One group analysis and many. Response to Farhad Dalal’s ‘One group analysis or many?’

Introduction

It is an honour and a great pleasure to respond to Dalal’s presentation. There is a pleasure in being ‘responsive’: in recognizing familiar thoughts, concepts and ideas; in listening to quotations and meeting favourite authors—Freud, Foulkes, Winnicott and Buber; and in thinking about the lessons from the Neem Tree. There is a breadth of reading leading to convincing thoughts. It is a great pleasure to respond to someone with experiences and ideals that I share or can share.

And there is an additional pleasure: the stimulation of one’s own thoughts in listening to or reading your presentation. ‘Dreaming’ the yes and the ‘nos’. Knowing that yes and no are often deeply connected with each other. And that it is a challenge and a pleasure to find something ‘in-between’, a synthesis. Usually we need other people to find out, what it is, that runs contrary to our beliefs. They help to reflect and to sharpen one’s thoughts. Often this is what happens in groups. ‘In-between’, perhaps, something new develops.

The title of this response, One group analysis and many, derives from both pleasures. Dalal writes: ‘The real answer to the question “one group analysis or many?” is that there are as many different kinds of group analyses as there are group analysts’ (Dalal, 2018: 331). This is a statement encouraging professional individuality of group analysts and stressing the complexity of group analysis. You could take this argument somewhat further—maybe, things are even more complex: I am not the same with different groups. I feel and act differently in different groups and use different experiences and concepts according to the groups I work with. So, if we are different in different contexts, there may be even more group analyses than there are group analysts. Or, from another perspective, there may be less: there may be more similarities between some of my colleagues and myself in working with some special groups (short term inpatient groups with patients with severe personality disorders for example) as compared to just me working with such a group and working with a kindergarten group or with a long-term outpatient group.

This point can be made in a somewhat different, more abstract way: There is something, most of us do share—knowledge, theories, experiences with and within groups. One could argue here—and I will, later on—that there also is ‘one’ group analysis; there is a common ground, which we can see, at least from some perspectives and some distance.

There usually are similarities and differences in what we look at. Among other influences it is a matter of knowledge, what we see—do we see just wine, or do we recognize a Bordeaux, still a bit too young to gain its full flavor? Often, in and between groups, we tend to avoid uncertainty, we do not ‘watch, wait and wonder’ and only see what we already know.

This is not just a matter of knowledge—it is also a matter of personality. There are ‘lumpers’ and ‘splitters’ in science and in life—people who love to find similarities (‘lumpers’) and those keen on finding and examining differences. Both perspectives are necessary. Discerning differences leads to progress in differentiation and knowledge; finding similarities leads to progress in insight. Both perspectives are necessary in groups: to differentiate and to experience belonging and cohesion.

Whether you lump and what you split is dependent upon your knowledge and personality—but not only on that. It also depends on your situation: if you work in a somatic hospital as a psychoanalyst, any staff member believing in something like a ‘psyche’ is a natural ally; if you work in a group analytic society, this is not sufficient. If others have thoughts about some aspects of theory, which you do not share, you may start wondering, whether they are people you can really count on. As group analysts or psychoanalysts we construct ingroups and outgroups—see Dalal’s article on Prejudice as Ideology (2015) and discussions on groups and power in Dalal (2002) and Blackwell (2003). Borders may be open or may be closed.

Sometimes I experience this myself: I am a ‘classical’ psychoanalyst, a ‘Sigmund-Freud Professor for psychoanalytically oriented developmental psychology’; and I am head of the ‘Working Party for Group Psychotherapy and Group Analysis’, a working party founded within a university context with a ‘scientific’ approach to groups. And while I do not like the ‘industrialized research protocols’ Dalal describes, I still want to be able to play according to the rules of the game—even if it is rugby and even if there are fouls. I want to find out more about, what is happening in groups and what works well for whom and under what circumstances. Empirical research with groups is demanding. The difficulties, however, are no reason to become complacent. If we cope with these difficulties, there is much value in doing so.

