The Capacity to Use the Group as a Corrective Symbiotic Object in Group Analytic Psychotherapy for Patients with Psychosis

Introduction

Group psychotherapy has been shown to be efficient in treatment of patients with psychosis (Kahn, 1984; Chavez, 2009). Transference reactions seem to be less intense in a group, because the patient has the opportunity to view the therapist as a real person (Slavson, 1950; Horwitz, 1994), but at the same time the situation is sufficiently intense to reactivate crucial childhood feelings (s.c. ‘dilution of intensity of transference’, Alikakos,1965; Ivezić, 1994; Urlić, 1999; 2012). Some of the difficulties of individual psychotherapy for patients suffering from psychosis such as hostility, mistrust, self centeredness, low tolerance for frustration (Kahn, 1984) are diminished and soothed in a group setting. Group psychotherapy has, generally speaking, an advantage over individual therapy, especially in attenuating transferential reactions and diminishing levels of regression and excessive transferential reactions (Urlić, 1999; Chazan, 2001). Goals, ways of implementation and the work technique in a group of psychotic patients substantially differs from those in groups where patients with psychosis are not included, and also depending on the therapist’s theoretical orientation (Schermer and Pines, 1999). According to group analytic concepts symptoms develop from a disruption in the communicative system, and this disruption is also present in a psychotic disturbance (Pines, 1981; Roberts and Pines, 1992). In the group analytic setting communication represents a major therapeutic factor, with free-floating discussion within the group representing meaningful communication at an unconscious level. All events are considered to be communication, and they are accepted as signs, symbols, or other messages, and meaningful when decoded and placed in the appropriate context and language (Zinkin, 1984; Foulkes, 1990).

From the traditional point of view, analytic technique is not adequate for group psychotherapy for patients with psychosis (Battegay, 1977; Kanas, 1980; 1985; 1986), while for others group analytic therapy, adjusted to degrees of regression for patients with psychosis, can be an effective method to approach and treat out-patients with psychosis (Alikakos, 1965; Kahn, 1984; Chazan, 1993; Urlić, 1999; 2012; Restek Petrović, 2010). Recent studies have confirmed the effectiveness of individual and group psychodynamic psychotherapy for patients with schizophrenia, compared with routine treatment (Rosenbaum, Martindale and Summers, 2013).

The therapist who believes in the psychodynamic model of mind, and sees psychoses on a continuum with other disorders, is likely to conduct the group in a relatively unstructured way with special modifications, in order to allow patients to experience the partial emergence of primitive regressive and transferential experiences, which then can ideally be resolved through interpersonal interactions and interpretations (Schermer and Pines, 1999).

Psychodynamic group psychotherapy strives to uncover and re-work pathological traumata, object relations, defences, and primitive phantasies, in contrast to treatment modalities, which provide sufficient structure to facilitate repression and to support the healthy ego (Schermer and Pines, 1999). It appears useful to promote a moderate degree of regression and its attendant anxiety, in order to influence—if not the psychotic core itself —then the psychotic defences and distortions reflecting primitive object relations. In this way, the patient is gradually ‘brought up’ to a higher level of development. The ingredients that are crucial to successful psychodynamic group psychotherapy with psychoses include engagement of the group by the therapist and focus on the here-and-now (horizontal) interactions rather than the there-and-then (vertical, historical) dimension. There is little published in the field of the application of group analytic principles in conducting groups of patients with psychosis. So, it is presently unclear what kind of patients with psychosis could benefit from group psychotherapy insight-oriented treatment. Several factors are described as selection criteria, such as severity of illness, phase of illness, course of illness, as well as ego strength. Takahashi and Washington (1991) and Cabeza and Gonzalez de Chavez (2009) have found that the insight factor might be especially helpful in the treatment of stabilized patients with psychosis, and might indicate a favourable prognosis.

