Contributions of Self Psychology to Group Psychotherapy: Selected Papers

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Stone's central interests include the development of the self, empathy, narcissism, shame, envy, rage and the group-self. He is concerned with several aspects of clinical technique [and] is especially sensitive to our co-creation of so-called "difficult patients". His understanding of dreams as both personal and group products which manifest visual narratives will be of particular interest to students of the social and collective unconscious. Stone's work with narcissistic and borderline patients developed in parallel with his work with the chronically mentally ill, who are often institutionalised. He demonstrates that group therapy for such patients is not only a matter of containment and holding in the service of administrative control, but also involves interpretative work based on an understanding of the primary need for a good enough self-object. Group analysts will be able to connect these ideas with their own theories of ego training in action, the complementarity and reciprocity of transference and countertransference processes, the maintenance of an optimal balance of involvement and detachment in conducting and convening groups, and finding crucial areas of engagement between the group-as-a-whole and the members of it. This work locates aggression within the system of aggressive feelings, frustration and failures in empathy and care. Clearly, Stone has contributed to the development of an authentic relational perspective in psychoanalytical group therapy.' - From the Introduction by Earl Hopper

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CHAPTER ONE: Contributions of the psychology of the self to group process and group therapy

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Walter N. Stone and Roy M. Whitman

Recent contributions by Kohut and his co-workers to the psychology of the self (Kohut, 1966, 1968, 1970, 1971; Ornstein, 1974; Gedo and Goldberg, 1973) and the vicissitudes of narcissism (Kohut, 1972) have direct relevance to the understanding of certain aspects of relationships of group members with one another and the leader as well as group formation, (group) cohesion, and (group) fragmentation. In this paper we propose to integrate the implications of narcissistic transferences as they emerge in group process laboratories and group therapy. We do not mean to negate other developmental and interactional considerations of the individual and group but are adding narcissism as a hitherto not clearly recognized central area.

Developmental models of therapy groups patterned after Freud's initial contribution (1921) and elaborated particularly by Bion (1960), and Bennis and Shepard (1956) emphasize the “object-love” relationships with the leader and subsequent “object-love” relationships with co-members. Their understanding of group behaviour was based on the model of transference neurosis. The relationships between the members of the group and in particular with the leader were considered object directed transferences involving libidinal and aggressive drives. Understanding the nature of the relationship with the help of the structural model, it is assumed that the group leader is experienced as a separate “object” who is loved or hated, or who, by his behaviour, or indeed by his mere presence mobilizes defenses against such strong feelings. The model for this approach to group behaviour is the oedipal model in which the leader (father) is seen as a person stimulating an intense, positive, erotic or, conversely, intense negative, hostile transference. As additional implication of this model is that the group members are seen as siblings who also relate along the lines of object-love. The opportunity to engage in multiple object-love or object-hate relationships, both vertically and laterally, has been an oft-stated advantage of group therapy over individual therapy.

 

CHAPTER TWO: The group self: A neglected aspect of group psychotherapy

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Sigmund Karterud and Walter N. Stone

Abstract: The authors explore and expand on Heinz Kohut's concept “the group self”, which is related to, yet different from the concepts “intersubjective field” and “group matrix”. The group self is defined as a collective project with inherent ambitions, ideals and resources. From this perspective the authors discuss group-as-a-whole phenomena, empathy, aspects of group development and the kind of discourse which is appropriate for group psychotherapy. This particular discourse should contain multiple selfobject functions as well as aspects of otherness not accounted for by the selfobject concept. Partaking in this discourse has a beneficial effect by itself which justifies a concept of “discoursive selfobject function”. This selfobject function is of a partial supraindividual nature. Two clinical vignettes illustrates aspects of group self development and fear of depletion of the group self.

Key words: The group self, self psychology, group psychotherapy, group-as-a-whole, selfobject function.

 

CHAPTER THREE: Group-as-a-whole: A self psychological perspective

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Walter N. Stone

Abstract: As Self-psychology has evolved from exclusively dyadic treatment, it has illuminated transference configurations that are applicable to group treatment. Selfobject transferences not only are directed to individuals and to the whole group. In addition the concept of the group-self, refers to members’ deeply felt inner experience of the group ideals and goals.

