Br. J . med. Psycho/. (1976). 49, 81-88 Printed in Great Britain
81
On limited-time group psychotherapy 11. Group process*
B Y JORGE L . A H U M A D A t
SOME NOTES ON ADMISSION AND GROUP FORMATION
While entrance into treatment presupposes a conscious desire for change, unconsciously it usually involves a wish for recovering a previous narcissistic equilibrium. According to Durkin (1968)the capacity to use experience to reinforce hopes of restoring perfect narcissistic conditions and omnipotently attaining ideal union with 'the other' is the most serious deterrent to patient change. To be coherent with therapeutic, as opposed to narcissistic, goals, the admission process should promote in future members an active role, geared to learning from internal and interpersonal experience as a task, and to a discrimination of patient's and therapist's roles in treatment. The therapist's role involves maintaining a well-structured and stable setting to make the therapeutic interaction and experience possible, and the required knowledge, manifested by interpretation, to make it fruitful. The patient's role includes respecting the contract and involving himself truthfully and personally in the group experience. Limited-time group therapy derived from institutional needs to provide insight-oriented psychotherapy to the greatest number possible (Ahumada et al., 1974). As the time limit imposes an added integrative effort, the admission process must be as precise as possible, and serve as a preparation for treatment. The selection process for our eighteen-month groups involves two initial individual interviews, two diagnostic group sessions, and a final individual interview; each step implies tasks for the prospective patient and fosters a degree of differentiation between his and the staff's roles. The first individual interview is basically open, while in the second the history of family, bipersonal and group roles is actively explored, as is the patient's capacity to define his emotional difficulties and the degree of motivation for internal change (Sifneos, 1968). Suitable candidates are referred to the diagnostic group, where their predominant roles, anxieties and defences are evaluated in a group situation, as are their grasp of the group's functioning and their ability to make use of clarifications. Additionally, the diagnostic group provides each one an experiential sample of how he fits and feels in a group. In the final individual interview the experience in, and grasp of, the diagnostic group sessions, and their relevance to the patient in terms of his problems, are assessed. Once a decision for referral to group therapy has been agreed upon we discuss problems likely to arise in it, be they specific fears (for example, of criticism or exclusion) or stereotyped defensive roles (for example, trying to help others as a way of avoiding his own emotional difficulties), linking them to his personal history and roles, and to his experience in the diagnostic group. Group formation criteria include, besides age-homogeneity, leaving no patient isolated as to cultural level and predominant defences, while seeking maximal defensive heterogeneity in the total group, to avoid monolytic group-wide defences precluding evolution. To convey the contract as clearly as possible, once a group is formed, we call members to
*
An earlier draft was read at the Asociacion Argentina de Psicologia y Psicoterapia de Grupo in July 1971.
t Staff member, Centro de Education MCdica e Investigaciones Clinicas, and Professor, Institute of Group Techniques of the Asociacion Argentina de Psicologia y Psicoterapia de Grupo. Buenos Aires, Argentina.
82
J O R G E L. A H U M A D A
an information meeting led by a staff member (never by its future therapist). Our contract is with the patient in the group, as a member with a task not only toward his own treatment but also toward the group's function as a therapeutic instrument. Our requirement of three patients to start a session, and the dissolution of the group if that number is not met for three sessions. point to a contract with the group. Also, it is conveyed that interchanges outside the session are definitely not a part of therapy and can seriously hamper it. To summarize, our admission process points to: (a) selecting patients able to function in, and benefit from, a therapeutic setting demanding sustained integrative efforts; (b) conveying an explicit contract; (c) fostering at least some hints of a concept of therapy as a task, linked to feeling and thought within the group; ( d )forming groups cohesive enough, but also flexible and heterogeneous enough to allow for group and individual evolution in the allotted time. THE LIMITED-TIME GROUP AS A DEVELOPMENTAL FIELD
The capacity to use experience to resist change through the maintenance of narcissistic expectations and omnipotently seeking ideal union involves a systematic distortion of experience. We see, following Rosenfeld (1964), narcissistic expectations and attempts at fusion with idealized objects (the ideal union with 'the other '1 as primitive unconscious ways of warding off persecutory anxieties. In limited-time groups group process can be studied as a developmental unit with a start and a termination; the typical evolution of group process through the eighteen-month duration of our once-a-week groups is described in this paper. This typical evolution implies the successive predominance of three group-wide configurations, reflecting specific uses of idealization to ward off paranoid anxieties through a split between idealized and persecutory objects. According to the predominant configuration, three phases can be schematically described in the development of these groups: (1) a dependence phase, with attempts at omnipotent control of the idealized therapist; (2) a group symbiosis phase, with idealization of the group itself and predominant fusion with other members; (3) an individuation phase, emerging under the impact of contact with reality and especially with the temporal element in the setting. Some comments seem pertinent at this point: (a) some acquaintance with the work of W. R. Bion (1959) on groups will be an aid for comprehension; ( b ) a comparison with other authors' views on group process and stages is outside our scope here; (c) technique is also not dealt with, but it must be said that we consider interpretation of the here-and-now as the basic therapist activity, and insight into internal and interpersonal reality in the here-and-now as the main determinant for patient change. A CLINICAL ILLUSTRATION
We shall sketch the development of an actual group, and then discuss a session showing the
use of acting-in* to reinforce symbiotization. A fragment, showing the vicissitudes of idealization as a defence against individuation and grief, as termination draws near, will then be described. There were three male and three female members, aged 22 to 25. In the first session Ada, a schizoid girl with an hysterical faqade, had talked in a flat voice about her drifting years in post-adolescence, living as a hippie with no home, smoking pot. and lost for weeks in a row, weeks she had no memories of: presently married. she was 'much better' but had no contact with her child and at times she forgot to feed him. She fainted on entering * We consider acting-in those acting modalities that preserve the temporal and spatial constants of the setting. that is. those occurring within the session. while calling acting-out those where the basic time and space constants of the setting are compromised. This distinction will be amplified in forthcoming papers.