Symbiosis and Transference of Patients with Psychosis

There is full agreement about the fateful nature of the mother–baby relationship, and increasing agreement that very early disturbances may play a major part in the susceptibility to psychosis in adolescent or adult life (Jackson, 2008), and that corrective symbiotic experience is important for recovery (Searles, 1961; 1975; Giovacchini, 1972; Urlić, 1999; Ivezić, 2003; Corradi, 2004; Jackson, 2008). The Searles’ experiences with therapeutic symbiosis (Searles, 1965) uncovered a great inclination for gratification of symbiotic needs in persons with psychosis. In cases where in early childhood the adequate symbiotic communication is not established, the patient continues expressing a tendency to establish the symbiotic relationship with his/her therapist in the treatment situation. This kind of relationship is often encountered working with patients with psychosis as an exaggerated dependency on the therapist. Searles points out that ‘patients with psychosis yearn for symbiotic union with the mother, but become frightened of a complete loss of self and annihilation of the object, as they begin to merge with the symbiotic partner’ (1961). This dilemma concerning intimacy in the symbiotic relatedness of the patients with psychosis has been conceptualized as a ‘need-fear dilemma’, in which there is ‘both an inordinate need and an inordinate fear of objects’ (Fromm Reichmann, 1974). The patient with psychosis has a conflict to be both close and distant from others, to be fused with and separated from the other (Fromm Reichmann, 1974; Pao, 1979).

The need/fear dilemma can be understood in Kleinian terms as a fear of the resurfacing of split off and encapsulated or externalized bad objects (Schermer and Pines, 1999). The fused and symbiotic relationships, that have been described as characteristics of psychosis (Searles, 1961). suggest an impairment in self–other differentiation. It is supposed that in psychosis there is disturbance of internalization (Meissner, 1981), and introjections are not differentiated enough. This is mirrored in vulnerability of the self and relationships towards others, as well as in a weak ego structure. During development of the psychotic personality structure the threatening aggressive introjections of the mother (motherly objects) are internalized, and the ego uses primitive defence mechanisms, such as negation, omnipotence and projective identification, to protect itself from dangerous introjections of the mother (Giovacchini, 1972). The experience of the outside world as threatening and endangering comes from projection of these introjections towards the outside world. The symbiotic phase is indispensable for stabilization of the psychological functioning of a person with psychosis (Searles, 1965). It has been shown that patients who are able to establish a good symbiotic relationship with the therapist have a better prognosis in treatment (Furlan and Benedetti, 1985; Ivezic, 2003).

The group provides a sufficient setting for activation and correction of disturbed development of object relations, where the child’s need for secure attachment as a basis for emotional growth, is provided by group cohesion and the group matrix (Roberts and Pines, 1992). The group acts as caring and care-giving entity, which helps individuals to bring together split aspects of the self. Part–object states and the paranoid–schizoid position are revived in the group under conditions of anxiety and regression (Aschbach and Schermer, 1987), where the split off or repressed parts of the self are projectively identified into the group matrix and experienced in allocation within the group rather than in the self, and the group-as-a-whole, like the responsive mother, changes to accommodate the projected elements. From the object point of view, transference in the group ranges from primitive to mature. Primitive transference in the group involves the group-as-a-whole, being unconsciously perceived as an early mother imago. The group can represent both good mother image, as well as a hostile, attacking, bad mother image.

We would like to illustrate the above-mentioned conceptualizations about the use of group psychodynamic psychotherapy in the frame of reference of comprehensive treatment of psychoses through our experiences of working with patients suffering from psychosis. In this article we focus on the possibilities of use of a group setting that enables the corrective symbiotic experience.

