Group Psychoanalysis

Relational Matrix and Self Psychology.

A possible approach to small group psychoanalytical psychotherapy

di Laura Selvaggi

The purpose of this paper is to estimate the opportunity and the effectiveness of applying to psychoanalitically oriented group psychotherapy a complex object-relation model, emerging from current studies and reflections. The fundamental lines of this model are reconstructed through contributions and proposals developed in different, but strictly connected contexts.
In detail, principle points can be identified in:

- A modern view of human development, based on Infant Research results, that enlighten the presence of a relational matrix, where the baby realises and develops its inborn potential, along a mutually influenced process with the human environment it lives within. Within this relational matrix (or dyadic-system) basis for fundamental personality structure are set. Research shows how infants are prepared from birth to organise their experience of the world according with several parameters. This capacity to distinguish specific features in every event and to generalise them in pre-symbolic representation (i.e. amodal representation) allows the Infant to recognise basic rules in interactions with its caregivers (interactive structure). These schemata, enriched and symbolically reelaborated, give rise to fundamental representation of Self, Object and Self-with-Object. This is the origin of both normal and pathological structures through which any individual direct himself around the world and gives shape to his experience. Mental structures originate from actual and observable events, rather than from baby's internal processes.
References: Stern, Beebe, Lachmann, Lichtenberg.

- A reading of Self Psychology in a key which emphasises its relational aspects, with particular attention to empathy and self-object concept. Clinical approach is fundamentally based on recovery of experiences necessary to build up an healthy and alive sense of Self. In Self-Psychology perspective, illness is essentially regarded as a consequence of a lacking environmental response to individual's evolutive needs. Such an idea (typical of many object-relation theories from Winnicott on) is broadened through critical contributions by Mitchell and Basch, the former underlining the importance of relational conflict, the latter advancing a more complex vision of development. Basch suggests a quite interesting linking between Self-Psychological basic concepts and Stern's current views of infants: each of the Self-object experiences corresponds to one of developmental stages of sense of Self described by Stern.
References: Kohut, Bacal, Newman, Fosshage, Basch

- An intersubjective clinical approach, that ri-define analytic tasks in terms of illumination and clarification of primary patterns - mostly "prereflective" - organising patient's experience. It includes that analytic action develops within a field ("contextual unit" ) constituted by the intersection between the subjective worlds of patient and therapist. Atwood and Stolorow's intersubjectivity is a further evolution of Self-Psychological clinical model and includes results of Infant Research. The conceptualisation of an intersubjective field places mutual regulation patterns between child and caregivers in the core of psychoanalytic theory, following a path opened by the concept of Self-Object. Infant development is described in terms of continuously changing psychological field constituted by the intersection of child subjective universe and those of caretakers. Pathology is the consequence of chronic asynchronies between the subjective universes of child and parents, which prevent child's psychological structure from meeting optimal responses distorting its development. Analytic therapy is thus addressed to the unfolding and transformation of problematic schemata organising individual experience, through intersubjective conjunctions and disjunctions patient and analyst experience within the therapy.
References: Atwood, Stolorow, Lichtenberg.

- A re-conceptualising of transference, that is no longer seen as a displacement, but rather as the activation within analytic setting of early organising principles. If the understanding of health and pathology is founded on models of experience, transference can't be defined as repetition and displacement - within the analytic situation - of reactions and feelings connected to significant persons of infancy. It rather represents a manifestation of a more general striving to organise experience through schemata formed during the formative years. This modern view of transference is also characterised by a phenomenological perspective, the statement that reality is always subjective (there's no objective one), the recognition of therapist's subjective world contribution to everything that occurs within analytic relationship.
References: Fossahge, Lichtenberg, Lachmann, Atwood, Stolorow

Lichtenberg's work (1989, 1992) is presented as an example of this new relational theory. Lichtenberg himself states his continuity with Kohut's work, furthermore his approach gives a central role to current developmental theories and to intersubjectivity. His conceptualising of "model scene", as an experiential model constructed together by the analyst and the patient to give an order to introspective data, is an integration of all the above mentioned elements. "Model scene" is in fact an experiential model, offered by the analyst and accepted by the patient, referred to Lichtenberg's motivation theory. This motivation theory is complex and differentiated enough to provide effective representation of patient's subjective experience, with no need to force it into fixed schemata.