On limited-time group psychotherapy. II
83
the second meeting, and when she joined the group half an hour later her depersonalized state was obvious to everyone. The others rallied around her and she became the 'needy one', who never acknowledged any needs but whose bland, lost way was quite effective in moving others to take care of her and 'feed' her with 'help'; also, it was clear that 'feeding' her with advice allowed the other patients to dissociate any needs of their own. When this acting on a member of the dual of the dependency group (Bion, 1959) was interpreted consistently, Ada gradually stopped being the depository of everyone's needs and the group showed the features of the dependent group. Members rallied around the therapist either on a 'teaching model' or on a 'medical model'. In the teaching model, members tried to transform the therapist into a guide and obtain directives, 'what we have to talk about, what we must do for a cure, which is the right way '. In the medical model the group demanded that the therapist 'give something '. a concrete but undefinable 'something' felt as possessed by the therapist and refused by him maliciously to the group. This 'something ' was often linked to technique, and questions about technique were then frequent; symptoms were left in charge of the therapist, as in a surgical operation requiring no direct patient activity. Desires for individual treatment were rampant, as were doubts about 'Howcan we be treated together when each one has his own (different) problem?' Patients were isolated from each other, and contact was felt as bound to provide nothing but more 'sickness' through emotional contagion: talk was often covertly addressed at the therapist. When dependent wishes were frustrated by the therapist's interpretative attitude hostility came to the fore; sometimes denied ('he knows what he's doing, that's the technique'), at other times emerging overtly in recriminations ('you are just sitting there doing nothing, giving us nothing'). The next, group symbiosis phase, was heralded by: ( a ) the increase in recriminations to the therapist; ( b )a feeling that sessions were 'too brief '; (c) the relevance of post-session meetings;* ( d ) a split between counter-dependents and dependents. The passage from the dependent to the symbiotic group is clear in the way a persistent request for longer sessions evolved. Marcia, who had pushed forcefully various demands during the initial phase, became the leader of this proposal, trying to convince the therapist to organize - or, later, to join a patient-organized weekend camping session; shortly thereafter the camping-group proposal became increasingly considered as an event that could take place without the therapist. Some thought he ought to be there if the occasion was to be thought of as therapy, while Marcia thought that his presence might be convenient though by no means necessary; patients came gradually to accept her views amid great hostility to the therapist who 'did not want to join the group'. The camping-group proposal also brought to the fore a split in the group: Ada, who overtly kept a great distance, asking nothing, but covertly was connected mostly with the therapist, used the others' counterdependence to secure a unique role: she was not joining the post-session 'cafC' meetings and found no meaning in a weekend group. Obviously the group was no more a dangerous place where members came to have a frustratingly shared contact with an omniscient therapist who protected them from emotional contagion from each other. It had become a unit from which the therapist was excluding himself by his refusal of longer sessions and the camping group, 'even though we want to include you'. The group had become its own raison d'etre, a timeless unit transcending the treatment's set limits. In this 'sibling group', as Ada contemptuously called it, members had finally recovered their archaic love objects. The therapist was felt to be either just another member, or a spoilsport who irrelevantly interrupted through interpretation the members' idyll. With Ada's exception, each was anxiously waited for. because 'if anyone is missing nothing can be done'. Therapy was * A \ mentioned before. the therapeutic contract made clear that outside meetings are not encouraged. are definitely not a part of treatment. and may seriously hamper the group's functioning as a therapeutic instrument. See Ahumada d ( I / . (1974).
84
J O R G E L. A H U M A D A
understood as intimacy-exaltation-fusion between members; sessions were anxiously waited for, and post-session meetings went on for hours: many incidents were kept out of hearing range of the spoilsport therapist. Noticeable symptomatic improvements took place at this time: Manuel, primarily impotent, had his first coitus, and even Ada, who hardly participated overtly, reported much better sexual relations. Improvements were taken for granted as just another proof of the symbiotic group's bountiful virtue. The idealization of being together, appearing in the camping-group fantasy brought, despite persistent interpretation, a group-wide acting out shared by all save Ada. They went to a member's seaside apartment, 'to get to know each other better'. The euphoric climate lasted the first day only, and soon they felt disillusioned with each other. When this acting was brought up in the next session, Saul summarized its results as follows: ' I thought with the group I had everything, now I realize we are a group only in therapy: that, for example, I get along better with my friends than with you fellows'. Another member, Daniel, did not feel disillusioned but cheated, and for many weeks he tried to bring the group back to the 'ideal' stage; he acted out this conflict at home, through fights with his 'unfeeling' mother that brought him to leave home temporarily. With the exception of Daniel, the group underwent achange after the weekend-group fiasco: the therapist as such came to have more meaning for the group, and interpretations were listened to as such and not as interruptions. While coming to the group kept having an attraction by itself, there was greater awareness of goals and a task, and that the therapist had a peculiar role, geared to an understanding of internal and interpersonal experience, in that task. In that atmosphere the annual vacations were drawing close, shortly after the weekend-group disillusion. Maria. a single girl, acted out her disillusion with the group and the oncoming separation by becoming pregnant and having an abortion, missing the last session before vacations. Ada, who was married, had an unplanned pregnancy while on vacation. The third woman, Marcia, had during vacations conscious desires for a pregnancy that were strong enough to scare her. Shortly after returning came the anniversary of the first session; this, and the evidence soon after that Ada had dropped out, brought strong separation anxieties. Recriminations toward the therapist ('you have to cure us. that's what you are here for') came again to the fore in a brief return to the mechanisms of the initial phase. When the situation was interpreted, Saul replied: ' I can gather now that there is nothing magical here, this is useful only to help me think about what goes on in me'. We shall see now a thirteenth-month session, illustrating the use of acting-in and the reinforcement of group symbiotization to deal with the impact of separation and oncoming loss brought in by the recent vacations, the anniversary of the first session functioning as a contact with the temporal dimension of the setting, and Ada's dropping out. In the last minutes of the previous session. Maria had mentioned that since the abortion she had no sexual desire. MANUEL( t o Muria): Why don't you go on with your problem? M A R ~ AI: don't feel like it. Briej silerice. Enter Ada. nho had already ririssed three consecutire sessiorrs arid ~ i ~ thcwforc i s - iiriless she q i i i ~ eii i d i d reii.s(iri - e.\-i~liidedtii~i~ordirip to oiir i~rritrac~t (Ahiriiiada et al.. 1974): she takes a seat. AD.^ ( . \ i r i i l i r i ~i r i Iier tihserit i i ~ i y ) :I came to tell you all that I am leaving the group: my schedules at the hospital were changed and I have to give classes at this hour so I won't be able to come. Severul irierrihers look at euch other and start talking. ADA (~~oritinirir~g): Also. I don't stand the group's climate. . . I had already missed three sessions. but I didn't want to leave without saying good-bye. MANUEL(eschrding Ada cor?ipletely):You were speaking, Maria. MARIA:No. I don't want to go on. Merirhers talk to euch other siriiirltaneoirsl~. THERAPIST:It seems clear that the group is trying to build a subject to exclude Ada and what she brought. MARIA:We already knew that she had left the group.