Individual's experience of whole group interpretations often stirs a basic ambivalence between group membership and self-expression. Self psychologically informed interventions, understanding and explaining, focus on therapists tasks of empathically understanding individuals prior to explaining (interpreting) the group-as-a-whole. Examples will illustrate transference and coun-tertransference aspects of the treatment process.

Key words: Selfobject; group-self; empathy; interpretative understanding; interpretative explaining.

Emerging from the ferment of interest in group phenomenon, Kurt Lewin (1951) conceptualized a group as a system, different from the sum of its parts. Groups were understood to have unique properties that were embedded in a hierarchy of systems and containing subsystems within their boundaries. Clinicians were thereby provided a conceptual tool with which to understand the interactions (verbal and behavioural) of a dynamic system frequently referred to as the group-as-a-whole. Systems’ views encompass group dynamic perspectives, including goals, boundaries, norms, roles and values.

 

CHAPTER FOUR: Dreams as portraits of self and group interaction

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Walter N. Stone and Sigmund Karterud

Abstract: Dreams presented in group psychotherapy portray different aspects of the dialectic between the group and the individual. A self psychology perspective emphasizes the interplay between the current self-state of the group-as-a-whole and the selfobject needs of the individual. With this focus in mind, the therapist should help the group to deepen its awareness and capacity to reflect upon emerging new abilities (“forward edge”) which dream imagery conveys, and the needed human responsiveness that can actualize these abilities, and thus help the individual and the group to break and transform chains of repetition compulsion. We illustrate this approach with two clinical examples.

From the time of Freud's classic monograph (1953/1900), dreams have been regarded as avenues into the unconscious world of wishes, conflicts, and defences. The interpretative task, with the aid of the patient's associations, was traditionally to decode unconscious elements that the dream disguised. In contrast, self psychology has focused its attention upon the dream's representation of the self and self in relation to others, others in the past and the here-and-now. As Ornstein (1987) wrote, “The dream is always about the self; that is, the dream always presents various aspects of self-experience to the dreamer's attention” (p. 101).

 

CHAPTER FIVE: A self psychological perspective of group development

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Walter N. Stone and Gil Spielberg

Abstract: This paper examines group development from the perspective of self psychology. Members’ search for particular selfobject responsiveness varies according to the particular phase of group development. In the first phase, patients’ wish for safety and understanding is managed by merging with the therapist as an idealized selfobject. In the second phase, members look for mirroring selfobject functions to their assertive/ aggressive self expression. In the third phase, members continue to have periods when idealizing and mirroring selfobject responsiveness assist them in maintaining inner balance. During this phase members continue to gain skills from alter-ego selfobject experiences.

In the final phase of a group, termination involves members’ ability to manage the narcissistic pain of loss and separation. Members utilize their inner consolidation and the continuing selfobject experiences to stabilize themselves as they experience loss associated with leaving the group and the real relationships they have developed. Across phases, members gradually internalize the values and norms of the group, which become part of the groupself. The leader's therapeutic and countertransference responses are also examined for each phase.

 

CHAPTER SIX: A self psychological perspective of envy in group psychotherapy

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Walter N. Stone

It is indeed a privilege to be asked to contribute to the examination of envy, which has received so little attention in the expanding exploration of the psychology of the self. Following receipt of the invitation to respond to Lionel Kreeger's presentation of envy preemption, I enquired if I might have a draft of his manuscript, which he promptly forwarded. I read it rather quickly, and proceeded with my research and my clinical explorations. I was aided in my study by the responses of my patients, colleagues and friends following the announcement of my forthcoming sabbatical leave that included three months in England.

In these circumstances, I recalled a paper by Manny Schwartz (1972), which I initially read with some dismay. He described a training group in which he would pick a theme, and then he would interpret all material along that single dynamic. I remember one theme that he chose was incest. Of course, soon all the students began reporting manifestation of incest occurring in their therapy groups. This process obviously ran the risk of seeing a theme where it did not belong. Discussion of the implications of this model is beyond the goal of this paper, but like the students, I saw envy where I had not seen it before, and my patients began to wonder what I had been studying. In the midst of this exploration, I received a second version of Dr. Kreeger's manuscript. My response was delight and amusement. We were similar; we had common experiences and thought (I too had found myself thinking of the Groucho Marx joke as a defense against being envied). We had addressed similar writing tasks, and I felt an identification with him. My preparatory anxiety diminished—was I experiencing an alter-ego transference.