The Group

The group consisted of nine female patients (aged 23 to 34 years) diagnosed with ‘schizophrenia’ according to ICD 10. At the beginning of group psychotherapy all patients were in remission according to clinical criteria. During four years of group psychotherapy (once a week for 90 minutes) the group had been meeting at the same time and the same place. Out of nine patients, seven of them were on a low dose of anti-psychotic medication, and two on no medication. It is important to note that all selected patients had supportive individual psychotherapy by the group therapist before they started group psychotherapy. The duration of the individual therapy that preceded the inclusion in the group was from six months to one year. The group was conducted by a group analyst according to a modification of group analytic method similar to psychodynamic reconstructive process described by Urlić (1999). The conductor of the group accepted the conceptual attitude that psychotic disorders were on a continuum of mental disorders, among which psychoses are the most severe (Schermer and Pines 1999; Urlić, 1999; 2012; Štrkalj-Ivezić and Restek-Petrović, 2008), and that psychotic experience represents part of human experience and can be understood in psychological terms. The group was supervised in peer supervision by the second author. During group psychotherapy one of patients was hospitalized for two weeks, and one patient was frequently hospitalized. All other patients remained in stable remission.

Clinical Example (c.e.) 1: Group as a Bad Attacking Mother

We describe a 25 year old, single, female patient, the youngest child in a family of five children. The patient’s mother suffered from psychosis, but was never treated. The mother had been absent since the patient was two years old, so she lived with her father, two brothers and two sisters. According to the patient’s statement, the father expected her to be perfect. As a child, she was her father’s favourite child. After a short period of individual psychotherapy she developed ambivalent symbiotic transference, frequently switching from a phase of idealizing the therapist to a phase of hostile feelings in transference, accusing and humiliating the therapist for not treating her nicely. She was only looking for gratification of her dependence needs in the transference. Most of the time the transference was psychotic, she was unable to experience an ‘as if’ quality of transference. Group analytic psychotherapy was suggested to her, with the aim of overcoming the psychotic transference, searching only for gratification of her symbiotic needs. It was expected that in the group situation the patient would establish a more realistic attitude to the therapist. This was conveyed to the patient and she accepted.

From the beginning of the group she tried to gain the therapist’s attention by sitting outside of the circle, reading newspapers, interrupting any interaction between the members and laughing at the therapist’s intervention in the group. Most of the group members were frustrated with this behaviour. The therapist’s intervention was a clarification that the patient was acting out frustration (aggression) rather than talking about it. The therapist expected her to be able to overcome these difficulties and that the group could help in achieving this.

The group tolerated her behaviour and encouraged her to express her feelings in the group. Very often she would say that the group was stupid and that everybody in the group including the therapist was stupid, and that she was the only one who was clever. Most of the group members felt hurt by her remarks and they felt very uncomfortable when she talked badly about the therapist. The therapist understood this as a projection of bad self and object component on the group. From the beginning, the group had been serving as a good container and tolerated this behaviour. In a further phase of group development she identified with the therapist’s role and took the position of adviser in the group. She had a resolution for all the problems expressed in the group. She commented on every contribution of every group member. The group found some of her advice useful, and in this way she received gratification from the group. As the group continued, it became obvious that she could not bear any burdening emotional situations within the group. When one group member expressed anger or depressive feelings, she immediately commented that ‘there is no need to have such feelings, that cannot happen to me’. In these situations she defended herself with an omnipotent attitude.

One such interchange was as follows; Group member:

I am so angry with my mother. When I was a child she used to beat me and never allowed me to cry. I am so angry with her, and I am afraid to be still angry with her.

She was crying while saying this.

As time passed, it became obvious that this patient could not bear any confrontation or interpretation of her behaviour, and at that time she considered the group and the therapist to be a bad attacking mother. Every confrontation she considered as an attack with the intention to tell her she was not good enough. She spent two years in the group and she was frequently hospitalized because of short psychotic episodes, which could be understood as her inability to overcome the need for gratification in symbiotic transference. It looked as if she attempted to gain the therapist’s attention in the acute phase of the illness. She was not able to use the group as a good object, and was not able to experience the ‘as if’ quality of transference. An interruption of group psychotherapy was suggested.

Commenting on the developmental line of this group member, it is evident that the therapist had not made an accurate enough assessment of that patient for analytically-oriented psychotherapy, because through time it became obvious that she did not have the capacity to use the group as a good motherly object that could be used for a corrective emotional experience. The perception of the group as a bad object provoked frequent hospitalizations.

