to the test of observation and are reformulated and revised (1969, p. 204).

Indeed, my own failures slowly began to emerge as successes when I was able to allow my patients to become my teachers and my colleagues my fellow students in dealing with difficult predicaments involving serious risks to others and themselves. Foulkes developed further his group-analytic experience in responding to the need to work at Northfield with a heterogeneous group of men who had become psychologically unable to continue with warfare, which society required of them during the Second World War. In talking about this experience he said:

Thus for me what could have been a frustrating time of trying to cure partly unwilling people in much too short a time and under altogether not very favourable conditions, became a fascinating and arresting period (1969, p. 204).

Thus, from the very beginning, group analysis was both art and science and it was applied in a social context. And it is this mixture of theory born from a pragmatic approach that has inspired my long journey in applying group analysis to those patients who present with social and sexual deviancy. Early in my career I was personally influenced by the teaching of Karl Menninger who believed that punishment neither helps the criminal nor protects society. As early as 1930 Menninger wrote that “the great joke” is that in every prison “the considerable majority of all prisoners are there for the second, third, sixth, or 20th time”. Nor does punishment deter others: it is an old story that in the crowds gathered to watch the hanging of pickpockets in England many had their pockets picked while they watched. Menninger said that regardless of its futility and expense, punishing criminals gratifies, comforts, and even delights the general public: “sadistic attacks in the name of righteousness” deal with the public’s unconscious guilt. I was fortunate to train at the Henderson Hospital which gave me a renewed sense of trust that a therapeutic place can exist for the benefit of the patients and not the staff. Stuart Whiteley of the Group-Analytic Society was Medical Director during the latter part of my time there.

In this Foulkes Lecture, I shall be talking about the application of group analysis in forensic psychotherapy, which is a new discipline aimed at the psychodynamic comprehension of the offender and his or her consequent treatment. It involves the understanding of the unconscious as well as conscious motivations for particular offending behaviour. I do not seek to condone the crime or to excuse the criminal. On the contrary, I wish to help the offender acknowledge responsibility in order to save both the offender and society from the perpetration of further crimes.

Resistance attached to the “real” understanding of the forensic patient is deeply ingrained. I believe that this illustrates our unconscious need to punish. For example, during the process of publicising this lecture, even its title underwent a significant change in one batch of the “fliers”; my title “Let the Treatment Fit the Crime” was altered to “Let the Punishment Fit the Crime.” Similarly, in their daily coverage of perverse or criminal acts, our tabloid newspapers gratify the need of their readers to feel reassured of their own “goodness.”

Many years ago I decided that my work in therapeutic groups should be carried out exclusively with forensic patients within the National Health Service. In 1971, I joined the staff of the Portman Clinic where analytical psychotherapy is used exclusively with patients who engage in acts of delinquency or criminal behaviour or who suffer from sexual perversions. Now we have had more than twenty years’ experience of treating sexually and socially deviant patients together in group therapy in an out-patient setting. Before describing how we work with such patients in analytical group psychotherapy, it may be helpful to discuss several important aspects of these very difficult patients.

Most of the Portman’s patients have deeply disturbed backgrounds. Some have criminal records and a very low sense of self-esteem, which is often covered by a facade of cockiness and arrogance; their impulse control is minimal and they are suspicious and full of hate towards people in authority. Some rebellious and violent ex-convicts have long histories of crimes against property and persons. Others, who feel insecure, inadequate and ashamed, tend to be self-referrals. They enact their pathological sexual deviancy, such as exhibitionism, paedophilia or voyeurism, in a very secretive manner, so that only their victims know about their behaviour.

The person suffering from “perversion” is unable to think before the perverse act because he or she is not mentally equipped to make the necessary links. The affect pervades the whole personality: the thinking process is not functioning in his or her particular area of perversity. At times the patient’s tendency to make sadistic attacks on his or her own capacity for thought and reflection is also directed against the therapist’s capacity to think and reflect, and it is then that the therapist feels confused, numbed and unable to make any useful interpretations. The failure of therapists’ treatment is for such patients a bitter triumph. It carries the inevitable axiom that the patients are untreatable, just as they felt as infants, unwanted, unlovable and unworthy of any consistent caring-therapeutic effort. Through their self-destructiveness they perpetuate the emotional pain inflicted by their parents. These adult patients have experienced—as infants—a sense of having been messed about in crucial circumstances in which both psychological and biological survival were at stake. In other words they were actually—in reality, not only in fantasy—at the mercy of others. These traumatic and inconsistent attitudes towards them have effectively interfered with the process of individuation and separation. There is a basic lack of trust towards the significant carer, which accompanies them all through their lives.