 

CHAPTER SEVEN: Frustration, anger, and the significance of alter-ego transferences in group psychotherapy

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Walter N. Stone

For most clinicians, the topic of the angry patient evokes associations to troublesome borderline and narcissistic individuals. There are patients who are not reliably capable of distancing themselves from their immediate therapeutic experience in order to cognitively contemplate their interactions. They are individuals who respond to treatment as a real life experience, without an “as if” quality.

Malcolm Pines, in a 1975 paper addressing the impact of the angry person on the group and on the therapist wrote:

Diagnostically most of these individuals fall into the “borderline” category; they are extraordinarily self-involved, sensitive, dissatisfied and angry. Their impact on the group may be intense and not always constructive, since they attempt to destroy, monopolize, and to provoke counter-aggression from other members. Moreover, they engage in struggle with the group leader which can be disturbing to the latter to say the least (p. 102).

Discussion of the angry patient, however, entails an understanding of the clinician's perspective on the genesis of anger affects in the therapeutic process. The psychology of the self, with its emphasis on the universal need for self-objects, has brought into sharper focus the affective responses to narcissistic injury. In this contribution, I will focus on the relevance of alter-ego and twinship transferences in understanding experiences of frustration and anger as they emerge in group psychotherapy. A clinical vignette will illustrate some of the selfobject transferences emerging in the relationships among the group members and with the therapist.

 

CHAPTER EIGHT: Self Psychology and the Higher Mental Functioning hypothesis: Complementary theories

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Walter N. Stone

Abstract: Self Psychology and the Higher Mental Functioning hypothesis emphasize positive aspects of patients’ efforts to stabilize defective (unstable) functioning and begin growth. The theories overlap and their application increases clinical awareness of transactions with the treatment setting. Clinical examples are presented from psychotherapy groups that illustrate applications, advantages and problems of the two theoretical approaches.

Key words: Empathy, injury, Higher Mental Functioning Hypothesis, Self Psychology, testing.

The theoretical basis informing clinical work has slowly evolved to place increasing emphasis upon the contributions of the therapist to the treatment process. Formulations that focused on understanding and interpreting transferences, as arising primarily from the patient, have been modified to examine with greater specificity the impact of the therapist in the treatment encounter.

In this communication, I discuss two major modifications of traditional psychodynamic theory that have influenced clinical practice and have substantial relevance to group psychotherapy: the Higher Mental Functioning Hypothesis (HMFH) (Weiss and Sampson et al., 1986; Weiss, 1993) and Self Psychology (Kohut, 1971, 1977, 1984). The HMFH is an object relations theory according to which, in the therapeutic encounter, patients actively attempt (albeit primarily unconsciously) to alter pathogenic beliefs. In this theory patients have plans, which they “test” in order to determine if beliefs that primarily arose in childhood will be sustained or refuted in the contemporary interaction with the therapist. If the test is passed, the patient no longer finds it necessary to retain archaic beliefs and modifies previously imposed self-preservative behaviours. Similarly, Self Psychology proposes that patients search for a therapeutic experience that will provide a remedy for a previously deficient selfobject experience, thereby enabling the individual to stabilize up to that point an unstable defective Self and restart growth. An archaic selfobject is not experienced by the disordered patient as a separate person but as part of the self, which serves to fulfil, and incompletely developed structure.

 

CHAPTER NINE: The role of the therapist's affect in the detection of empathic failures, misunderstandings and injury

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Walter N. Stone

Abstract: Therapists cannot be expected to always understand their patients or the process of their group. Using evolving self psychology and theories of Intersubjectivity, this manuscript explores the affective responses of therapists as a valuable indication that such misunderstanding is occurring. Clinical vignettes will illustrate three specific reasons for therapist misunderstanding: over-adherence to theory, boundary crossing, and inexperience. Additional examples will illustrate how countertransference can disrupt treatment when the group therapist conveys material or affects outside his or her awareness.

Key words: Group psychotherapy, countertransference, therapist's affect; errors; misunderstanding; empathic failures.

Therapists often do not appreciate the potential for their interventions to adversely affect the therapeutic process. They fail to recognize that a well-meaning interpretation, observation, or question may be experienced by the patient as unempathic and hurtful. If a patient rejects an intervention, is it because the comment was experienced as ill timed, or touched an area of vulnerability requiring protection, or was it simply inaccurate? These certainly are knotty problems.

