CLINICAL AND THERAPY
The Dynamics of Analytical Group Psychotherapy
|Leonardo Ancona *
* Psychiatric Clinic, Catholic University of Rome
The Dynamics of Analytical Group Psychotherapy
Relation presented at the Ukranian-Italian Meeting "Psychopharmacotherapy and Psychotherapy", Lviv, 9-11 October 1998
In Italy, analytical group therapy is a product of the psychiatric revolution introduced in 1978 by the Law 180; or at least this event has given it a great expansive boost. In the previous psychiatric regime at such a date an analytical group treatment was indeed unthinkable, because when the groups were gathered, they took place in the psychiatric institution and could not be analytical: These last operate only in a democratic "climate" of freedom, with no other bonds but those set by the group itself.
Nevertheless analytical and non analytical group psychotherapy is to be considered a part of that cultural revolution, promoted by the Law 180, which can nowadays be defined as the demolition of the vertexes".
First of all, this term expresses the fact that today schools detaining prominence, where the thought of the school's representative dominates, stands out, is an authority by which everyone has to be inspired, cannot be accepted anymore. And there are no more schools strictly limited to a single field and which have shut out everyone else.
These cultural vertexes are today generally demolished, which doesn't mean that there are no more schools or mental health centres organised vertically and where only one line of thought is taught, but that these schools are obsolete, and in them assistants, patients, and teaching staff have had enough, are frustrated, aren' t convinced anymore; they feel that there's something else to do and that the other schools' colleagues cast them out. On the contrary, there is an awareness ot the importance of a research for circularity and intramoenia communication of various perspectives, so as to put them together.
A second aspect of the 'vertexes" demolition concerns welfare, where the passage from the vertex, which at one time was the hospital, to a horizontal dimension has analogously occurred. The vertex concerned medicine, but mostly psychiatry.
Actually every singie psychiatric operation converged, lived, acquired meaning in the hospital, to the extent that outside the institution psychiatry didn't even exist. This was the welfare vertex advantageously demolished by the Law 180, whose message was to look beyond the walls, on the "territory".
The territory was once only a word-made reality, but later on, with some difficulty, it made its way in, with a sense of annoyance, of confusion, of incertitude, of non conviction:
the territory… but what exactly was the territory? Everything seemed to dissolve whereas the hospital continued to be well planned, like a sort of propulsive core, something that could be concretely managed.
On the other hand, the territory was vague, indefinite, the people working in it felt deeply uneasy, and rejected its implementation: the persistence in preserving exclusive structures, the success of private clinics, the great problem of the so-called psychiatric hospitals' "residues" which couldn't be eliminated (and neither did we succeed nowadays), have tried to oppose the change. But, as years go by, things are slowly changing and the territory is becoming a primary reality, a sort of new horizontal dimension of psychopathology and psychotherapy, which finds in the intermediate structures its reasonable place.
Epidemiology made its appearance then in the psychiatric field, a discipline once widely ignored and which is becoming widespread as an inportant aspect of study in psychiatry, and this as well is an example of "demolition" in the welfare field.
Now, the cultural and welfare reorganisation itself allowed the possibility of a fundamental change of mind, which practically took place with the shift from the primary consideration of the individual to the primary consideration of what the individual itself means; that is, with recognising the fact that saying individual doesn't mean saying the single individual, because an individual reflects himself in others and is reflected by them: this has made the passage from the individual to the group become the constituent opportunity of the psychiatric operation's implementation.
In strict co-ordination with the exploration of personal unconscious accomplished by psychoanalysis, this collectivisation process has later promoted the process of research on "group unconscious". These are the basis of group analysis as a therapy in Psychiatry.
It is now suitable to underline that group analysis is a paradoxical therapy as regards medical and cultural tradition, especially in the psychiatric field; clinical medicine’s fundamental criterion, as a matter of fact, is that therapy is the action of one person on another, and even when it is a therapeutic team we're dealing with, it is still nevertheless dependent on a personal strategy.
Group analysis, on the other hand, asserts the assumption that "the group heals": the real therapeutist is the group, and not its leader. The latter can at the most play the role of "catalyst" of a work the group accomplishes, and because the group participates as operator, deep and effective therapeutic operations, impossible to achieve through other ways of psychiatric treatment, are obtained (L. Ancona, A.M. Mangiarotti, 1989; L. Ancona, 1989).
With group analysis one is confronted with a new sort of clinic, and this calls for a change in the leader's training, a cognitive and pragmatic change of mind about the group's value; furthermore it requires a revolutionary perspective on what the group can obtain operating as such, on the basis of the potentiality it hides within.
The notion of group certainly isn't immediate, because it has to be conceived as a "gestalt reality", that is, as a formation arising from the sum of various parts but which exceeds them all: it cannot be considered a composition, an addition, in fact a new entity reveals itself when the different parts forming it "assemble" in a functionally harmonic way. As "gestalt" the group has specific functions, which cannot be delegated to others, and which cannot above all be added to the therapeutic functions performed by a single individual, that is why their acknowledgement and clinical use are of the utmost convenience.
In order to pass now from this general approach to a clinical one, let's see how the complex problem of group's functioning may be sorted out.
For group analysis, the following analogy can be derived from psychoanalysis, within which it originated: in the analytical relation, the special dimension of the "transference" activates. It is the specific instrument which engenders the emerging, from the unconscious of the person in analysis, of his archaic past, thus the possibility of recognising, developing, and dealing with it. Now, the analogue of transference in group analysis cannot be the transference, because this is a process occurring between two people, even though it soon becomes full of other people; what in the group corresponds to the transference, and performs its maieutic functions, is the "matrix" process, proposed by Foulkes (1964).