Clinical Example 2: Group as a Good Caring Mother / The Capacity to Use Group as a Good Object

Since the beginning of therapy a patient was constantly accusing doctors, family, and society of not having enough understanding for psychiatric patients who were constantly rejected and condemned. She attacked her previous psychiatrists because they were ‘giving her the wrong advice’. She said that her family members should be treated, and not her. She saw herself as a victim, that she was doing everything and understanding everybody, and that nobody was seeing her (Ormay, 2013). She did not expect any help from the group. The attempt by the therapist and the group to confront her with the possibility that she could not blame others for the inconveniences in her life often brought about bursts of anger from the patient. This resulted with her ever stronger conviction that nobody could understand her.

This patient protected herself from marked symbiotic (dependent) needs by excessive use of negative transference. She disturbed the group process on many occasions by monopolizing the group and requiring only confirmation of her behaviour in the group. During a very long period, for about three years, she did not have enough ego strength to endure the anxiety of frustration of symbiotic needs, in that way working against the analytic method. She could not use the group as a good object.

In a group session towards the end of the second year of attending group therapy the patient started talking angrily: ‘My husband should be here, he tells me I am crazy and I should be in the madhouse. He insults me constantly, avoids me, everyone in my house blames me for being ill, and they think it useless for me to come here’.

Group member:

What do you think about it?

Looking at the patient’s type of participation in this group, it might be said that during group therapy the patient was constantly attacking the group, the therapist, or the other people outside of the group. At the beginning of the fourth year of group therapy she started talking about her deep feeling of humiliation when she was separated from her mother during childhood, and when her environment looked for signs of craziness in every detail of her behaviour. The message the group was frequently sending to her was that they were not experiencing her as a person that should be ashamed, and the message helped her to enhance her feelings of self-esteem. In this case the group helped the patient to interrupt the cycle of acting out her anger and to start to talk about it, helping her to use the group as a good object. Two years after the end of group psychotherapy her illness was in remission, and she was very much improved in her social functioning.

Clinical Example 3: Group as an Empathic Mother

This patient was abandoned by her mother when she was one year’s old. Her father found a woman to look after her. According to her memory she was very often left without food and clothes. At the age of five she was sent to her grandmother, and at that time she rarely saw her mother. From time to time, her mother would visit her, bearing presents.

After one year of individual psychotherapy she joined the group. During the individual psychotherapy she developed strong positive symbiotic transference, or idealizing self-object transference. From the very start of the group she expressed only positive symbiotic transference towards the therapist and the group members. She found everybody in the group adorable, especially the therapist. She gave a lot of compliments to members of the group, finding them extremely interesting, nice, etc. The whole group enjoyed these compliments. The group-as-a-whole functioned as ideal self-object. The fantasy was going on: ‘This group is the best in the world, you are nice people, you are special’. She was very happy to come to every session. She spoke of how happy she was because of coming to the group. This need for mutual idealizing mirroring of group members was empathically understood by the therapist, and was not interpreted at the beginning. The group was accepted as a good object. At the beginning she could not stand any criticism of the group or therapist, and she was particularly unhappy when V. remarked that therapy had no value. Later in the group work she was able to work with her symbiotic experience in an analytic way. In the fourth year of group analytic therapy she talked about humiliating feelings in her relationship with her boyfriend: ‘We were walking and I felt hungry. He continued walking and did not offer me lunch. I felt humiliated and started to cry. He asked me what happened, and I was staring at him and said nothing. I felt very humiliated’. She was crying while talking about it.

Group member:

Why didn’t you say that you were hungry?

The therapist interpreted the transference nature of her feelings associated with her experience of a bad symbiotic mother who did not nourish her when she needed—at a time when she was unable to convey her needs into words. Later, she would be able to do this, and express her needs in a way that could be fulfilled. The feelings of hunger were connected with feelings of being humiliated when she was a child who was abandoned, and inadequately nourished with either with food, clothes or emotion. She could accept this interpretation.

