The history of group therapy may be best understood as part of a larger intellectual and social development in which interest in human groups has become increasingly prominent. Its harbinger appeared as an adjunct to medical treatment in the New England of William· James, Ralph Waldo Emerson and their contemporaries who were moving rapidly away from the rigidities of Victorian religion, philosophy, ethics and science. This progressive spirit was itself a product of the nineteenth century's long struggle toward social, economic and political democracy.
Democracy in education brought about a very practical need to utilize groups. Social scientists, liberated from nineteenth-century strictures, began investigating groups. Not surprisingly, therefore, people in the field of health began exploring group methods in the early twentieth century. The first to do so was Joseph Hershey Pratt. He inaugurated his "class method" in 1905 at the Massachusetts General Hospital in order to help his tubercular patients adhere more consistently to the rules of diet and hygiene which were so important to recovery. Pratt and his many followers worked with large groups in an inspirational way for the purpose of physical rehabilitation, rather than with small groups for personality reconstruction. However, they discovered that members of peer groups can help one another; that emotional factors play an important role in recovery, and that group processes as described by the sociologists and social psychologists of the day * could be harnessed for therapeutic purposes.
Trigant Burrow, a forerunner of group psychoanalysis,7 sought to study social as well as intrapsychic factors through group treatment. His approach was more research than treatment-oriented, failing to win recognition until decades later. But in the early thirties three innovators - S. R. Slavson23, Paul Schilder22, and Louis Wender28 - quite independently of one another set up analytic models of group therapy which, with variations, formed the mainstream of analytic group psychotherapy.
In the late thirties similar experiments were in process in a number of social agencies and guidance clinics which were hard-pressed to meet their growing caseloads. Prominent among these innovators were social workers and psychologists** who had received psychoanalytic training as members of the orthopsychiatric team, in order to assist the psychiatrists who were in charge of treatment. Most of these pioneers also worked independently of one another and for the most part without knowledge of their immediate predecessors.
S. R. Slavson had the vision to see that group therapy could become a whole new discipline in the mental health field, and he undertook to bring together all those who were interested. With prodigious energy and determination he worked toward forming a professional organization. Its purpose would be to exchange information, to develop a sound theoretical foundation which combined group interaction with analytic techniques, and to set and maintain high standards. His dream came true in 1942 with the setting up of such an organization which was from the beginning interdisciplinary.
Meanwhile John Jacob Moreno,19 a contemporary of Slavson's, who very early in his career had advocated and used group techniques, introduced the unique group methods of psychodrama and sociodrama, basing his work on sociological rather than psychoanalytic principles.
While analytic group therapy flourished in the forties, social and behavioral scientists were developing a whole new body of knowledge concerning the psychology of small groups. They produced voluminous research on the formation of groups, their processes and their development. Since the goals of this new field of group dynamics were academic rather than clinical, there was a minimum of contact among them for over a decade.
By the nineteen-fifties, a small number of group dynamicists, such as H. Thelen26, R. Hill, Dorothy Stock26, M. Harm, and W. Dobbs17 became interested in applying their findings to therapy groups. There was an immediate protest from analytic group therapists, whose spokesmen, S. R. Slavson25, A. Wolf and E. K. Schwartz31, argued that no one should attempt to do group therapy without training in psychopathology and psychological treatment methods. Furthermore they insisted that the group as such cannot be the principal focus, i.e. the "patient."
The latter argument was also leveled at the British group analytic schools whose leaders, W. Bion at Tavistock6 and H. S. Foulkes at Maudsley Hospital 12, were psychoanalysts who combined the gestalt notion of the group as a force field with psychoanalytic techniques.
For a time, the controversy over the relative importance of group versus individual factors in group therapy raged. Saul Scheidlinger21 and Helen Durkin9 were among the few clinicians who expressed the conviction that the two approaches were complementary rather than antagonistic. Gradually the two approaches came closer in practice and the false dichotomy was at least partly transcended so that communication and friendly scientific exchange could take place. Thus, the theoretical base of group therapy was extended.