Foulkes has developed a group model where individual unconscious is substituted by group unconscious. The latter appears as a network in which individuals still exist, being the knots where threads cross in order to form the network. This is the "matrix", which incorporates individual unconscious, but surpasses it and allows to grasp the consequences of the impact the group has on the individual and vice versa.
A new therapeutic group procedure has thus been introduced, and it is based on three principles:
1) Group interaction is repeated, in an isomorphic way, in the mind of each participant, and sets off archaic levels of psychic functioning; in fact for the gestalt theory the whole exceeds the part, therefore in the interaction group functioning reveals itself above individual functioning, and this is exactly the human mind's primitive way of functioning: in the evolution, the group comes before the individual, even if it seems an absurdity (L. Ancona, 1998)
2) One can consequently consider that the eventual traumatic impact of the individual with reality, discovered and described by Sigmund Freud with psychoanalysis, took place in his "group mind" more precociously than it takes place in his already established individuality; therefore the roots of psychopathology, and of its future maladjustments, are to be found in unsuccessful primary group interactions: in a conflict between the evolutionary environment's group and its internal group entity (L. Ancona, 1984).
3) The group matrix allows to decipher the physiological, and eventually the pathological past of each member, to translate it from the state of unconscious to that of awareness, to work on it: "what an initial, pathogenic group has spoiled, a therapeutic group can therefore rectify" (Pat De Mare', 1972). Practising a Group therapy paying attention to the unconscious of the individual as well as of the group, in succession (binocular approach, using Malcolm Pines’s words) or in simultaneity (bi-logical approach, using Matte Blanco’s words), allows therefore a deep psychotherapy, even deeper than the one reached by means of an ordinary psychoanalysis, namely a group-analysis through the group.
As already mentioned, the Gestalt theory applied to the group says that in the mind of each participant, according to how much he believes in the group and "infers" it, an isomorphic mental group is instantaneously repeated; each interaction reoccurs inside the participant's psychic field, it becomes a part of himself which is temporarily separated from the other parts, confronted with them, made aware: so one sees reflected in others, and above all in the interactions with them, inner social parts which would otherwise remain unknown, repressed in the unconscious.
Parts of oneself which had been alienated, hidden because painful, removed from consciousness, are thus restored; these parts, to awaken, have called for the group situation, which reached them and started them off. Old reminiscences become then concrete reality, tangible because represented in the body and in the actions of other people, and things never understood before are finally realised; things that had been lived "outside" oneself and that in the group have become person in the body of the other members. It is then not only possible to act therapeutically on them, but also to reach a remarkable personal maturation in every single participant, the process that Foulkes denoted "ego training in action"; and social maturation, described by Cortesao (1967) as "endogenous pattern" of the group, meaning the whole of the insights, the functions, the projects, the norms, the values and the principles of Democracy that a group discloses as soon as it is left to act according to its inter-active nature.
It also needs to be said that the practice of group-analysis according to Foulkes has allowed to grasp the existence, in the group, of a "primordial matrix", which refers to when the human individual still wasn't able to function on the basis of symbolic exchanges, as it happens in ordinary interactions: because he was still immersed in the pre-symbolic, in what Gustav Jung has described as "collective unconscious".
This emerged particularly well in the management and exploration of that setting called "Large Group", that is extended to 50, 60 and more individuals who have accepted to gather in order to explore together what emerges in this abnormal setting: actually, an anonymous and menacing hoard, whose "inference" calls for a particular availability due to the fact that what is being experimented is self fragmentation, the impression that your "head goes to pieces".
But this is exactly how one reaches the deepest, older, ancestral level of oneself: the level of the interactions which have been experienced at the beginning of life in the meeting, or collision, of one's internal group field with the massive group who welcomes, or exposes, the human individual in his neonatal or even prenatal cycle. The "Large Group" is proving to be a precious instrument for knowledge and, perspectively, for therapy, and actually, when it is adequately practised, it ends with the manifestation of a thought, a neo-thought (L. Ancona, 1998, quot.).
In conclusion, the specific difficulty that the Psychological model of the Group, whether it be small or large, has to deal with is an obvious one: it's the difficulty of its 'inference", that is, of its acceptance, because the "matrix" seems to require giving up one's individuality. In fact, the matrix formation implies the Group leader as well, and is easily experienced as a narcissistic wound of the Ego; due to this there's a missed intake of the "inference", hence the impossibility to see it and to work on it.
Those who have the courage to do it, are rewarded by an extraordinary enrichment of their knowledge and therapeutic efficiency.
L. Ancona, M.M. Mangiarotti: La ricerca del metodo in gruppo-analisi A) Teoria della Clinica, in F. Fanni (edited by), Atti del Convegno A.P.G., Attuali Modelli Psicoanalitici del Gruppo, Cortina, Milano, 1989, 121-130.
L. Ancona: Del metodo in gruppo-analisi, B)Clinica della Teoria, in F.Del Corno, M.Lang (edited by), Psicologia Clinica, V° Trattamenti in setting gruppali, Angeli, Milano, 1989, 75-81.
S.H. Foulkes: Therapeutic Group Analysis, Allen Unwin, London, 1964 (It. Translation by Boringhieri, 1967).
L. Ancona, Interventi brevi di gruppo: i Large Groups, in L. Piccione, A. Crispini (edited by), Prevenzione della salute mentale, Carocci Editore, Roma, 1998, 263-268.
L. Ancona, Introduzione alla Psichiatria, Mondadori, Milano, 1984.
P. De Mare, Perspectives in Group Psychotherapy, Allen Unwin, London, 1972.
E.Cortesao, Some Further Thoughts on the concept of Matrix, in Group Analysis, I°, 1, 1967, 35-36.