The suboptimal group is the group we can find ourselves conducting
when trying to establish an analytic small group in the Foulkesian mould. I
propose external and internal determinants and discuss some of the dynamics of
this particularly challenging area of our work as group psychotherapists. I
describe the suboptimal contexts of three groups. I suggest that the suboptimal
group is psychotherapy straddling a variety of forms, calling on the full range
of our skills and one which when persisted with can have therapeutic value for
those involved..
Key words: Suboptimal,
Foulkesian idealism, incomplete family, incomplete self, unstable equilibrium
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ZELASKOWSKI’S FRONT PAGE
There are times when it is it
is extremely difficult to talk about our experience as psychotherapists. In
particular, incompetence, embarrassment and shame do not make for easy
listening or reading. It feels uncomfortable exposing our shortcomings amongst
our peers. So, like many of our clients, we keep quiet or steer discussion in a
comfortable direction. I am of course talking about myself, but prefer the
collective pronoun because I believe myself to be talking for some of you.
I once considered that the things, of which I am to talk were
teething problems, vicissitudes of the training or newly qualified
psychotherapist. Perhaps to a degree they are. However, they have not gone
away, nor indeed do they show any signs of doing so.
To give you some indication of what I mean. Since first starting my
training group some seven years ago, during which time I have started five slow
open psychotherapy groups, the occasions when I have been conducting an
optimally balanced group of seven or eight members have been extremely
infrequent and, more distressingly, those occasions have tended to precipitate
a terrible blood letting, as if being whole and together, those oft touted
therapeutic goals, could not be borne.
What it is
I once attended, over a period
of two years, a large group which numerically, at least, never once achieved
more than twenty members present and was, as such, a median group. However, I
would now describe it as having been a suboptimal large group. An experience no
less profound for myself, in particular, as a constant theme was the
relationship between hopes and expectations and the reality we were a part of.
I always remember the disappointment at the start of the day that my desire to
be part of a large group was again to be dashed.
The suboptimal group exists in similar relation to the Foulkesian
small group. It is the group which persistently exists on or below the
Foulkesian breadline of five members, for which selection and composition
represent distant ideals and, at its other extreme, it is psychotherapy on the
cusp bordering individual and group. It can have as few as two active members
and is precariously close to being something else, be it individual
psychotherapy or inexistence and, as such, survival and annihilation are key
themes - which I will come to later.
The suboptimal group is the
group that many of us work with while attempting to set up and conduct analytic
small groups. It is not the group we hoped we were setting up but is the one we
all too often find ourselves working with.
My experience in the field, being trained within an NHS department
largely devoted to providing group psychotherapy, working for two analytically
oriented voluntary organisations and in setting up a private group practice,
along with my formal and informal contacts with a fair number of colleagues and
practitioners, suggests to me that it would not be unreasonable to conclude,
albeit unscientifically, that the suboptimal group, without being the norm, is
commonplace. This awareness is reassuring because the bulk of my experience as
a group psychotherapist working with ‘patient’ groups has been one of working
with suboptimal groups. This paper seeks to give substance to and to
contextualise my suboptimal experiences, by rendering them less marginal and
giving them a place in the wider field that can be talked about.
Before I continue, I would like to note two products of this
experience: on the one hand, a somewhat chastened belief in the therapeutic
potential of what I practice, although I have no doubts of the potential for
some; and on the other a pressing wish to conduct a well functioning
psychotherapeutic group in optimal conditions, which pays well.
Foulkesian Idealism
The
ideal number for an intensive group such as the analytical one is 7 members ...
A group below 5 is too small to work with
... In a well-conducted group which is regular
it rarely happens that more than one or two persons are absent in any
particular one session.
(S. H.
Foulkes, 1975: 85)
I have rarely (in a slow/open
client group context) worked with the ideal number and the latter level of
absence has not always been my experience. However, I have learnt that a group
below five, unwished for though it may be, is not too small to work with.
I am much in sympathy with and very grateful for Morris Nitsun’s
anti-group. Nitsun offered what became for me a soothing possible means of
understanding my experiences as a practitioner. Without ever fully
understanding what Nitsun was getting at and with my groups constantly seeming
to be living close to the edge, I began to believe that I was held in thrall by
the anti-group. A punishing and painful experience was suddenly a real and
respectable phenomenon, supplanting the prior belief that my ambivalence,
inexperience and incompetence were the cause of my groups’ apparent inability
to sustain themselves at an optimum level. Here was a concept that was
beginning to describe my experience and so, at least initially, I took refuge.
Not only did it challenge the hegemony of Foulkes’ model and ideas, omnipresent, omniscient and paid
homage to in every paper of Group
Analysis, but it explained away some of my anxieties about being less than
the required standard. I could now press ahead and be respectably suboptimal.