On limited-time group psychotherapy. ZI
85
MARCIA:There is no sense in going back to that. M A R ~ A( t o Ada): I didn't like that bit about the group's climate.. . MARCIA( t o Ada): You were never a part of the group. ADA: I'm feeling very well lately and my work is going well too; I feel I don't need to come at this time and also I can't: I can get into treatment again at a later date, if I need to The rest of the members ignore Ada and try again to build a subject. THERAPIST ( t o Ada): You came in today to say good-bye and you already did. I think it is better to stop here. She gets up. we shake hands and she leaves. Tense silence. MANUEL:I'd never have thought Ada would come to say good-bye. MARI'A:Neither did I . MARCIA:Oh, she was just an intruder. never one of us. Si1eni.r. MARCIA(smiling. tries to cheer the group): This looks like a funeral. Silence. THERAPIST:Nobody seems to accept Ada's good-bye. nobody can accept her good farewell as everything bad is stuck into her: that's why everyone tried to build a 'good' subject to exclude Ada. As everything bad is stuck into Ada, her leaving is not felt as a departure but as a funeral. SAUL:We didn't d o enough for her, we could have found a way for her to talk about herself. MANUEL: She never wanted to talk. MARLA: Perhaps we didn't let her, really. MANUEL:She didn't cooperate, I don't feel responsible. MARCIA:Let's not lose more time talking about Ada . . .she was there but she wasn't one of us. . .perhaps I'm putting things of mine into her, but I was scared when she came in and I felt much relieved when she said she was leaving. . .and the sooner the better. so we can go on. . . ( t o the therapist) You were just fine, doctor. when you kicked her out. SAUL: I felt sorry for her when the doctor told her to leave. THERAPIST:Everyone feels Ada was thrown out of the group, and this as something that I did: it seems to me the group is trying to expel her now. to deny her farewell. MANUEL:Well, Ada was always different, she had no contact with herself. Silence. MARCIA:Why is everybody silent. we are doing nothing. we are losing our time. . .we were talking about something relevant. DANIEL:I didn't know the doctor kicked her out to gain time, if that is so it seems wrong to me. I think Saul is right. THERAPIST:Ada was already out of the group by her absences, and she came to say good-bye received her good farewell and she was abruptly set aside to keep everything bad stuck into her and get into a 'good' subject, so I interrupted to preserve both Ada and the group. All that is felt as bad in the group has been expelled into Ada, and that is denied by pushing the expulsion into me and going on, as was done with the abortion. Because of this. Ada's leaving is not felt as a departure or a farewell, but as a funeral. If this is denied and put into me. it stays in the group as a secluded abortion-funeral. MARLA(highly nioved): It's like the abortion, it's the same. . .leaving it aside makes it worse still, it's putting it behind a screen but it stays inside all the same. . . MANUEL:When Ada came in I wanted to go on. . .to gain time. . .now I realize it is not a question of gaining time. . .that these events in the group are important. THERAPIST:Vacations. the anniversary, and Ada's leaving bring up the separation here and how will each one leave the group: expelling that into Ada and gaining time is a way of not looking at termination, because it's painful to think about what has been brought to the group and what has not. what is felt as accomplished and what is not: but if all that stays put into me the group gets into an expulsion- termination functioning as an abortion. MARCIA(very irnpacted): I see the group coming to an end and I don't get anything. I can't think. THERAPIST:Marcia brings to us the part of each that cannot think, because if she thinks she gets depressed. So the alternatives seem to be, either to 'gain time' by avoiding all contact with the idea of the termination of the group, or to think about it. But if one does that then the fear comes up of an unmanageable depression, like a funeral. just as the group did here on making contact with Ada's departure and termination.
86
J O R G E L. A H U M A D A
In the next session, the initial climate was one of nervous laughs and jokes (Marcia: 'beware of the doctor, he's trying to get us to think'), and then feelings of loneliness and depression, due to a better contact with the limits of the group and to a lessening of omnipotence. came up. Starting from a comment by Saul, the need was acknowledged of recuperating ego-aspects that allow a greater personal integrity after separation. The central fact in the session transcribed is the group's refusal to tolerate the 'good' part of Ada's leaving. her farewell as such. In order to preserve their ideal group, and that includes their ' non-terminating * group, they transform Ada's leaving into the expulsion of a non-member dealt with as a non-person. It is only through interpretation that this extremely aggressive acting-in can be understood by patients as a way of fending off their own feared loss of the idealized symbiotic group. We shall now transcribe a fragment two months before termination. In the meantime. Marcia left the group under an apparently reasonable cause, to marry, as her fiance was going abroad on a scholarship. MANUEL: I'm sure the group won't end on its date. they can't leave us just as we may then be. M A R ~ AIt: will finish. we were told it was eighteen months. MANUEL: But each one's need is different. I think we'll be included in another group. D A N I E L . :I was wking the secretary the other day: she told me that when you finish you are included in another group. M A N U E L : I knew it had to be that way , . . ( I r c ~u>rrrrirerit,sd m i i t riot krtowirig if tlrempy h d heerr of crrry iise to hirir. orril t h t irr tlrc lust sessiori ' iw'II he told Iroii. ii'c (ire. ii'e hrriwr ' t heerr told rrntil i t o w '). M A R ~ A If: you think in the last session you'll be told more. . .the last session is going to be a session like any other. MANUEL: Doctor. is it true that one can get into another group'? THERAPIST:You'll be called for evaluation. and referral if necessary. six months after termination. but there is no possibility of inclusion into another group here. SAUL:It's better this way. so therapy won't become a crutch. . .there are many things I still have to solve but I don't want therapy to become too necessary. to become indispensable. D A N I E L : I don't care too much. . ,for me the group ended already. , . I don't know if it's necessary to come to the last sessions. no new things will come u p . . .and I don't need the group as much as before.. .do you remember when we felt the group was the most important thing we had? all that is gone long ago and I'm starting many new things. marriage, the new apartment. it's going to be quite a change.