The connection with group therapy is provided by Self Psychology, reproposing within group setting the evolution of the presented model.
Though Kohut took direct interest in group only within the context of applied psychoanalysis, his notes on Group-Self allow us to extend his approach beyond individual setting. First Self-Psychology explicative and therapeutic potentiality is described through the comparison with Bion small group theory. Self-Object needs and fear of fragmentation proved to be key concepts also for explaining those phenomena which are typical of "bionian group" (Lofgren 1984; Basch 1991).

Contributions of several group analysts practising a Self-Psychological approach (Bacal 1990; Stone 1992a; Ashbach & Schermer 1992) make clear that group setting tends to amplify Kohut's therapeutic principles. The presence of a number of people - and of the group as a whole - increases the opportunity to experience those kind of relationship each patient needs more. For instance, both Alter-ego and Adversarial Self-object experiences are greatly enhanced in respect to dual therapy, because individuals are within a "peer group", a set of sibling members.
On the other side, relationships within the group are much more complex and involve lots of dangers for individual. So the analyst is required to be alert to every single member's subjective experience. Since the role of conductor is so difficult, some authors suggest to detail his/her tasks separately according to different level of experience and to and different phases of therapy.

Stone (1992), in his analysis of Self-Psychological perspectives on group psychotherapy, distinguishes three different level of experiences: Group-as-a-whole phenomena (i.e. group as a Self-object in an idealised transference), interpersonal phenomena (not only Alter-Ego self-object relations, but also idealised and mirroring ones, assuming different modalities when addressed to a sibling member rather than to psychotherapist), intrapsychic phenomena (individual deficits and defence mechanisms may assume within group interaction the shape of distinctive "roles").

Ashbach and Schermer (1992) deepen these distinctions enlightening as analytic work goes through five main phases, each of them requiring analyst a specific kind of empathy:

1. screening:
Since this approach is base on the therapeutic effects of experiencing empathic response form group, standard patient should be able to restore a cohesive sense of Self within an empathic environment. Trial empathic interpretations during the screening interview can be useful to test this capacity, or to exclude individuals that would benefit from a more structured approach.

2. initial phase:
Creating a safe and comfortable context where patient can develop significant ties requires a special attention for single members. Group setting may expose patients to strong sense of shame as a consequence of the fact that they are "socially" identified as insane or have to express their feelings in the presence of many strangers. Even the role of "simple member" - that is feeling the lack of any specialness or particularity - may cause a relevant diminution of self-esteem. Thus during this phase an exclusive reference to group as a whole is not advisable. Furthermore, an empathic contact with every single member allows analyst to approach each patient's subjective experience in the specific time and place where they usually happen. This opportunity of observing "in vivo" patient's dysfunctional interactive patterns is particularly precious, because - according to Weinstein's happy analogy - there's a great difference between <<hearing from your child about a problem with another child, and actually accompanying your child to the playground to see first hand what goes wrong>> (1991, p. 220).

3. Self-object transferences and intensification of narcissistic affects:
When members feel safe enough, they can unfold within transference those aspects of Self the evolution of which has been stopped. Self-object needs can be shown both at an individual level (i.e. a shy member expresses his repressed grandiosity becoming a monopoliser) and at a group level (i.e. idealisation through the "perfect group" utopia). Coming into contact with their own split-off parts may be deeply destabilising for patients and therapist's monitoring and support are essential. Conductor is expected to maintain an empathic touch and to mitigate transferencial expressions to restore relationship after every disruption. In this phase analyst's personality is fundamental, especially his/her narcissistic balance, since his/her task is to understand and contain group's strong affects, remaining at the same time differentiated enough. In this way analyst not only avoids extreme consequences of these emotional states, but he/she also actually shows how an individual can experience his/her own narcissistic needs and vulnerability without being overwhelmed by rage or shame, that is keeping whole and cohesive his/her sense of Self. At this stage analyst may possibly have to set or restore boundaries or limits in order to cope with members' frequent acting (subgrouping, excessive extra-group contacts and so on). Such a function should be seen as a sort of containing and anyway it doesn't include judgement or recalls to an "objective reality".

4. Transmuting internalisation and integration:
The empathic and reliable Self-object matrix group provides, allows patients to recognise split-off aspects of their personality. The following step is the progressive integration of these denied elements. Such an evolution, according to Kohut, is possible thanks to transmuting internalisation. In group this process assumes several specific features. Ashbach and Schermer underline the importance of the connections the analyst makes between collective and individual memories or experiences, enlightening both group history and members' life trajectories as individuals. Transmuting internalisation takes shape as a learning process, in this case as a learning to make connections between events and to apply new responses and resources.