Foulkes optimistically invites us to “trust the group”. He implies
that from the cut and thrust of group life an innate capacity for healthy
well-adjusted development will inevitably hold sway. His optimism would seem to
be based on an idealised model of a group where the optimum conditions prevail
and where the group is “well-conducted”. On the other hand I do see the value in
striving to trust the group. I have found that as a group therapeutic attitude
it has provided an antidote to any messianic tendencies that I have carried
into groups. While this is perhaps something of what Foulkes intended, it is of
little help when the conditions are suboptimal. Nitsun (1996: 30) writes:
My own experience of trusting
the group is that in a carefully composed group with fairly sound intellectual and emotional resources, meeting in a
controlled, protected setting, the maxim
’trust the group’ is certainly supportable and that the group usually fulfils
the belief in its intrinsic potential. But many group therapists run groups in
less than perfect situations, in which they are not able to select patients according to established principles: the
membership of the group may be highly disturbed, volatile, and prone to acting
out; there is a large degree of ambivalence about attending group therapy; and
the setting itself is unpredictable, even hostile, such as in some out-patient clinics or hospital departments.
Regrettably, this is often the reality we work in, and we may ask: which is the
true test of the power of group-analytic
psychotherapy - the problematic or ideal setting? If the former, there are
serious questions to be asked about the application of the model with more
disturbed populations, what modifications in theory and technique may be
required in these circumstances, and
whether a theory is sufficient if it relates to only a segment of the
population.
The Suboptimal
Conditions
The conditions that are likely
to promote suboptimal groups are:
1) an insufficient supply of
clients;
2) a hostile or incompatible
sponsoring agency;
3) a sponsoring agency for whom
group therapy is marginal to the core activity.
Therapists
I have to ask myself, what is
it about me that means I tend to run suboptimal groups? During my training I regularly had the
feeling that my group was grappling with my issues. Perhaps also I was
narcissistically preoccupied with the need for mine to be a good group, in fact
the best - I have a vocal super-ego demanding no less. But does this mean that
I am a suboptimal group psychotherapist?
Not only is this my private suspicion but it is also official, in that
although I am let loose on clients by two publicly respected organisations, I
am not yet registered with the UKCP. It seems that, for the time being, it has
been decided no doubt quite properly that my training falls short of required
standards. Consequently, I am driven by a covetous desire for membership, I
envy those who have what I want and am murderously angry with those who exclude
me. Non membership restricts my professional movement and, although I am not
clear as to how, shapes my work.
Group psychotherapy is a stratified and divided world. There are
high and low church forms. Foulkesian group analysis is the dominant mode
against which all forms are seemingly measured. While it is important no doubt
to set and maintain standards, I sense an idealising drive towards homogenising
experience - the suboptimal therapist is in this respect an inevitable outcome.
Clients
The suboptimal group is more
likely to attract suboptimal clients. Therapists feel under pressure when the
group is short of members to adopt a less discerning approach to client selection
and group composition, to grasp at potential group clients when they come
along, to, as it were, ‘pack them in’ regardless of suitability in the spirit
of there being ‘nothing to lose’. The destructive potential of this dynamic is
partially off-set when there is a number of groups to which the client could be
referred, i.e., particular therapists and particular groups seem to do better
with certain categories of more difficult clients. However, when there is just
one group, as is so often the case in private practice or small organisations,
the pressure to include can be great. Group composition begins to be
experienced as a distant and burdensome ideal.
I would add what I see as the problematic nature of applying a clear
set of ‘inclusion and exclusion criteria’. There is a risk that what we strive
for is not a microcosm of the world out there but a rarefied form of group
which has excluded and split off the more destructive parts of our world. As I
said, under suboptimal conditions there is pressure to broaden one’s boundaries
and to become more inclusive. This I think contributes to the particular
atmosphere of the suboptimal group as being somehow close to the edge.
Background Factors
The post-modern condition
It is a symptom of the
diminishing role of group psychotherapy in the rapidly expanding field of
‘talking cures’ and ‘alternative therapies’. With the recent dramatic growth in
the number of counselling courses, psychotherapy trainings and alternatives to
mainstream medicine, there are simply not enough patients to go around. This is
particularly damaging to the group therapist. There is a competitive market and
perhaps we sell ourselves less well than our competitors. What I would conclude
though at this point is that to a
degree it is the inevitable post-modern condition for group therapists, in
that, in a wide range of working conditions we are in less of a position to
rely on a sufficient and regular supply of ‘positively indicated patients to
sustain long-term optimally balanced slow/open groups.