We can see here the denigration of the actual group and the bonds within it as a defence against the grief of termination and separation. The idealization of the last session (Manuel), of future and past groups (Manuel and Daniel), as well as the fears of losing one's identity into extremely idealized bonds (Saul's fears of addiction to therapy) must be interpreted systematically in this phase. They are defences warding off the actual feelings of loss (Maria: 'the last session is a session (just) like any other'; Daniel: I don't know if it's necessary to come to the last sessions'): the same is valid for the idealization of the symbiotic group (Daniel). Only through their consistent interpretation can feelings of loss be experienced and desymbiotization accomplished. This fragment also shows the envious attacks on the benefits of therapy, evident in the case of Manuel who, for the first time, had a more or less normal sexual life, because of the narcissistic wound attached to receiving valuable benefit. A CONCEPTUALIZATION
The characteristics of the dependence phase are clear in the clinical example: while members meet to receive from an idealized omniscient therapist (Bion, 1959), they strenuously resist any attempt by him to provide what he can really provide, learning on the basis of experience: the dependence group functions against actual experience, seen as irrelevant. In our view, the attribution of omniscience and omnipotence to the therapist is an unconscious collusion to
On limited-time group psychotherapy. ZI
87
control hostility and persecutory anxieties in the group. The ideal therapist at this moment would be one providing enough control of frustration to exclude anxieties and hostility from each member's internal reality, a 'peace through fulfillment' excluding, of course, the pains of learning from experience. That is why while members regard the therapist as omniscient and omnipotent, and as the prime depository of treatment, at the same time they behave as if they knew precisely what he should 'deliver': as the dependency leader (Bion. 1959) the therapist is required to deal with the persecutory objects. the 'mental disorder' from which the rest of the group is fleeing. When, by refusing to provide advice or more than the essential support, the therapist declines to act as an idealized object, alternative objects are sought, especially when ambivalence toward the ' non-providing ' therapist becomes too intense. The evolution of the camping-group proposal illustrates this passage to the symbiotic group: patients become to one another what the therapist declines to be to any of them, and all that is unsatisfactory and persecutory is felt as not belonging to the group. It may belong to Ada, the ' non-member ', to the unfeeling and spoilsport therapist, to scapegoats on the outside (mostly parents or spouses) or to society as a whole, but not to the idealized group. Feelings within the group are often close to enchantment; this need and pleasure of togetherness - or, more precisely, of 'oneness ' - tends to disappear as disillusion ushers in the individuation phase. It must be emphasized that hostility comes to the fore whenever idealization is threatened; the way the group transformed Ada's leaving into a funeral, and herself into a non-person, is an example. By her departure, Ada was felt as threatening the ever-present ideal group, and this triggered a sort of murder; in fact, any threat to the split between idealized and persecutory objects can determine an acting episode, in or outside the session, if the threat to the ideal object is felt as massive and the psychic pain not tolerated. As interpretations are geared to psychic reality and not to the reinforcement of the split between ideal and persecutory objects, they are usually not applauded. However, as transference in the symbiotic phase points not only to the therapist but also to other members and the group as a whole, he is in a more neutral position, allowing his interpretations to be at least half-listened to as such.* In fact, a systematic interpretative activity is necessary to preclude the split between ideal and persecutory objects becoming too wide, to prevent or at least diminish acting-out, and to prepare members for the inevitable loss of the all-solving idealized group; loss. that is, however strongly they try to deny it. already implicit in the set termination date. The individuation phase results from disillusion with the idealized group and the idealized self of the symbiotic phase. Disillusion results from contacts with reality coming from inter-member interaction, as in the seashore weekend acting-out, and from interpretation, as when Ada's role as depository of everything bad and persecutory was clarified. Another important, and interacting, source of contacts with reality derives from the time limit itself as well as from events that evoke it: the anniversary conveying that two-thirds of the group's duration has elapsed, vacations proving the group is not always available. All these evidence the group's failings as an omnipotent and ever-present ideal object. Disillusion may have a number of effects. Patients may get pregnant at this point, literally replacing the lost group symbiosis with a bodily symbiosis: they may suddenly find or change jobs, form couples and/or leave the group. Or a series of grief periods may be ushered in, sometimes quite suddenly, and lead through working-through to individuation, with 'increased capacity for symbolization of affects as opposed to acting unrecognized feelings. If the capacity * Rosenfeld (1969)makes the important point that 'it is only the sane dependent parts of the self separate from the analyst that can use introjectiveprocesses uncontaminated by the concreteness caused by omnipotent projective identifications; the capacity for memory and growth of the egodepends on these normal introjective processes'.
88
J O R G E L. A H U M A D A
to tolerate frustration is enough, feelings of sadness -related to the loss of the group as a therapeutic instrument, to actual separation from the other members and the therapist, and to whatever expectations, realistic or not, can now be seen as unaccornplished -come to the fore. There is clearer recognition of interpretations as conveying knowledge, of time as an unavoidable life dimension, and of thought as an essential individual function. Therapy is now seen as depending partly on each member's contribution to it, partly on the group as a unique and changing structure, and partly on the therapist, all playing complementary roles. Differences in the capacity to bear frustration can lead to intra-group splitting, as in Ada's or, later, Daniel's case, to acting-in as in Ada's farewell, to acting outside while staying in the group. or to leaving the group and starting or reconstructing outside symbiotic relations, as Ada did by becoming pregnant and then dropping out. Dellarossa (1971) has compared these groups to multi-stage rockets leaving sections behind upon termination. Patients with strong symbiotic needs and low frustration tolerance tend to drop out when the idealization underlying symbiosis is compromised. We see then in these groups not only initial desertions during the first twelve weeks. as described by Yalom (l966), but also desymbiotization desertions during the last months. While in the last third of therapy the group struggles with desymbiotization and rage, as well as reactivations of symptoms, usually this subsides by the last month, dominated by feelings about separation from the group, the therapist and each other, as well as preoccupation about maintenance of personal gains once the group is over, satisfaction about these gains and, in some patients at least, feelings of gratitude. A patient recently dreamt, before the last group session, that he was in a large room with many persons, attired in full dress: this he related to the formalities of death and the end of the group. When another patient pointed that full dress is used for parties, not for funerals, he said: 'well, this morning I was thinking we sure deserve a party for what we have been able to come across'. SUMMARY
In her review of Bion's ideas on groups, Rioch (1970) remarked that the shift in perspective from the individual to the group, though often given lip service. is difficult in actual practice but essential in order to grasp social phenomena. This paper attempts to conceptualize the evolution of the total group. as well as members within it. in limited-time closed groups. The vicissitudes of idealization. first of the therapist defining the dependence phase. then of the other members and the group itself in the group symbiosis phase. as well as the ulterior contacts with internal and inter-personal reality, bringing about individuation. are described. A clinical outlook is chosen to attain some clarity in the description of complex but relevant phenomena. ACKNOWLEDGMENTS
Thanks are due to Drs A. Dellarossa. R. H. Etchegoyen and G. Ferschtut for their continuing support. REFERENCES
A H U M A D A , J . L.. ABIUSO. D., BAIGUERA. N. & GALLO,A. (1974): On limited-time group psychotherapy. I . Setting. admission and therapeutic ideology. Psychiatry 37. 254-260. BION,W. R. (1959). E.rprrienccs in Groups. New
York: Basic Books. DELLAROSSA, A. (1971). Comments on this paper's presentation. Asociacih Argentina de Psicologia y Psicoterapia de Grupo. Unpublished paper. DURKIN. H . (1968). Comments on Mrs Abercrombie's letter. Group Analysis 1 . 73-74. RIOCH. M . J . (1970). The work of Wilfred Bion on groups. Psychiatry 33. 56-66.
ROSENFELD. H . (1964). The psychopathology of narcissism. In P . ~ y d i ~ ~States. t i c . London: Hogarth. ROSENFELD. H . ( 1969). On projective identification. Paper presented to the International Colloquium on Psychosis. Montreal. SIFNEOS. P. E. (1968). Learning to solve emotional problems: a controlled study of short-term anxietyprovoking psychotherapy. In R. Porter (ed.). T / I K Role of Learning in P.V?.c/rot/ic,rtrpy.London: Churchill. YALOM. I. D. (1966). A study of group therapy dropouts. Archs. g m P.v?.chiat. 14. 393414.