Also in the fifties a conceptual rift which had been growing within psychoanalysis reached its climax in the group therapy movement. The new conflict, like previous ones, reflected a wider societal struggle between the forces of reason and those of emotion. Just as achievement at the time was at a premium in the educational and economic sphere, so was precision in scientific theory. Psychoanalytic ego psychology reflected this trend. Its recognition that only the ego was subject to therapeutic influence had the effect of shifting therapeutic focus somewhat away from regression, and toward the analysis of the resistance. The change was welcomed by most group therapists because it was congruent with the nature of the new situation in which reality and the functions of the ego could not be minimized. Unfortunately, the already much-criticized tendency to intellectualize increased among those individual and group analysts who were overly intent on perfecting the techniques of defense analysis.
In counteraction to this intellectual emphasis, other voices had begun to clamor for quite different alterations of theory and technique. Prominent among them were Homey, Fromm and Sullivan, who insisted that reality and cultural aspects which influence emotional illness had been too much ignored. Among other criticisms, they felt that injunctions against counter-transference and the protection offered by analytic anonymity prevented the therapist from "being more of a real person with feelings of his own." They encouraged free expression of the therapist's feelings and values. At its extreme this change in procedure constituted a clear-cut break from classical analysis.
The cultural-experiential approach flourished in the congenial atmosphere of group therapy. Most traditional group therapists continued to adhere to the analytic principle of focusing primarily on their patient's emotions while listening with "the third ear." But those whose training had been in the cultural schools and others without much previous psychoanalytic training went much further.
Having observed the highly emotional effects produced by the members' subjective interactions, they decided to engage themselves similarly with the group. Some of them openly expressed their feelings, fantasies and dreams (Mullan, 1955). Departing ever further from traditional group therapy, they tended to reverse the analytic rule and taught, "Respond, don't analyze." The avant garde among them eventually gave up exploring the genetic roots of transference (Mullan, 1955). The more conservative continued to utilize transference interpretations but emphasized the role of "mutuality" between therapist and patients, rather than insight, as a therapeutic technique.
The rift between the experiential and the traditional approaches caused a serious conflict in the American Group Psychotherapy Association. The conservative members fought for the theoretical purity of analytic group therapy. The progressives wanted change. There was a memorable debate in the fifties about the comparative merits of rational and irrational therapy.30 The conflict was only partially resolved by a truce in the A.G.P.A. A whole series of new techniques were invented to enhance the experiential emotional factor in the therapeutic process. They became popular as a non-clinical means of achieving personal growth, relaxation, recreation, and an escape from desperation. This blurring of the distinction between professional and social applications has been confusing to theoreticians and misleading to prospective patients.
The new techniques are often somewhat inaccurately lumped together as "the encounter movement." They have in common a tendency to derogate psychoanalytic techniques and the goal of bringing into awareness profound and often primitive repressed emotions. They include marathons, relying primarily on time to achieve their results; "encounter groups," an extension of experiential therapy emphasizing the value of peer confrontation after the model employed at Phoenix House; "T" and sensitivity groups, stepped-up versions of the conservative models first developed at the National Training Laboratories; and the gestalt techniques consisting of an infinite variety of "games," "exercises" or "laboratory situations" designed to evoke emotion through planned action. In most sessions, any combination of these may be used in accordance with the clinical judgment of the therapist, whose role resembles that of a stage director.
On the whole, these methods have not been adequately conceptualized or put to the rigorous test of scientific validation. They generally embrace a holistic and humanistic philosophy. Emotional experience in the here and now is considered the major agent of change. Insight may follow, but is in itself considered incapable of bringing about change. Resistance is bypassed and transference considered beside the point.
Encounter techniques do release strong feelings much more rapidly than does the analysis of transference and resistance. The question remains whether the resulting behavior changes can be maintained on a permanent or structural basis when the unconscious infantile conflicts and fantasies have not been identified, worked through and resolved. Another moot question is whether or not these techniques may be integrated into the theoretical framework of group psychoanalysis. Dr. Elizabeth Mintz, who has made a special study of the subject, feels that they can and in fact must be so integrated if effective results are to be expected.