We have found that group-analytical therapy may often be the best treatment for severely disturbed patients suffering from sexual perversions. We have reached this conclusion after much careful thought and research. Our own initial sense of frustration, disillusionment, hopelessness has led us gradually into changes regarding selection criteria, preparation, composition of the groups and leadership techniques. I have felt the need to challenge both my own previous selection criteria and those of others, the most familiar and obvious criteria being those of Irvin Yalom, in which he advocates group treatment for those Young, Attractive, Verbal, Intelligent, and Successful—also called YAVIS—people. As a matter of fact, I believe that often the opposite holds true. Those who are thought to be old, ugly, illiterate, unverbal, dull, and failures can do extremely well in group therapy. I have found it most rewarding to watch a metamorphosis taking place and these people become attractive, intelligent, verbal, and successful!

Similarly, whereas I once thought that extreme secretiveness was in itself a contra-indication, clinical evidence has proved that group analysis can be the treatment of choice in incest, in which victims and perpetrators share, by nature of their predicament, a history of an engulfing, intense, inappropriate, distorted, physical and sexual relationship of a highly secretive type within the family situation. Assessments of these patients can easily trigger off emotional responses in the professionals which may interfere with clear and unbiased treatment recommendations.

Fiona, aged forty, had a history of prostitution, the outcome of having been a victim of paternal incest. On previous occasions she had tried to obtain help because of a suffocating attitude, which included sexual approaches, towards her daughter aged nine. Her requests had never been taken seriously; on the contrary, she had been told not to worry, this was “only due to her maternal instinct.” She was so determined to give her daughter better mothering than she ever had, that she began to work as a prostitute at night when her daughter was asleep.

Incidentally, Fiona was one of the women who initially alerted me of the existence of maternal incestuous feelings and acts which led me to further my research on female perversion, later published in my book Mother, Madonna, Whore: The Idealization and Denigration of Motherhood (1988).

Treatment programmes may fail because of inappropriate professional interactions. For example, the victims could succeed in making the therapist feel not only protective but also possessive about them, which in turn could lead to patients feeling favoured and unique in individual treatment. Alternatively, the therapist might feel either like the consenting child or the seductive parent in the incest situation. On the other hand, when dealing with the perpetrators, the therapist may feel cornered or blackmailed by confidentiality issues which may provoke feelings of collusion. Such patients present great difficulties for group-analytic psychotherapy, yet they present a worthwhile challenge, when the potential benefits of a group experience for such “antisocial” and “asocial” people are considered. It was often claimed that these patients either did not respond to group therapy or that it could be effective only if one such patient were integrated into a “neurotic” group. However, such claims do not derive from experience. It could just as easily be claimed that individual therapy deprives these patients of the benefit of being able to interact with the social microcosm provided by group therapy and which can afford them a much better understanding of their problems since they are so deeply related to antisocial actions.

I have observed that the group, by facilitating solidarity and open rivalry among its members, effectively stops the offer or “pushing” of a gift, a frequent occurrence in individual therapy which at times may render the therapist a receiver of stolen goods.

Some exclusion criteria are also born from clinical experience. For example, voyeurism and chronic schizoid forms of paedophilia have clinically proved to be contra-indications for this treatment. Group sessions are used by voyeurs as a captive audience for the concrete acting-out for their perversion without the intricacies of inner changes associated with the acting-in during the sessions. They become in reality “peeping Toms” who are very inquisitive and appear superficially to be “insightful” in their questioning of female patients’ sexual lives. Their inclusion in these groups has deleterious effects on the other members and hinders the development of trust and cohesiveness in the group process.

I believe that basically, family influence is crucial, and, therefore patients who have been subjected to an intense, suffocating relationship with one parent are particularly suitable candidates for group therapy. Groups provide them with a much warmer and less threatening atmosphere than they could usually find in one-to-one therapy, in which their experience of authority is so intense. Also, most violent patients are unable to tolerate closeness and intimacy, feeling uncontained in a one-to-one relationship. They experience intense, fearful vulnerability at any separation, which is immediately felt to be traumatic because they do not believe that the therapy will last, and they are convinced that they will be let down by the therapist. This, too, tends to stimulate aggressive and violent impulses and to increase the likelihood of an attack on the therapist. Such patients function better in groups with their peers, in which they experience their violence to be much better contained and understood. Serious criminal patterns are not reasons in themselves for exclusion, providing the delinquency does not preclude the personal disclosures required for therapeutic progress. This could become rather complicated with patients whose daily life depends on their close associates’ delinquent actions, which could be disclosed or “leaked” in the sessions.