Variability within one concept

‘One group analysis and many’ is a cornerstone of what we teach in our working group—we call it ‘variability within one concept’. And it may be necessary to describe the development of the AGG, our ‘working party for group psychotherapy and group analysis’—which is a bit different from other institutes of Group Analysis in Germany. The AGG is a rather informal working group—originating in Goettingen within the context of a university department on group psychotherapy and a teaching hospital with a strong psychoanalytic orientation.

Quite a few of the patients in this hospital did not benefit from a psychoanalytic approach and not from a group analytic approach. Some got worse. Franz Heigl and Anneliese Heigl Evers—with many others—tried to find out which patients profit from a so called ‘classical’ psychoanalytic approach, as Dalal described it for Britain—and who needed something else. Research started around 1970 and mainly focused on inpatient psychotherapy and groups—a large part of the health care system in Germany (e.g. Heigl-Evers, 1971).

In-patient psychotherapy is psychotherapy within a group. So my predecessors looked at concepts of group psychotherapy and invited the exponents of different schools of thoughts: the psychoanalytic ones, the group analytic ones, the humanistic ones. They experimented with CBT approaches, with Ruth Cohn’s Living Learning, with psychodrama and the concepts of Foulkes, Bion, Ezriel, Argelander, Stock-Whitacker, Lieberman, Slavson and Schindler (Heigl-Evers, 1978).

Dalal described that a CBT trainee was chastised by his supervisor for being ‘too psychoanalytic’. I would like to report a detail from the Munich study on Chronic Depression (Huber et al., 2012, 2013; Zimmermann et al., 2015), a RCT (the ‘gold standard’ of psychotherapy research) with psychoanalysis proper, CBT and psychodynamic psychotherapy—no group analysis, unfortunately. CBT therapists were especially successful with this difficult group of patients, when they had many ‘psychoanalytic’ interventions in their therapies. We only can get to know this, if we try and look carefully—if we devise a randomized controlled trial that shows, what works well for whom.

Integrating these group approaches and looking at neighbouring sciences, the ‘Goettingen Model of Group Psychotherapy’ was developed. It became influential in Germany. Many hospitals adopted it—many psychotherapists used it after their training (Heigl-Evers and Heigl, 1973; Staats et al., 2014).

This is not an occasion to go into a description of this model. Just as a response to Dalal’s description: There seems to be an indication for the more classical psychoanalytic work in groups, the concepts of Bion, for example; there also is an indication for classical group analysis following the early conceptualizations of Foulkes (1964); and there is an indication for a concept, which we call psychoanalytic interactional psychotherapy—a concept, where the group leader tries to avoid interpretations and, instead, to establish a space ‘in-between’, using an ‘antwortenden Modus’, a ‘responding’ or ‘responsive mode’. Here, similar to models in post-Foulkesian theory (Dalal, 1998), the social has clear priority and is seen as determining the intrapsychic.

Intersubjectivity is marked and addressed as the mainstay of this approach. Dalal described his stance as ‘measured transparency’. What we call ‘selective authenticity’ of the therapist seems similar—compare the concepts of Ruth Cohn (1975, 2009). The Goettingen Group Model has been influential mainly in Germany. However, some of the work from our group is translated into English, a few studies have recently been published in English (Leichsenring et al., 2010; Salzer et al., 2014). And a former head of our group, Karl König, was the first German to have the honour to hold a Foulkes lecture—in 1987 (König, 1987). Therapists working with these different techniques and positions learn a framework for understanding groups (‘one group analysis’) that has place for different ways of conducting groups and for individual adaptions and styles (Foulkesian and Post-Foulkesian Group Analysis and the Goettingen Model, see König (2008)).

The down to earth, scientific approach to group psychotherapy (within our working party and in other groups, in Germany especially by Bernhard Strauss (e.g. 2007) has led to a special situation for group psychotherapists in Germany. Group therapy is strongly promoted within the health-care system: For analytic groups, the health insurance system reimburses 150 double sessions of group therapy at a fair price. Helpful and differentiated treatments can be offered to many people.