Family therapy, another new treatment modality which also became popular in the sixties, is of a different order. There are almost as many variations of the method as there are family therapists, but most of them fall into one of two categories. The first, developed by Dr. Nathan Ackerman, is based on an extension of cultural psychoanalysis adapted to treat the family as a unit. A quite different model which brings still another conceptual challenge to analytic group therapy is also gaining wide acceptance. It is a systems model derived from cybernetics or communication theory, which grew out of the Bateson and Ruesch studies on therapeutic communication3 and schizophrenia.2 They led to the conclusion that it is the family system rather than the designated patient which needs to be changed. On the basis of these assumptions, they and their colleagues at Palo Alto, California including J. Haley2,13, P. Weakland 2,27, D. Jackson2,16 and many others continued research in therapeutic communication and developed their own model of family therapy.
Like other contemporary innovations, the new family therapy constitutes a holistic approach and denies the therapeutic value of transference interpretation. Unlike them, the method is well conceptualized, but its techniques have not yet been fully developed. In general, the therapist calls attention to fixed counter-productive communication patterns among the members and guides the input and processing of new information in the here and now, so that the members may become more spontaneous and realistic.
Although the clinical aspects of family therapy have been widely adopted, especially among those who are attempting to meet the needs of the community at large, the new theoretical framework has not been fully grasped by the average analytic group therapist for whom it must ultimately pose still another conceptual challenge. Mastery of the technique will take further study.
While the new group techniques proliferated and internal conceptual conflicts raged, opportunities for the expansion of group therapy multiplied. The Federal Law of 1963, extending mental health services to the entire population with the establishment of nationwide community mental health centers, was momentous. Because of the shortage of time and trained personnel, group therapy was destined to play a crucial role provided it could make the major theoretical and technical adjustments necessary to meet the wide variety of needs in the new populations it would serve.21 Many prospective "clients" simply did not know what kind of help was available, but many more were not prepared to accept such help, either because of their socioeconomic needs or because of the nature of their problems. For example, neither hospitalized psychotics nor delinquent youth are really accessible to analytic group psychotherapy. Of necessity, practical experimentation preceded conceptualization in making the necessary adjustments. A good start has been made, especially in certain advanced progressive hospitals, like Einstein in New York City,20 but many problems have arisen and many communities have as yet been scarcely touched.
Besides the problem of client accessibility, there is the problem of training, especially that of the paraprofessionals and lay personnel who have to be drafted to carry out the extended programs. And although the multiplicity of methods is potentially useful, the consequent lack of conceptual unification undermines the effectiveness of broad group programs. In any one hospital or community center, for example, each individual group therapist is likely to proceed according to his own, often inadequately thought-out hypotheses, to the confusion of both administrators and patients who might be caught in the crossfire of actually contradictory goals. Lack of communication among group therapists is compounded by lack of communication among the helping disciplines, between professional and other hospital staff, between administration and staff, and between hospital and community.
Today, the field of group psychotherapy is in ferment. While the prospects for growth are greater than ever, theoretical fragmentation and conceptual conflict are producing much anxiety and defensive argument among clinicians. We are faced with the paradox that while the individual clinician is most effective when he works with a high degree of conviction about his theoretical approach, scientific progress depends on his ability to take a broader and more objective outlook. For those trying to meet both goals, Cassirer's dictum is useful. Theory does not constitute knowledge; it represents a gap in knowledge. Moreover, the history of science proves that conflict, however alarming, is essential to progress. In the long run, while any particular theory may be superseded, its relevant truths will be encompassed in the ultimate outcome and its false assumptions will drop out as they are replaced by new information.
Our greatest immediate problem is to bring some conceptual clarity and order into an almost chaotically splintered field (Scheidlinger, 1969). It is time to reassess our theoretical approaches and search for some unifying trends among them if we are effectively to serve our patients. Since systems theory has provided bridges between the physical and the social and behavioral scienees, possibly a searching investigation of its principles may reveal new ways of resolving the problems of group psychotherapy.
HELEN E. DURKIN, Ph.D.
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