We are aware that our patients are very much in need of three structures: fellow patients, therapist and institution. All are deeply related in their mental representations which constitute a process of healthy triangulation. Because of their fears of intimacy in a one-to-one situation these patients form a strong transference to the Clinic as an institution. The setting is of utmost importance for both therapist and patients whose problems involve acts against society and this is better served within the National Health Service. The therapists’ inner knowledge that the state is paying for their professional services becomes invaluable while working with this patient population. It reinforces both parties in the contractual agreement on which the therapy is based. The therapists are protected from blackmail and the patients feel neither exploited nor able to exploit about money matters.

Preparation techniques

Many patients used to drop out after the first few sessions of group therapy. I decided that this might be related, at least in part, to the length of time that had elapsed between initial selection and the inception of treatment. Therefore, now, from the first diagnostic consultation when patients have been thought to be suitable for group treatment, I offer them irregular, brief sessions so that they can discuss their fears and feelings related to starting the group. The point of being irregular and brief is not to become involved in actual therapy but much more to give some nurturing in a series of holding sessions. I warn them that whereas at the start they might feel tempted to drop out it is worthwhile to persevere and to sustain the effort of continuing attendance, for in a short time they will develop a sense of belonging to the group and they will feel more at ease about it.

In these individual sessions they are told of the rules and regulations, such as the necessity for a serious commitment to group treatment, which will take years as opposed to weeks or months; the importance of being punctual; and if attendance at a session is impossible, prior notification of absence. Also all communication becomes the property of the group and the therapist is not available for any individual communications. Messages about absenteeism or lateness will be given to the group, who are expected to take action, for example, in writing letters to absent members via the Clinic. In the case of requests for information, such as court reports or reports to other pertinent professional bodies, all group members have to voice their views and suggestions. They are also advised that to see the other members outside of group sessions might jeopardise then-treatment. I believe that giving rules is not entirely helpful, but on balance I consider that they are essential, because they create a sense of belonging and a sense of responsibility for the development of the group.

Patients are told that the process of termination is of vital importance in consolidating the improvements and changes achieved. A general consensus should be reached among members and therapist about the date for leaving and this should be agreed at least three months prior to the actual termination. This will give some time to deal with the anticipation of missing therapy for those who are to leave and also for those who are to stay to voice feelings about missing them. In this way, they become aware both of previous unacknowledged grief and mourning for many losses in their lives and they start to value what they are about to offer of themselves to others.

There are a few practicalities which are expected from patients, such as ticking their own names with a pen of their own on the weekly attendance sheet. Chairs are not pre-arranged but group members are expected to set out a number of chairs to sit on. If a decision is reached to write a letter, they get the stationery from the receptionist, write and sign it themselves (never expecting me to sign the letters). However, it is my responsibility to take the letter and have it posted, as they have no access to anybody’s address.

Leadership, authority and power

At the start of a group both authority and power reside within the therapist and institution. From the preparation time patients become aware of their own participation as essential for the group’s survival and development. If there are no patients, there is no group. The patients’ anti-authority feelings are so deceitfully present and their vulnerability so apparently absent that for them it is excruciatingly difficult to be aware of their own sense of power, in which they experience the group as theirs and not the therapist’s. It is only when power is located in the patients’ membership and authority in the therapist that gaining of insight and real changes can take place.

This provides the right balance for them to exercise their power in attending or not, in being late, in producing havoc during group sessions and in challenging the therapist’s authority. The group therapist has to use his authority in offering the necessary ingredients for patients to feel contained and able to express their anger, which facilitates the relocation of power in patients. The therapist will also offer links which will make it possible for patients to learn about thinking.

Each and every member experiences a powerful sense of belonging to the group. Throughout treatment patients gain a capacity for self-assertion, emotional growth, independence, and individuation. They see themselves and others developing into respected individuals with self-esteem which is acknowledged by others and by themselves. They are not only allowed but encouraged openly to express anger and frustration which has been kept hidden for lengthy periods. This encouragement comes especially from “old” members who have gone through similar predicaments and who are now ready to leave.

What type of group therapy and why?

Group analysis offers a strict sense of boundaries with awareness of links between acts and unconscious motivations. The interpretation of “vertical” transference of the group in relation to the therapist, usually with regressive elements, facilitates independence. “Horizontal” interpretations to do with mixed feelings about sibling figures provide the needed capacity to empathise with “others,” who ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• PERMISSIONS
• ABOUT THE EDITOR AND CONTRIBUTORS
• INTRODUCTION
• PART I: FORENSIC PSYCHOTHERAPY
• PART II: FAMILY DYNAMICS
• PART III: ORGANISATIONAL CONSULTANCY
• PART IV: ANTIDISCRIMINATION/FEMINISM
• PART V: SUPERVISION
• PART VI: EDUCATION
• PART VII: COMBINED THERAPIES
• PART VIII: RESEARCH
• PART IX: ADDICTIONS
• INDEX