The patient used the group as a good object (Ormay, 2013). She obtained a corrective emotional experience. After the therapy was over, two years later, she married and found a job.

Clinical Example 4: Exploring Feelings of a Patient with Psychosis

The patient who developed the capacity to use the group as a good object, during the course of therapy verbalized (during a group session in the fourth year of group therapy) that during the previous week she could hear a child crying inside her. It was as if her mother was inside her, in her body, and it made her feel intense fear. One patient, a group member, asked how she was feeling presently. She said: ‘I feel helpless, as if I want to cry. I try not to cry all the time. When I was little it was horrible, my mother used to beat me for no reason . . . I was not supposed to cry and I had to beg her for forgiveness even though I had not done anything wrong . . .’ Group member:

You said last time that you have a satisfactory love relationship and that you were feeling very good about it.

Patients with schizophrenia have a fear of being overwhelmed by emotions. They believe that their needs will never be met. They believe that their rage can harm the object. They are afraid to be confused with the object. A group can help to establish a better differentiation of self from the object, and in diminishing the confusion between the past and present experiences, as was the case with this patient

Discussion

Group analysts do not see obstacles in treating people that suffer from psychotic disturbances with group analytic technique, modified for application according to the level of regression and anxiety (Urlić, 1999; Chavez, 2009). Nevertheless, not many research results or clinical articles have been published in this field, so far. It is possible that a good selection of patients could increase the application of group analytic psychotherapy in treatment of those suffering from psychosis.

The aim of treating patients with psychosis is to attain remission and recovery, and to prevent new episodes of disturbance. The corrective symbiotic experience is connected with the stabilization of psychological functioning, and a preventative influence regarding the possible relapse of psychosis (Mahler et al. 1975; Corradi, 2004) In this article we are interested in analysing how the group can help to achieve the corrective emotional experience.

Difficulties arise during the symbiotic phase of those suffering from psychosis. It would be expected that during transference elements of the original symbiotic experience may appear, as well as elements of a need to accomplish a good symbiotic experience. This longing for symbiosis in people with difficulty in testing reality may cause psychotic transference, causing frequent hospitalization. Therefore, it is necessary to enable the correction of symbiotic experiences, so as to prevent more serious difficulties in testing reality.

Many patients with poor symbiotic experience will, in relationships with others, try to accomplish the symbiotic experience that they always lacked. Therefore, patients with psychosis project an idealizing aspect of the self-object in the transference, in an attempt to establish a symbiotic relationship (as it was shown in c.e.1). The possibility of using the group as a good symbiotic object is connected with a better outcome for patients treated in group psychotherapy, and an increased capacity to work on an analytical level (as it was shown in c.e. 2, 3 and 4). The functioning of the group as good symbiotic object can be related to the functioning of the group as an envelope, which offers its members a secure and containing place in which they can explore the parts of themselves as yet unexplored (Gimenez, 1996). If building the group as an envelope is absent in groups with a psychotic member, this can result in a difficulty in creating a communication network—which will not lead to experiencing the group as a secure place (Vollin, Gimenez and Bonnet, 2015).

On the other hand, only searching for gratification of symbiosis is connected with frequent psychotic decompensations and the absence of the capacity to work on an analytic level (c.e.1). In order to select patients that might benefit from group analytic psychotherapy we suggest an assessment of the capacity to use the group as a good symbiotic object. During this process it might be helpful to have a tentative period of individual psychotherapy, or several individual sessions.

Individual psychotherapy helps to evaluate the capacity of the patient for analytic psychotherapy (the ego strength and the capacity for ‘as if’ transference, positive transference). If, during the period of short individual psychotherapy, patients experience the therapist as a predominantly good object, this will facilitate the introduction of a patient to a group, and facilitate the processes of experiencing the group as a good object, which is of importance for the process of corrective symbiotic experience (as was experienced in our clinical examples 2, 3 and 4).

From the beginning of group psychotherapy the group is experienced by its members as an extension of the therapist. The therapist is an important nucleus around which the group cohesion develops. Unlike other groups that do not have members with psychosis, here the therapist is more active, and encourages the development of positive transference in which the idealized self objects are projected onto the whole group. This helps to develop a perception of the group as a good motherly object, or a good symbiotic object.