5. Termination:
According to Kohut (1977), a successful outcome of therapy is detectable from two phenomena. First, at the end of the treatment a "joyful Oedipal" emerges, with no diversion in the sense of Self. Therapeutic environment provides to oedipal exhibitionistic and voyeuristic impulses those optimal responses that had not been available in the past. The second critical aspect is the consolidation of ambitions and ideals, proving an higher level of self structuring. These two indicators give evidence to the achievement of a more complex sense of Self, of a Self that is able to internalise complex object relations. In this phase analyst's connections should be addressed to establish and strengthen the application to daily life of the experiences and skills patients achieved within the safe context of group.

Self-Psychology perspective on group thus gives a great relevance to single patient's subjective state. In group analysis, anyway, observation and intervention should be focused on what happens among members, that is interactions and relationship keeping them together. Besides, the idea of an intersubjective and phenomenological approach to group psychotherapy is not new. Already Foulkes in 1948 had stated that the concept of individual is an artificial abstraction, since a person represents a "nodal point" in a social nexus and is basically and inevitably determined by it. This perspective continues with the concept of "matrix"(Foulkes, 1964), defined as the common shared ground from which the meaning of all events and communications derives.

The clinical case reported by Harwood (1992) gives an example of how complex and effective interventions could be if analyst's attention is primary addressed to the intersection of participants' inner experience.
In a recently started group, conducted by Harwood and a male colleague, one member, Charles, missed the second and fourth sessions because of business engagements. Another member, Andrews, who can't stand Charles for his official and arrogant attitude, accused him of not getting involved as the others had. Charles had a violent reaction and expressed his scorn about the artificial friendship the others seem bound by, adding that there was no basis for reciprocal trust and that all the member were just pretending. From preparatory single interviews, therapists had collected information about past history of both the members enlightening the meaning of this interaction.

Charles's family history was characterised by the continuous struggle between his parents and their "rebel" older daughter. The girl, banished from home during her adolescence, turned to drugs and ended by dyeing when Charles started college. This event persuaded him of the dangerous and deadly quality of independence, driving him to a complete compliance towards his parents expectations, even affecting his sentimental and professional choices. Andrew, instead, had broken off any relations with his mother, since her continuous demands - that she expected to be always fulfilled - cause him an unbearable anxiety. Since then the avoidance of any intimate relationship has been the main defence against the loss of cohesion he experienced because of his "sense of duty" towards others' desires.

Charles's aggressive attitude towards group can be understood as an attempt to challenge "therapists/parents" stating his personal point of view. Andrew, on the other side, repeated in group his total compliance to rules established by others, in this case to what he believed to be therapists' expectations. This interpretation could not be overtly offered because neither Charles or Andrew had shared their personal history with group. Harwood decided to focus her intervention on Charles, even if addressing to Andrew, and said: <<I wonder if having committed yourself to group, opened yourself up, maybe doing so because that is what you think is expected of a group member, and then seeing that someone else has not done so, makes you feel like you gave up a part of yourself while Charles has not?>> (p. 24) Andrew answered affirmatively and added that he was envious of Charles for for his capacity of not feeling obliged to comply rules. Furthermore, the analyst let Charles and the others know that compliance to perceived rules was not a group ideal and that anyone should find his/her own way to be in group. At the same time, she recognised Charles's expression as a right and rewarded him for doing so, and presented to Andrew the possibility to take the same risk.

In this way the analyst shows that accurate intervention is possible both on single patients and on intersubjctive context: the different levels in interpretation correspond to the multiplicity of subjective worlds involved and their complex intersection. In this intervention Harwood sums up two basic therapeutic strategies in intersubjective approach, that is structural transformation of dysfunctional schemata and providing those experience the lack of which caused a developmental arrest.

The relational model presented is thus a promising developmental line for psychoanalytically oriented group psychotherapy. Furthermore, this kind of setting seems to increase therapeutic potentiality of this approach, since group is a more complex context, but also a richer one for relational opportunities. In group there's a number of available partners and any individual has a greater chance to choose and unfold his fundamental patterns of interaction. From this point of view, we can hypothesise that small analytic group is a particularly suitable setting for an intersubjective relational approach.