81
On limited-time group psychotherapy 11. Group process*
B Y JORGE L . A H U M A D A t
SOME NOTES ON ADMISSION AND GROUP FORMATION
While entrance into treatment presupposes a conscious desire for change, unconsciously it usually involves a wish for recovering a previous narcissistic equilibrium. According to Durkin (1968)the capacity to use experience to reinforce hopes of restoring perfect narcissistic conditions and omnipotently attaining ideal union with 'the other' is the most serious deterrent to patient change. To be coherent with therapeutic, as opposed to narcissistic, goals, the admission process should promote in future members an active role, geared to learning from internal and interpersonal experience as a task, and to a discrimination of patient's and therapist's roles in treatment. The therapist's role involves maintaining a well-structured and stable setting to make the therapeutic interaction and experience possible, and the required knowledge, manifested by interpretation, to make it fruitful. The patient's role includes respecting the contract and involving himself truthfully and personally in the group experience. Limited-time group therapy derived from institutional needs to provide insight-oriented psychotherapy to the greatest number possible (Ahumada et al., 1974). As the time limit imposes an added integrative effort, the admission process must be as precise as possible, and serve as a preparation for treatment. The selection process for our eighteen-month groups involves two initial individual interviews, two diagnostic group sessions, and a final individual interview; each step implies tasks for the prospective patient and fosters a degree of differentiation between his and the staff's roles. The first individual interview is basically open, while in the second the history of family, bipersonal and group roles is actively explored, as is the patient's capacity to define his emotional difficulties and the degree of motivation for internal change (Sifneos, 1968). Suitable candidates are referred to the diagnostic group, where their predominant roles, anxieties and defences are evaluated in a group situation, as are their grasp of the group's functioning and their ability to make use of clarifications. Additionally, the diagnostic group provides each one an experiential sample of how he fits and feels in a group. In the final individual interview the experience in, and grasp of, the diagnostic group sessions, and their relevance to the patient in terms of his problems, are assessed. Once a decision for referral to group therapy has been agreed upon we discuss problems likely to arise in it, be they specific fears (for example, of criticism or exclusion) or stereotyped defensive roles (for example, trying to help others as a way of avoiding his own emotional difficulties), linking them to his personal history and roles, and to his experience in the diagnostic group. Group formation criteria include, besides age-homogeneity, leaving no patient isolated as to cultural level and predominant defences, while seeking maximal defensive heterogeneity in the total group, to avoid monolytic group-wide defences precluding evolution. To convey the contract as clearly as possible, once a group is formed, we call members to
*
An earlier draft was read at the Asociacion Argentina de Psicologia y Psicoterapia de Grupo in July 1971.
t Staff member, Centro de Education MCdica e Investigaciones Clinicas, and Professor, Institute of Group Techniques of the Asociacion Argentina de Psicologia y Psicoterapia de Grupo. Buenos Aires, Argentina.
82
J O R G E L. A H U M A D A
an information meeting led by a staff member (never by its future therapist). Our contract is with the patient in the group, as a member with a task not only toward his own treatment but also toward the group's function as a therapeutic instrument. Our requirement of three patients to start a session, and the dissolution of the group if that number is not met for three sessions. point to a contract with the group. Also, it is conveyed that interchanges outside the session are definitely not a part of therapy and can seriously hamper it. To summarize, our admission process points to: (a) selecting patients able to function in, and benefit from, a therapeutic setting demanding sustained integrative efforts; (b) conveying an explicit contract; (c) fostering at least some hints of a concept of therapy as a task, linked to feeling and thought within the group; ( d )forming groups cohesive enough, but also flexible and heterogeneous enough to allow for group and individual evolution in the allotted time. THE LIMITED-TIME GROUP AS A DEVELOPMENTAL FIELD
The capacity to use experience to resist change through the maintenance of narcissistic expectations and omnipotently seeking ideal union involves a systematic distortion of experience. We see, following Rosenfeld (1964), narcissistic expectations and attempts at fusion with idealized objects (the ideal union with 'the other '1 as primitive unconscious ways of warding off persecutory anxieties. In limited-time groups group process can be studied as a developmental unit with a start and a termination; the typical evolution of group process through the eighteen-month duration of our once-a-week groups is described in this paper. This typical evolution implies the successive predominance of three group-wide configurations, reflecting specific uses of idealization to ward off paranoid anxieties through a split between idealized and persecutory objects. According to the predominant configuration, three phases can be schematically described in the development of these groups: (1) a dependence phase, with attempts at omnipotent control of the idealized therapist; (2) a group symbiosis phase, with idealization of the group itself and predominant fusion with other members; (3) an individuation phase, emerging under the impact of contact with reality and especially with the temporal element in the setting. Some comments seem pertinent at this point: (a) some acquaintance with the work of W. R. Bion (1959) on groups will be an aid for comprehension; ( b ) a comparison with other authors' views on group process and stages is outside our scope here; (c) technique is also not dealt with, but it must be said that we consider interpretation of the here-and-now as the basic therapist activity, and insight into internal and interpersonal reality in the here-and-now as the main determinant for patient change. A CLINICAL ILLUSTRATION
We shall sketch the development of an actual group, and then discuss a session showing the
use of acting-in* to reinforce symbiotization. A fragment, showing the vicissitudes of idealization as a defence against individuation and grief, as termination draws near, will then be described. There were three male and three female members, aged 22 to 25. In the first session Ada, a schizoid girl with an hysterical faqade, had talked in a flat voice about her drifting years in post-adolescence, living as a hippie with no home, smoking pot. and lost for weeks in a row, weeks she had no memories of: presently married. she was 'much better' but had no contact with her child and at times she forgot to feed him. She fainted on entering * We consider acting-in those acting modalities that preserve the temporal and spatial constants of the setting. that is. those occurring within the session. while calling acting-out those where the basic time and space constants of the setting are compromised. This distinction will be amplified in forthcoming papers.