Learning to change perspectives: Learning group analysis

There is a point I see somewhat differently from Dalal. He writes:

Each training insists that their trainees should interact in these ways, and only these ways. To deviate is to do wrong. In effect, trainings and institutes create faiths with disciples. The classical psychoanalyst must only interpret . . . what has happened is that method has been generalized into a totalized methodology. (Dalal, 2018: 318 )

This is something I did experience, too. But it is only part of my experience. I learned from different supervisors and group leaders. There were no final examinations. Thinking and questioning often was welcome. There was playfulness in supervision and in experiencing the group method, you wanted to learn.

Dalal posed three questions:

I want to address them briefly. As a psychoanalyst I am not happy with the way in which Dalal describes the relationship between group analysis and psychoanalysis (e.g. 1998). Again I think: context matters.

Did Freud really put humans back onto the side of things, as Dalal writes? Certainly this was not the case in his treatments—highly relational and (inter-) subjective as we know. There was little ‘analytic reserve’ as compared to today. Concepts are used within a given context: What is needed at a time and what can be taken for granted? Therapies in Freud’s time often were very personal. It was important here to stress a ‘detached’ position. Today, in times of the ‘ego’ and marked individuality, theory stresses the therapeutic relationship and attachment theory—other aspects of life seem less endangered and thus less important. Context also matters with the famous quote of ‘Anatomy is destiny’. If we read on, we can see that Freud uses this as a quote from Napoleon. His view is more varied as it may seem stating later on: ‘ . . . you are bound to have doubts . . . . and must conclude that what constitutes masculinity or femininity is an unknown characteristic which anatomy cannot lay hold of (Freud, 1933)’.

Not so many clear cut boundaries again, when context is taken into account, when we want to understand others and put ourselves ‘in their shoes’— a very descriptive phrase; when we want to discuss in and with groups, argue dialectically and aim at some form of synthesis. There rarely is but one reason or method. There are ‘many reasons why’ . . . and it may be good to resist the temptation to explain the world from one point of view and think in single causes or methods—’beware of a man with a method’ (Horst Kächele, 2002, personal communication).

Is the practice of group analysis a scientific activity? No, it is not in the strict sense of the word. But group analysis can be used as a profession—and as a profession it has the obligation to care for patients, to try to improve and to think and argue scientifically.

To this end, we do have some good observations, decent studies and rich experimentation. Much of this good, I think, we owe to the ‘Medical Model’. Dalal writes: ‘Having no manual, having no bearings, I trust to my intuitions’ (Dalal, 2018: 328).

I often discuss this question with students: What is intuition? Experience without theory, even just your own implicit theories, is of little use—you cannot generalize to new situations. And theories without experience are of little use, too. Intuition arises from reflecting one’s practice—caring what are the results, inquiring what is happening after treatments end. Sometimes this is a sobering experience. And—so much for the medical model—often intuition leads astray. The history of medicine is a history of procedures performed that seemed sensible—but were not. Often it was careful studies, sometimes RCTs and EBM that showed that what seemed so clearly helpful and right was not helpful but harmful. Or, maybe, it worked—but only in some circumstances. Again: context matters.

Dalal writes: ‘the responsivity of the therapist is necessary and critical . . . as it is the means by which the responsivity of the ones-who-come-for-help is brought alive. I have suggested that the essence of our work is mystery . . .’ (Dalal, 2018: 330).

It is good to hear this personal account, a bit of ‘the flavours of the old wines that have collected in my bottle’. Usually we develop differently according to where we come from and what we experience. Often this is happening by chance. I am a psychoanalyst and a group analyst and a scientist and a medical doctor. I very much appreciate the pointing out of responsivity—there is much similarity to the developmental concepts of a ‘responsive mode’. I can also appreciate the idea of mystery—but I like to add the striving for reason and the sober handling of uncertainties—of not knowing. This seems to be the ‘rough ground’ to me—living with uncertainty but keeping on trying to find out and to stay curious.

Maybe—it is mystery and reason, relationship and reflection, compassion and detachment that constitutes a mother or a father child interaction, which is good enough—and, I want to add this, even if it may sound strange, not too good—to foster development. And while art may remain in part a mystery, good craftsmanship is not mysterious.

Belonging to a group and also to many other groups—being with someone and being on one’s own and with other people—opens up mentalizing your belonging to your group of belonging. If this is what happens, working with groups may be both: One group analysis and many.