The therapist (in our clinical examples) facilitated processes that caused group cohesion, which helped members of the group to experience the group as a good, motherly object. Group cohesion in a group of people with psychosis represents one of the important therapeutic factors of the group that contributes to the development of experiencing group as a good symbiotic object.

Our experiences from this group are in accordance with Aschbach and Schermer (1987): the group-as-a-whole might represent a good mother image and can provide a sufficiently adequate setting for activation and correction of the disturbed development of object relations, and promotion of emotional growth (Roberts and Pines, 1992).

When the group-as-a-whole functions as a good object, it is possible to internalize a good object, which enables the group to use it for a corrective emotional experience (c.e. 3). Under the protection of the group as a good object it is also possible to view projection of the negative self-objects, to initiate the process of integration (c.e. 2), and to make better differentiation between self and object representation (c.e. 4). This helps to move the group to work on a more analytical level. Patients who succeed in using the group as a good mothering object are less afraid to work on an analytical level; because of this it is possible to talk about emotional traumatic experiences from the past (c.e. 2–4), to relate the situation in the here-and-now with the situation of the than-and-there, and to accept interpretation (c.e. 3). The therapist’s function is to facilitate projection of the idealized self into the group-as-a-whole, because it helps to create the experience of the group as a good object, and fosters internalization of the good symbiotic experience. After experiencing the group as a good symbiotic object, the group process might be fostered at an analytic level, similar to the elaboration of working with patients expressing neurotic psychopathology. Interpretation is of no use without the capacity for ‘as if’ transference, and without the patient’s internalization of the group as a good object. Patients with strong symbiotic needs, who exclusively demand gratification of symbiotic transference, are not candidates for group analytic work (c.e. 1).

Group analytic psychotherapy has an advantage over individual therapy, because it stimulates less regression, enabling the expression of a less intense transference reaction (Slavson, 1950; Horwitz, 1994). According to our experience from this group, it allows better control of developing malignant symbiotic transference, which longs, exclusively, for the gratification of symbiotic needs in transference. The possibility of using the group as a good object is not only the projection of the idealizing object or self in the transference, but it is also the chance for a new experience for corrective internalization. The corrective symbiotic experience represents an important aspect of psychological stability (as shown in our clinical examples), and may be an important factor in recovery from psychosis, or reducing the risk or recurrence.

Besides general guidelines, such as ego strength, level of expression, and phase of disturbance, the capacity to use the group as a good object represents one major criteria, which is the possibility of using the group for corrective emotional experience. The internalization of a good symbiotic experience can enable a better differentiation between the self and object (c.e. 2 and 3). This could enable psychological stability, empowerment of the ego, and an increased capacity for the analytic level of elaboration of psychological contents. We agree with Takahashi and Washington (1991) and Cabeza and Gonzalez de Chavez (2009)—that the insight factor might be particularly helpful in the treatment of stabilized patients with psychosis, and might indicate a favourable prognosis.

In all of our above-mentioned clinical examples, group psychotherapy was useful in maintaining remission whenever patients could use their capacity to accept the group as a good object. A different process was shown in the clinical example when the female patient was incapable of using group as a good symbiotic object for corrective symbiotic experience (c.e. 1). The said patient insisted on continuous gratification of her symbiotic needs, which increased the need for repeated hospital treatment.

Conclusion

Group analytic psychotherapy is useful for patients that are able, without more significant deformation of reality, to use the group as a good symbiotic object for corrective internalization of symbiotic experience in an adequately selected group. It is important that such a group is conducted by a therapist who modifies analytic psychotherapy. This means conducting the group by stimulating the development of positive transference, thus aiming towards a group-as-a-whole, and to experience the group-as-a-whole as a good object. The experiences from this group confirm observations from other authors—that insight oriented analytic group psychotherapy is adequate for people suffering from psychosis.