On limited-time group psychotherapy. II
83
the second meeting, and when she joined the group half an hour later her depersonalized state was obvious to everyone. The others rallied around her and she became the 'needy one', who never acknowledged any needs but whose bland, lost way was quite effective in moving others to take care of her and 'feed' her with 'help'; also, it was clear that 'feeding' her with advice allowed the other patients to dissociate any needs of their own. When this acting on a member of the dual of the dependency group (Bion, 1959) was interpreted consistently, Ada gradually stopped being the depository of everyone's needs and the group showed the features of the dependent group. Members rallied around the therapist either on a 'teaching model' or on a 'medical model'. In the teaching model, members tried to transform the therapist into a guide and obtain directives, 'what we have to talk about, what we must do for a cure, which is the right way '. In the medical model the group demanded that the therapist 'give something '. a concrete but undefinable 'something' felt as possessed by the therapist and refused by him maliciously to the group. This 'something ' was often linked to technique, and questions about technique were then frequent; symptoms were left in charge of the therapist, as in a surgical operation requiring no direct patient activity. Desires for individual treatment were rampant, as were doubts about 'Howcan we be treated together when each one has his own (different) problem?' Patients were isolated from each other, and contact was felt as bound to provide nothing but more 'sickness' through emotional contagion: talk was often covertly addressed at the therapist. When dependent wishes were frustrated by the therapist's interpretative attitude hostility came to the fore; sometimes denied ('he knows what he's doing, that's the technique'), at other times emerging overtly in recriminations ('you are just sitting there doing nothing, giving us nothing'). The next, group symbiosis phase, was heralded by: ( a ) the increase in recriminations to the therapist; ( b )a feeling that sessions were 'too brief '; (c) the relevance of post-session meetings;* ( d ) a split between counter-dependents and dependents. The passage from the dependent to the symbiotic group is clear in the way a persistent request for longer sessions evolved. Marcia, who had pushed forcefully various demands during the initial phase, became the leader of this proposal, trying to convince the therapist to organize - or, later, to join a patient-organized weekend camping session; shortly thereafter the camping-group proposal became increasingly considered as an event that could take place without the therapist. Some thought he ought to be there if the occasion was to be thought of as therapy, while Marcia thought that his presence might be convenient though by no means necessary; patients came gradually to accept her views amid great hostility to the therapist who 'did not want to join the group'. The camping-group proposal also brought to the fore a split in the group: Ada, who overtly kept a great distance, asking nothing, but covertly was connected mostly with the therapist, used the others' counterdependence to secure a unique role: she was not joining the post-session 'cafC' meetings and found no meaning in a weekend group. Obviously the group was no more a dangerous place where members came to have a frustratingly shared contact with an omniscient therapist who protected them from emotional contagion from each other. It had become a unit from which the therapist was excluding himself by his refusal of longer sessions and the camping group, 'even though we want to include you'. The group had become its own raison d'etre, a timeless unit transcending the treatment's set limits. In this 'sibling group', as Ada contemptuously called it, members had finally recovered their archaic love objects. The therapist was felt to be either just another member, or a spoilsport who irrelevantly interrupted through interpretation the members' idyll. With Ada's exception, each was anxiously waited for. because 'if anyone is missing nothing can be done'. Therapy was * A \ mentioned before. the therapeutic contract made clear that outside meetings are not encouraged. are definitely not a part of treatment. and may seriously hamper the group's functioning as a therapeutic instrument. See Ahumada d ( I / . (1974).
84
J O R G E L. A H U M A D A
understood as intimacy-exaltation-fusion between members; sessions were anxiously waited for, and post-session meetings went on for hours: many incidents were kept out of hearing range of the spoilsport therapist. Noticeable symptomatic improvements took place at this time: Manuel, primarily impotent, had his first coitus, and even Ada, who hardly participated overtly, reported much better sexual relations. Improvements were taken for granted as just another proof of the symbiotic group's bountiful virtue. The idealization of being together, appearing in the camping-group fantasy brought, despite persistent interpretation, a group-wide acting out shared by all save Ada. They went to a member's seaside apartment, 'to get to know each other better'. The euphoric climate lasted the first day only, and soon they felt disillusioned with each other. When this acting was brought up in the next session, Saul summarized its results as follows: ' I thought with the group I had everything, now I realize we are a group only in therapy: that, for example, I get along better with my friends than with you fellows'. Another member, Daniel, did not feel disillusioned but cheated, and for many weeks he tried to bring the group back to the 'ideal' stage; he acted out this conflict at home, through fights with his 'unfeeling' mother that brought him to leave home temporarily. With the exception of Daniel, the group underwent achange after the weekend-group fiasco: the therapist as such came to have more meaning for the group, and interpretations were listened to as such and not as interruptions. While coming to the group kept having an attraction by itself, there was greater awareness of goals and a task, and that the therapist had a peculiar role, geared to an understanding of internal and interpersonal experience, in that task. In that atmosphere the annual vacations were drawing close, shortly after the weekend-group disillusion. Maria. a single girl, acted out her disillusion with the group and the oncoming separation by becoming pregnant and having an abortion, missing the last session before vacations. Ada, who was married, had an unplanned pregnancy while on vacation. The third woman, Marcia, had during vacations conscious desires for a pregnancy that were strong enough to scare her. Shortly after returning came the anniversary of the first session; this, and the evidence soon after that Ada had dropped out, brought strong separation anxieties. Recriminations toward the therapist ('you have to cure us. that's what you are here for') came again to the fore in a brief return to the mechanisms of the initial phase. When the situation was interpreted, Saul replied: ' I can gather now that there is nothing magical here, this is useful only to help me think about what goes on in me'. We shall see now a thirteenth-month session, illustrating the use of acting-in and the reinforcement of group symbiotization to deal with the impact of separation and oncoming loss brought in by the recent vacations, the anniversary of the first session functioning as a contact with the temporal dimension of the setting, and Ada's dropping out. In the last minutes of the previous session. Maria had mentioned that since the abortion she had no sexual desire. MANUEL( t o Muria): Why don't you go on with your problem? M A R ~ AI: don't feel like it. Briej silerice. Enter Ada. nho had already ririssed three consecutire sessiorrs arid ~ i ~ thcwforc i s - iiriless she q i i i ~ eii i d i d reii.s(iri - e.\-i~liidedtii~i~ordirip to oiir i~rritrac~t (Ahiriiiada et al.. 1974): she takes a seat. AD.^ ( . \ i r i i l i r i ~i r i Iier tihserit i i ~ i y ) :I came to tell you all that I am leaving the group: my schedules at the hospital were changed and I have to give classes at this hour so I won't be able to come. Severul irierrihers look at euch other and start talking. ADA (~~oritinirir~g): Also. I don't stand the group's climate. . . I had already missed three sessions. but I didn't want to leave without saying good-bye. MANUEL(eschrding Ada cor?ipletely):You were speaking, Maria. MARIA:No. I don't want to go on. Merirhers talk to euch other siriiirltaneoirsl~. THERAPIST:It seems clear that the group is trying to build a subject to exclude Ada and what she brought. MARIA:We already knew that she had left the group.