 

CHAPTER TEN: Technique in group psychotherapy of narcissistic and borderline patients

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Walter N. Stone and James P. Gustafson

Advances in theory regarding narcissistic and borderline disorders have reawakened interest in the group treatment of patients in those diagnostic categories. Even though theoretical points of view vary, often to the point of polarization, for the group therapist the translation of theory into technique remains in a nascent stage.

The interplay between theory and technique is seldom made explicit, but therapists use their theoretical base to organize the diverse material presented in the group and then intervene in accordance with theoretical understanding. Nevertheless, theory can be constricting for therapist, since it may offer the security of the familiar and therapists may thereby avoid the complexity of exploring new possibilities for understanding patients. In addition, there is a risk that patients will conform their responses to the theories of the therapist. A useful theory would provide the group therapist with ways of organizing the material and his approaches to his patients while minimizing the constrictions.

 

CHAPTER ELEVEN: Affect and therapeutic process in groups for chronically mentally persons

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Walter N. Stone

Abstract: A dynamic group treatment model for chronically ill persons allowing them to determine the frequency of attendance empowers the members and po tentiates group development. This format respects patients’ needs for space as represented by missed meetings. In this context, absences are f ormulated as self-protective and self-stabilizing acts rather than as res istance. In an accepting supportive environment, members can be helped to explore affects and gain insight into their behaviours. A clinical example illustrates patients’ examination of the meaning of missing and attending sessions, with particular focus on intensity of involvement, autonomy, and control. In the process of the therapist and group, members show capacity to gain insight into recent in-group and extra-group behaviours.

The ravaging effects of schizophrenic and bipolar illness on though and affect remain a therapeutic challenge. The multiple biolog ical, social and emotional needs that are the basis and consequence of severe and persistent mental illness defy simplistic so lutions. Medication may alleviate some of the chaos but fails to reverse or halt impairment in essential areas of human functioning—relations with the self and with others from which come a sense of wellness and comfortable regard.

 

CHAPTER TWELVE: Strivings and expectations: An examination of process in groups for persons with chronic mental illness

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Walter N. Stone

In the past half-century, models for treating schizophrenia have traversed a path from a primary reliance on psychotherapeutic intervention to one that emphasizes medication as the first line of treatment. Concern for patients’ quality of life has been submerged as research became focused on finding medications that alleviated the major (positive) symptoms. A significant breakthrough in phar-macotherapy occurred with the recognition that clozapine impacted upon negative symptoms, providing increased hope for cure. However, the overall outcome for schizophrenia has not altered appreciably, with patients continuing to have considerable deficits in ability to fulfil expectable roles and to engage in emotionally meaningful discourse (Bustillo, Lauriello, Horan, & Keith, 2001).

No single factor can account for the multiple and varied aspects of patients’ deficits. Most likely biological, developmental and social elements contribute to patients’ failures to achieve an average expectable life trajectory. Viewed through a psychosocial/ developmental lens, many children who subsequently will be diagnosed with schizophrenia exhibit developmental peculiarities that evoked aversive responses within the family, school and play, leaving the person emotionally scarred (Walker & Lewine, 1990). When overt symptoms appear, often necessitating hospitalization, adolescents or young adults become further alienated from their peer group and further impaired in their ability to fulfil usual role expectations.

 

CHAPTER THIRTEEN: Saying goodbye: Exploring attachments as a therapist leaves a group of chronically ill persons

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Walter N. Stone

Abstract: This clinical report highlights some of the processes arising in a therapy group of persons with persistent and chronic psychiatric illnesses as they cope with the stress of their long-standing therapist's impending retirement. Members’ were initially disbelieving that the therapist would leave and were also concerned about their future care, particularly in terms of medications. Gradually they were more able to experience their feelings of loss and their genuine caring for the therapist and the group, using higher-level defenses and increasing their ability to tolerate strong affects. They became increasingly able to demonstrate empathy, notably in their ability to consider the therapist's emotions. The clinical material also illustrates the therapist's personal involvement, countertransferences and expressions of concern.

“Now schizophrenics proper … are able as long as they are not too disturbed to relate themselves meaningfully to others. They have early gained experience in looking introspectively at interpersonal processes and gathering and reporting correct, meaningful data” (Fromm-Reichmann, pp. 52–53).

 

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