The Incomplete Family
With the decline of the larger
extended family, the concomitant growth of the nuclear, single-parent and
reconstituted forms of family, it is possible that the suboptimal group is
symptomatic of these growing family forms, in particular when one considers
their relation to the cultural ideal of the family - a minority form and
increasingly maligned as a place to grow up. The heterogeneous Foulkesian small
group of 7 or 8 members begins to resemble some cultural ideal of family life -
mum, dad, kids and extended family. On entering the group each individual seeks
to allay the inevitable anxieties of the experience by resorting to hitherto
preferred ways of behaving, enabling in the current context but likely to be
restrictive in the long run, which unconsciously put pressure on the group to
be familiar, to be like their own primary family group. The suboptimal group,
usually in some discernible way or other, begins to resemble the family groups
of origin of each individual member, so often fragmented and incomplete. It is
for this reason that it can survive. The very familiarity of having grown up in
families somehow short of the cultural ideal enables surviving group members to
persist.
The Incomplete Self
On entering psychotherapy
client feels fragmented and incomplete in relation to their ego ideals and are
likely to feel similarly in relation to the psychotherapist. They have sought
help to become “more the person I am” or “to become more whole” or something
along these lines. The suboptimal group which emerges from these incomplete
selves can I think be thought of as symbolising this sense of incompleteness.
As a mirror it reflects back the incompleteness of each member - there is
something very familiar about it. There should be no surprise that groups so
redolent with incompleteness become themselves incomplete.
Psychodynamics of the Suboptimal Group
Annihilation and survival
The suboptimal group has often
felt like the unwished for child, depleted and struggling it feels organically
damaged and chronically at risk, and I am unable to escape my disappointment. I
feel awash with doom and existential anxiety and much less able to adopt an air
of analytic detachment. Professional survival, my livelihood and the group’s
survival begin to feel too intricately bound up. The struggle to survive
becomes uppermost and a profound sense of loss pervades. Each session is
prefaced by anxieties, sometimes persecutory, concerning who will and will not
be there. I remember sessions starting with just myself, one in particular when
I firmly believed that this was it - annihilation. I overcompensate for what
feels like an insufficient libido by becoming
too present - and of course with fewer people about this cannot be
avoided.
Present and absent groups
Members stay away, stop leaving
messages, leave, seem to show less interest in each other and collude with each
other’s more familiar defensive, regressive or destructive behaviour. I think
as a defence against loss, i.e., “I am not going to risk getting to know you
because I’m too worried you might leave me, as all the others have.” Under such conditions absence begins to take
on a permanent and gnawing presence, the empty chairs frequently outnumbering
those filled, and those present gradually become more absent. Over time the
group begins to feel split between discernible absent and present groups. Much
more work is done outside the group usually in relation to the absent group,
through writing letters, seeing people individually as a way of hopefully
bringing them back into the group, worrying about absent members and discussing
them in supervision. As a therapist I feel under much greater pressure to look
after or shelter those that attend, I become more supportive, less
interpretative, less likely to challenge or confront, more likely to nurture
links between those present and to steer the group away from conflict. The
present group becomes a supportive sub-group taking shelter from the lost or
absent group.
The wish for individual therapy
Nitsun places this at the core
of the anti-group process. The struggling “bad breast” group catalyses
fantasies of a “good breast” therapy, where the complications inherent in group
are absent, a place where “I can talk about what is really bothering me” and
“where my needs will be met”. As each
member leaves, the group feels closer to being the wished for object and
furthermore, the optimal larger group is increasingly fantasised as the bad
unwished for object.
Individuals and groups
When is an individual a
group? Intrapersonal and
phenomenological approaches blur the conceptual boundaries of individualness and groupness. Foulkes’
(1948: 10) earlier radical voice helps here:
Each individual - itself an artificial, though plausible
abstraction - is centrally and basically
determined, inevitably, by the world in which he lives, by the community, the group of which he forms a part. The focus
of the group therapist, and this is quite probably a defining attribute of the
group therapist, is the groupness of experience.
Angela Molnos (1995: 440), an individual and group therapist,
argues that in any given moment the group
analyst sees the individual in the context of a group and tries to help him to solve his problems within and through the
group.
I have conducted a number of
group sessions where there was only one group member present and many others
where only two or three members were in attendance. At these times I strive to
hold on to a group focus, the inner groups, the absent group and so on, despite
the inevitable and (often) painful sense that there is no group. In this sense
group psychotherapy is not just a therapeutic approach involving a collection
of individuals, it is also a method for working with individuals.
Not good enough parents
The group with few members,
seemingly unable to take in new members and with permanently empty chairs, is
at an unconscious level the unreliable, unpredictable, narcissistically wounded
and not good enough parent whom the member may feel increasingly inclined to look after or get away from. Attendance may stabilise about the parenting
children, the co-dependent, the psychotically fused, those for whom the
group is replicating a familiar
dynamic.