On limited-time group psychotherapy. ZI
85
MARCIA:There is no sense in going back to that. M A R ~ A( t o Ada): I didn't like that bit about the group's climate.. . MARCIA( t o Ada): You were never a part of the group. ADA: I'm feeling very well lately and my work is going well too; I feel I don't need to come at this time and also I can't: I can get into treatment again at a later date, if I need to The rest of the members ignore Ada and try again to build a subject. THERAPIST ( t o Ada): You came in today to say good-bye and you already did. I think it is better to stop here. She gets up. we shake hands and she leaves. Tense silence. MANUEL:I'd never have thought Ada would come to say good-bye. MARI'A:Neither did I . MARCIA:Oh, she was just an intruder. never one of us. Si1eni.r. MARCIA(smiling. tries to cheer the group): This looks like a funeral. Silence. THERAPIST:Nobody seems to accept Ada's good-bye. nobody can accept her good farewell as everything bad is stuck into her: that's why everyone tried to build a 'good' subject to exclude Ada. As everything bad is stuck into Ada, her leaving is not felt as a departure but as a funeral. SAUL:We didn't d o enough for her, we could have found a way for her to talk about herself. MANUEL: She never wanted to talk. MARLA: Perhaps we didn't let her, really. MANUEL:She didn't cooperate, I don't feel responsible. MARCIA:Let's not lose more time talking about Ada . . .she was there but she wasn't one of us. . .perhaps I'm putting things of mine into her, but I was scared when she came in and I felt much relieved when she said she was leaving. . .and the sooner the better. so we can go on. . . ( t o the therapist) You were just fine, doctor. when you kicked her out. SAUL: I felt sorry for her when the doctor told her to leave. THERAPIST:Everyone feels Ada was thrown out of the group, and this as something that I did: it seems to me the group is trying to expel her now. to deny her farewell. MANUEL:Well, Ada was always different, she had no contact with herself. Silence. MARCIA:Why is everybody silent. we are doing nothing. we are losing our time. . .we were talking about something relevant. DANIEL:I didn't know the doctor kicked her out to gain time, if that is so it seems wrong to me. I think Saul is right. THERAPIST:Ada was already out of the group by her absences, and she came to say good-bye received her good farewell and she was abruptly set aside to keep everything bad stuck into her and get into a 'good' subject, so I interrupted to preserve both Ada and the group. All that is felt as bad in the group has been expelled into Ada, and that is denied by pushing the expulsion into me and going on, as was done with the abortion. Because of this. Ada's leaving is not felt as a departure or a farewell, but as a funeral. If this is denied and put into me. it stays in the group as a secluded abortion-funeral. MARLA(highly nioved): It's like the abortion, it's the same. . .leaving it aside makes it worse still, it's putting it behind a screen but it stays inside all the same. . . MANUEL:When Ada came in I wanted to go on. . .to gain time. . .now I realize it is not a question of gaining time. . .that these events in the group are important. THERAPIST:Vacations. the anniversary, and Ada's leaving bring up the separation here and how will each one leave the group: expelling that into Ada and gaining time is a way of not looking at termination, because it's painful to think about what has been brought to the group and what has not. what is felt as accomplished and what is not: but if all that stays put into me the group gets into an expulsion- termination functioning as an abortion. MARCIA(very irnpacted): I see the group coming to an end and I don't get anything. I can't think. THERAPIST:Marcia brings to us the part of each that cannot think, because if she thinks she gets depressed. So the alternatives seem to be, either to 'gain time' by avoiding all contact with the idea of the termination of the group, or to think about it. But if one does that then the fear comes up of an unmanageable depression, like a funeral. just as the group did here on making contact with Ada's departure and termination.
86
J O R G E L. A H U M A D A
In the next session, the initial climate was one of nervous laughs and jokes (Marcia: 'beware of the doctor, he's trying to get us to think'), and then feelings of loneliness and depression, due to a better contact with the limits of the group and to a lessening of omnipotence. came up. Starting from a comment by Saul, the need was acknowledged of recuperating ego-aspects that allow a greater personal integrity after separation. The central fact in the session transcribed is the group's refusal to tolerate the 'good' part of Ada's leaving. her farewell as such. In order to preserve their ideal group, and that includes their ' non-terminating * group, they transform Ada's leaving into the expulsion of a non-member dealt with as a non-person. It is only through interpretation that this extremely aggressive acting-in can be understood by patients as a way of fending off their own feared loss of the idealized symbiotic group. We shall now transcribe a fragment two months before termination. In the meantime. Marcia left the group under an apparently reasonable cause, to marry, as her fiance was going abroad on a scholarship. MANUEL: I'm sure the group won't end on its date. they can't leave us just as we may then be. M A R ~ AIt: will finish. we were told it was eighteen months. MANUEL: But each one's need is different. I think we'll be included in another group. D A N I E L . :I was wking the secretary the other day: she told me that when you finish you are included in another group. M A N U E L : I knew it had to be that way , . . ( I r c ~u>rrrrirerit,sd m i i t riot krtowirig if tlrempy h d heerr of crrry iise to hirir. orril t h t irr tlrc lust sessiori ' iw'II he told Iroii. ii'c (ire. ii'e hrriwr ' t heerr told rrntil i t o w '). M A R ~ A If: you think in the last session you'll be told more. . .the last session is going to be a session like any other. MANUEL: Doctor. is it true that one can get into another group'? THERAPIST:You'll be called for evaluation. and referral if necessary. six months after termination. but there is no possibility of inclusion into another group here. SAUL:It's better this way. so therapy won't become a crutch. . .there are many things I still have to solve but I don't want therapy to become too necessary. to become indispensable. D A N I E L : I don't care too much. . ,for me the group ended already. , . I don't know if it's necessary to come to the last sessions. no new things will come u p . . .and I don't need the group as much as before.. .do you remember when we felt the group was the most important thing we had? all that is gone long ago and I'm starting many new things. marriage, the new apartment. it's going to be quite a change.
We can see here the denigration of the actual group and the bonds within it as a defence against the grief of termination and separation. The idealization of the last session (Manuel), of future and past groups (Manuel and Daniel), as well as the fears of losing one's identity into extremely idealized bonds (Saul's fears of addiction to therapy) must be interpreted systematically in this phase. They are defences warding off the actual feelings of loss (Maria: 'the last session is a session (just) like any other'; Daniel: I don't know if it's necessary to come to the last sessions'): the same is valid for the idealization of the symbiotic group (Daniel). Only through their consistent interpretation can feelings of loss be experienced and desymbiotization accomplished. This fragment also shows the envious attacks on the benefits of therapy, evident in the case of Manuel who, for the first time, had a more or less normal sexual life, because of the narcissistic wound attached to receiving valuable benefit. A CONCEPTUALIZATION
The characteristics of the dependence phase are clear in the clinical example: while members meet to receive from an idealized omniscient therapist (Bion, 1959), they strenuously resist any attempt by him to provide what he can really provide, learning on the basis of experience: the dependence group functions against actual experience, seen as irrelevant. In our view, the attribution of omniscience and omnipotence to the therapist is an unconscious collusion to
On limited-time group psychotherapy. ZI
87
control hostility and persecutory anxieties in the group. The ideal therapist at this moment would be one providing enough control of frustration to exclude anxieties and hostility from each member's internal reality, a 'peace through fulfillment' excluding, of course, the pains of learning from experience. That is why while members regard the therapist as omniscient and omnipotent, and as the prime depository of treatment, at the same time they behave as if they knew precisely what he should 'deliver': as the dependency leader (Bion. 1959) the therapist is required to deal with the persecutory objects. the 'mental disorder' from which the rest of the group is fleeing. When, by refusing to provide advice or more than the essential support, the therapist declines to act as an idealized object, alternative objects are sought, especially when ambivalence toward the ' non-providing ' therapist becomes too intense. The evolution of the camping-group proposal illustrates this passage to the symbiotic group: patients become to one another what the therapist declines to be to any of them, and all that is unsatisfactory and persecutory is felt as not belonging to the group. It may belong to Ada, the ' non-member ', to the unfeeling and spoilsport therapist, to scapegoats on the outside (mostly parents or spouses) or to society as a whole, but not to the idealized group. Feelings within the group are often close to enchantment; this need and pleasure of togetherness - or, more precisely, of 'oneness ' - tends to disappear as disillusion ushers in the individuation phase. It must be emphasized that hostility comes to the fore whenever idealization is threatened; the way the group transformed Ada's leaving into a funeral, and herself into a non-person, is an example. By her departure, Ada was felt as threatening the ever-present ideal group, and this triggered a sort of murder; in fact, any threat to the split between idealized and persecutory objects can determine an acting episode, in or outside the session, if the threat to the ideal object is felt as massive and the psychic pain not tolerated. As interpretations are geared to psychic reality and not to the reinforcement of the split between ideal and persecutory objects, they are usually not applauded. However, as transference in the symbiotic phase points not only to the therapist but also to other members and the group as a whole, he is in a more neutral position, allowing his interpretations to be at least half-listened to as such.* In fact, a systematic interpretative activity is necessary to preclude the split between ideal and persecutory objects becoming too wide, to prevent or at least diminish acting-out, and to prepare members for the inevitable loss of the all-solving idealized group; loss. that is, however strongly they try to deny it. already implicit in the set termination date. The individuation phase results from disillusion with the idealized group and the idealized self of the symbiotic phase. Disillusion results from contacts with reality coming from inter-member interaction, as in the seashore weekend acting-out, and from interpretation, as when Ada's role as depository of everything bad and persecutory was clarified. Another important, and interacting, source of contacts with reality derives from the time limit itself as well as from events that evoke it: the anniversary conveying that two-thirds of the group's duration has elapsed, vacations proving the group is not always available. All these evidence the group's failings as an omnipotent and ever-present ideal object. Disillusion may have a number of effects. Patients may get pregnant at this point, literally replacing the lost group symbiosis with a bodily symbiosis: they may suddenly find or change jobs, form couples and/or leave the group. Or a series of grief periods may be ushered in, sometimes quite suddenly, and lead through working-through to individuation, with 'increased capacity for symbolization of affects as opposed to acting unrecognized feelings. If the capacity * Rosenfeld (1969)makes the important point that 'it is only the sane dependent parts of the self separate from the analyst that can use introjectiveprocesses uncontaminated by the concreteness caused by omnipotent projective identifications; the capacity for memory and growth of the egodepends on these normal introjective processes'.
88
J O R G E L. A H U M A D A
to tolerate frustration is enough, feelings of sadness -related to the loss of the group as a therapeutic instrument, to actual separation from the other members and the therapist, and to whatever expectations, realistic or not, can now be seen as unaccornplished -come to the fore. There is clearer recognition of interpretations as conveying knowledge, of time as an unavoidable life dimension, and of thought as an essential individual function. Therapy is now seen as depending partly on each member's contribution to it, partly on the group as a unique and changing structure, and partly on the therapist, all playing complementary roles. Differences in the capacity to bear frustration can lead to intra-group splitting, as in Ada's or, later, Daniel's case, to acting-in as in Ada's farewell, to acting outside while staying in the group. or to leaving the group and starting or reconstructing outside symbiotic relations, as Ada did by becoming pregnant and then dropping out. Dellarossa (1971) has compared these groups to multi-stage rockets leaving sections behind upon termination. Patients with strong symbiotic needs and low frustration tolerance tend to drop out when the idealization underlying symbiosis is compromised. We see then in these groups not only initial desertions during the first twelve weeks. as described by Yalom (l966), but also desymbiotization desertions during the last months. While in the last third of therapy the group struggles with desymbiotization and rage, as well as reactivations of symptoms, usually this subsides by the last month, dominated by feelings about separation from the group, the therapist and each other, as well as preoccupation about maintenance of personal gains once the group is over, satisfaction about these gains and, in some patients at least, feelings of gratitude. A patient recently dreamt, before the last group session, that he was in a large room with many persons, attired in full dress: this he related to the formalities of death and the end of the group. When another patient pointed that full dress is used for parties, not for funerals, he said: 'well, this morning I was thinking we sure deserve a party for what we have been able to come across'. SUMMARY
In her review of Bion's ideas on groups, Rioch (1970) remarked that the shift in perspective from the individual to the group, though often given lip service. is difficult in actual practice but essential in order to grasp social phenomena. This paper attempts to conceptualize the evolution of the total group. as well as members within it. in limited-time closed groups. The vicissitudes of idealization. first of the therapist defining the dependence phase. then of the other members and the group itself in the group symbiosis phase. as well as the ulterior contacts with internal and inter-personal reality, bringing about individuation. are described. A clinical outlook is chosen to attain some clarity in the description of complex but relevant phenomena. ACKNOWLEDGMENTS
Thanks are due to Drs A. Dellarossa. R. H. Etchegoyen and G. Ferschtut for their continuing support. REFERENCES
A H U M A D A , J . L.. ABIUSO. D., BAIGUERA. N. & GALLO,A. (1974): On limited-time group psychotherapy. I . Setting. admission and therapeutic ideology. Psychiatry 37. 254-260. BION,W. R. (1959). E.rprrienccs in Groups. New
York: Basic Books. DELLAROSSA, A. (1971). Comments on this paper's presentation. Asociacih Argentina de Psicologia y Psicoterapia de Grupo. Unpublished paper. DURKIN. H . (1968). Comments on Mrs Abercrombie's letter. Group Analysis 1 . 73-74. RIOCH. M . J . (1970). The work of Wilfred Bion on groups. Psychiatry 33. 56-66.
ROSENFELD. H . (1964). The psychopathology of narcissism. In P . ~ y d i ~ ~States. t i c . London: Hogarth. ROSENFELD. H . ( 1969). On projective identification. Paper presented to the International Colloquium on Psychosis. Montreal. SIFNEOS. P. E. (1968). Learning to solve emotional problems: a controlled study of short-term anxietyprovoking psychotherapy. In R. Porter (ed.). T / I K Role of Learning in P.V?.c/rot/ic,rtrpy.London: Churchill. YALOM. I. D. (1966). A study of group therapy dropouts. Archs. g m P.v?.chiat. 14. 393414.