On the difficulty of introducing new members
Intrinsic to the suboptimal
experience is that new members are urgently needed. Equally intrinsic is the
pressure to introduce them as soon as they become available, neither at the
optimal moment (with sufficient settling-in time before a break) nor with
optimal preparation including time for the group to prepare.
The new member enters the group and immediately encounters a
struggling group, one in grave need of his/her presence and, paradoxically and
frustratingly, a too obvious and acute sense of the group’s despair and
ambivalence. The new member will be either severely tested and/or closely
checked out. A few examples: some or all of the group will be absent; there
will be nobody there for the start of the group; the new member will be
pressurised to disclose too much of him/herself. Another possibility is that
the new member encounters a small but extremely intimate dyad, triad and so on,
where s/he feels too excluded or too intrusive and immediately withdraws. This
feeling is part and parcel of the experience of joining any group, however
there is an amplification within the suboptimal frame, a sense of too much too
soon pervades and early drop out is more likely.
A view based on research
Research conducted by
Fulkerson, Hawkins and Alden, as outlined by Yalom (1985: 283),
looked at 5 groups, from a clinic with 19, that met for 6 months or more
with four or fewer members and identified 5 “striking characteristics”:
1) limited member-to-member
interaction (the group interaction occurred primarily between patients and therapists);
2) passivity (group direction,
sharing of time, and the nature of problem solving were all determined by the therapist);
3) a negative group “image,”
(members regarded the group as a “loser’s group”);
4) good attendance (because of a
sense of obligation rather than of true alliance);
5) poor group development
(inhibited, competitive, uninvolved groups).
Yalom’s (1985: 284) preferred solution to the suboptimal
group is to meld two small groups rather
than to continue meeting with insufficient membership.
Technique
One approach, as an anti-group
process sets in or as referrals dry up, is to refuse to collude with the
suboptimal group. Sessions below a certain level of attendance are cancelled or the group is suspended until new membership
is acquired or the group is
terminated and possibly merged with another. While these responses may be
understandable in the search for job satisfaction and the basic need to earn a
living, they may also be suggestive of an unwillingness to work with some of
the more primitive elements within the group. It is very tempting to give up on
what is often an extremely bad experience.
I have an uncomfortable commitment to staying with the group while
it is suboptimal. The group which becomes an individual session I bring to an
end at 50 minutes, usually with some reluctance, drawing some sort of symbolic
line. With two members I am actively engaging each, and if they know each other
well, it can feel as if they are a couple. As much as I can - and I am aware
how pressurised I feel to steer away from this - I refer material to the here
and now experience of the group and encourage reflection on “how we got to this
point”. Avoidance of the here and now is perhaps a key feature of suboptimal
groups. I find myself struggling to contain and bring back the lost or absent
group into the here and now and am usually having to remind myself that even
though this is not how I would have it, this
is, nonetheless, the group.
Psychotherapy in Equilibrium
In my experience the group
usually, though not always, survives. A curious thing can occur to the group
caught up in what feels like an English cricket team’s middle order collapse
and for whom the end seems not far off. Surprisingly the rot stops and
surviving members begin to settle down. An unexpected and much wished for,
albeit unstable, sense of equilibrium is experienced. People stop leaving and
those that stay, begin to attend more regularly, often to develop a much more
secure attachment then previously seemed possible. While on the one hand there
is much talk of this as not the experience they entered the group for, at the
same time the group begins to feel more and more like the wished for
therapeutic experience, closer to (but at the same time not) individual therapy
and smaller than the Foulkesian optimum - which begins to be talked of as too
big and threatening. An equilibrium is arrived at while striving to do
something else, occurring in the course of group therapy and which, while
difficult to break away from, in my experience can have substantial therapeutic
value for those involved. What was set up as an analytic group becomes
something else, a hybrid, encompassing the occasional individual session,
interspersed with sessions of two (couple counselling?), three or four (family therapy?). What emerges I
believe is psychotherapy which straddles a range of forms. It is not what it
set out to be, nor is it couple, family or individual therapy. However, it is
constantly insinuating these forms. I imagine an aphorism: ‘Life is what happens while you are trying
to do something else.’ Similarly, with
psychotherapy in suboptimal groups. And anyway, as we all know, the individual
and the group are two ways of saying the same thing.
While the optimal analytic small group is grounded in good sense and
sound therapeutic values, it is nevertheless also an abstraction can prove
unworkable when conducted in conjunction with certain inevitable realities.
What I am suggesting is that the suboptimal psychotherapy group - the unwanted
group, the antithesis of the abstract ideal, the group that we often find
ourselves conducting - can be worked with. We are faced with little choice if
we are to practice group psychotherapy on the front line.
Three Suboptimal Groups
Group A: