Individual versus Group Psychotherapy. How to Choose?

Dr Paul Coombe

Abstract

This paper will focus on factors that come to bear on the decision to recommend either analytic group therapy, individual psychoanalytic psychotherapy or psychoanalysis for a patient. I will consider influences of experience, knowledge and theory as well as the influence of bias, prejudice and personal opinion. This is meant to be an introductory exploration at this stage for myself and I am sharing this with the reader. It is the case that there are many ways of approaching an understanding of the individual patient and their suffering.  Similarly, there are multiple ways of helping such patients move from the position of suffering and emotional pain to being able to live a more pleasing, productive and creative life.  The paper includes a consideration of the indications and contraindications for the three types of therapeutic intervention discussed and the importance of assessment.  The concept of a social neurosis and the relationship to individual neurosis will be introduced and discussed. Finally, an exploration of factors in the therapist, the therapy and the patient that determine outcome will be developed.

Introduction

In this paper I want to address the matter of when and how to choose Group or Individual therapy for a presenting patient.  It is important to address these matters carefully and not just because I am a member of either an analytic group therapy Association or an individual psychoanalytical psychotherapy Association as the case may be.  The matter of personal bias or prejudice and the role of personal opinion or personal experience is always important to acknowledge and I hope I can take account of these aspects.  We need to be authentic in acknowledging that personal experience does in fact contribute to our opinions about these matters but we can adjust for, or take account of these influences, at least to some degree.  But to what extent can each of us be aware of and acknowledge this matter of prejudice in the pursuit of objectivity?  I will give you some examples as follows:

A psychoanalyst, for example, may possibly struggle to be aware of the value of exploring an individual’s interpersonal life in a group setting especially if they have not been exposed to such views or ways of working in their professional development.  Early in my career a supervisor of mine, a psychoanalyst at the Royal Children’s Hospital in Melbourne, stated to me that Family Therapy did not work.  On the other hand, I have heard a family therapist, some group therapists and group analysts say something of the same in relation to psychoanalysis or individual psychoanalytic psychotherapy.  Here the comment may be made that an investment in psychoanalysis will draw a patient into an interminable and redundant exploration of the self, sometimes referred to in the most egregious circumstances as “navel-gazing”.  More often, the claim is made not in such an absolute fashion, but with a criticism that shrouds, or casts doubt, on the less favoured approach, whatever it may be.

So, from what experience or on what basis do I present this paper seems a fair question to briefly consider?  I have worked with groups from a psychoanalytical perspective for nearly 40 years here, in hospitals and in London at the Cassel Hospital, and in private practice.  For many years I have conducted analytical groups twice weekly.  Correspondingly, I have worked as a psychoanalytical psychotherapist with individuals in the same way for a similar time.  Similarly, I have participated in both contexts in trainings and as a patient in Melbourne and London.  I have been fortunate to experience deep and prolonged formal psychoanalytic exploration of myself.

It is important to say that there is no single way of working with patients with emotional needs, vulnerabilities or psychopathologies of one sort or another. We cannot properly claim that one type of intervention is clearly of first choice in all circumstances.  Early on I came to understand that the therapist, the nature of the therapy, and the patient, not in any order of importance, all need to be considered in assessing outcome.  What do I mean by this statement?  I will come back to this matter later, but as an introduction I would say that outcome is determined by factors in the patient, for example the nature of their suffering or disturbance.  Then there is the therapist, the nature of their training, personality, early life experience, extent of self-exploration and especially awareness of themselves.  The variations here can determine what success or not a particular therapist will have in their work.  Finally, outcome can be determined by the nature of the therapeutic intervention and its aims.  There are also some therapies that are more suited to certain patients who cannot or choose not to pursue deep self-exploration.  In such cases a more brief and simpler approach may benefit them such as CBT or what we can call supportive psychotherapy.  I think it is also the case that, with work, some patients can by helped to move toward being able to benefit from an exploratory approach, over time.  Another aspect is that an approach that is fundamentally based upon the nature of conscious thought alone can still offer some patients help.  However, if one has become familiar at a deep level with the close relationship between child development, early family relationships and subsequent adjustment to life, then it is possible to understand and help a patient profoundly.  So here I am talking of psychoanalytic forms of interventions.  This can be the case even when a patient suffers from a condition that may be considered to have a substantial inherited or biological contribution.

Put more simply how can one appreciate the value of psychoanalytic experience and understanding deeply if one has neither studied it in detail nor participated in it as a patient or analysand?

I have wanted to begin pursuing this exercise for some years now and this paper and is meant to be an introduction to the question of how to choose either individual or group therapy for a patient.  Another closely related question is what does each mode of therapeutic intervention have to offer over another?

In Australia, in my experience, it is uncommon for someone to present with a request to join an analytic group for treatment in private practice but it does happen. Sometimes a patient may have been prepared by another therapist or mental health professional who may have a particular reason in their mind or be aware of a colleague’s personal training and interest.  It can be more of an opportunity in a public hospital or clinic setting in which case the mental health professionals may have access to groups as they are conducted in-house and may be offered as part of basic training for the professionals.  However, sometimes such groups are very short term, for example, only an option whilst an individual is an inpatient or for a relatively short time in an outpatient setting.  This is, I think, the reality in our current climate in terms of the availability of services although there are occasional exceptions.  It has been this way for many years but was not always the case.

It seems also to be the case that group therapy is relatively unpopular in this country and far and away the most popular mode of psychotherapy is of the individual nature.  In Europe and the United Kingdom group therapy is quite popular and available and most countries including the Eastern Bloc and some Baltic States and beyond, conduct training programmes and some have for at least 25 to 30 years or more.  The Scandinavian countries, for example, can have some hundreds of trainees in any one year.  It is similarly the case for Germany, Spain, Portugal, Italy, Greece, the Czech Republic and, as I said, virtually all European countries.  In the United States group therapy is also popular and the American Group Psychotherapy Association is an important institution.  The AGPA has about 3,000 members and it is multidisciplinary.  The International Association of Group Psychotherapy or IAGP has members from 22 countries and the AAGP has seeded members to it including Sabar Rustomjee who was a Past President of the IAGP.

Indications or Contraindications for Group or Individual analytic therapy

This can be considered as looking at what characteristics in the patient might cause the therapist to consider either group or individual therapy.  I think if a patient presents with any of the usual range of neurotic problems that we are familiar with then a useful group referral can be made.  It may especially be the case that someone who presents with problems that reflect moderate difficulties in their social habitus (Elias, 1987, 2010) they could benefit from group especially if this is their primary complaint.  If there are major social inhibitions or difficulties of a severe phobic nature with a long history then probably individual work is wise at least as a preparation for later group work. Also, patients who present with symptoms that are a source of major shame or are likely to lead to rejection by a group may need careful consideration.

A patient that a colleague, Fran Minson, and I assessed for a group quite some years ago and conducted under the auspices of the VAPP Glen Nevis charitable clinic in Melbourne is relevant.  He had a fetishistic focus on a part of his body in a masturbatory fashion, and we did not take him on in a group.  Here the issue was the possibility of severe shaming that we were concerned about.

It is sometimes said that patients who present with relationship difficulties such as in a marriage or relationship can benefit from a group focus but this is not generally the case in my view.  An important matter is the assessment which can allow examination of the focus of psychopathology.  While there may be pain at the level of the couple, if the individual is the focus or stimulus of maximal pain, then at some point that will need close examination.  The primary indication for a group referral to be made I think is when a patient shows an interest in this direction themselves.  A good test is to present the idea of group to a patient and consider the response: a sort of Rorschach test in a way.  Immediate anxiety at the suggestion is a good indication to avoid this path.  Generally, attempting to persuade or pressure a patient to join a group is not advised.

The author (1995) reported conducting an out-patient co-therapy group with a Cassel Hospital nurse for over 2 years for a group of outpatients in London at the Cassel Hospital.  This group was conducted some 30 years ago and was the subject of a paper published in the Australian and New Zealand Journal of Psychiatry.  These patients were collected for me to form and conduct a group on my arrival there.  It seemed to include those that were deemed not suitable for individual therapy and were at first sight very difficult in the sense of being fixed and maybe least likely to be able to make progress with group therapy or any form of exploratory psychotherapy.  They seemed to not want to be present for much of the time and most seemed to lead isolated and miserable lives.  Throughout their experience with us they often complained about the process and us directly and it was a difficult experience for us both.  But over that time most made significantly positive adjustments in their lives and we came to consider that this was a major achievement and had much to do with our ability to contain and survive the group and their sometimes extreme irritation.  Somewhat surprisingly an expected poor prognosis was confounded.  A major feature was the support of supervision which also helped us as co-therapists survive what was in some ways a significant ordeal and caused frustration and irritation in us and in our co-therapy connectedness.  So sometimes a pleasing and even surprising outcome can be achieved.

Another factor to consider is the level of need or experience of deprivation in a patient.  Some patients by virtue of early life experience seem to need the close attention in an ongoing way of the individual therapist over a very long period.  If we place such a patient in a group they can suffer interminably as a result of insufficient space for their personal needs to be understood and may well give up.

Sometimes patients with a background of struggle within their family of origin for a place can benefit from a group in a particular way.  In such cases the opportunity to re-work such family of origin experiences and find new pathways is gratifying.  In fact, I would go so far as to say that this may well be a most important indication for group treatment and opportunity for greater contentment in life.

Assessment of the Patient

An important factor to be considered in decision making about pursuing a path to either group or individual therapy is the personal history of a patient.  I do think that a detailed developmental history gathered over several sessions with close attention to the factual details of remembered history is vital. However, in addition, aspects of the transference and countertransference as they are experienced in these early assessment sessions, are very helpful.

I can recall a young man who was eager to please with an unremembered early life history, that is, who reported nothing of note, until a traumatic separation of his parents in adolescence.  He subsequently married and the couple had a child but the patient became overtaken by severe and intractable depression which failed to respond to a variety of therapeutic approaches provided by numerous psychiatrists and psychologists.  These included multiple and combined drug regimes such that no further medication could be suggested and it also included a variety of cognitive behavioural approaches offered by numerous psychologists.  He was referred for group therapy by an individual psychotherapist/psychiatrist.  I placed him in a group which he seemed to manage at first, but he soon became almost mute and found any conflict within the group unbearable and left the group following a therapy break after about a year.  This seemed to indicate he struggled with bearing anger toward me and others.   I continued with him in twice weekly individual therapy and he made good but slow progress over some years.  The issue here was his suggestibility or his tendency to agree to suggestions with eagerness, too much so in retrospect.  He was hungry for love and acceptance but had very little in the way of relational skills or the ability to connect to develop these in his personal life.  One positive outcome of the group for him, however, seemed to be his newfound ability to develop friendships and participate in some sort of social life including his work:  he could now function in a social group.  As a result of our ongoing work, I subsequently became aware of his experience as a boy of very little connectedness with either parent, which was not apparent early on.  He seemed to need to be able to become aware of deeply hidden anger at those he came to depend upon and the negative transference was important to uncover in the work together.  The numerous psychologists and psychiatrists and therapeutic interventions he had sought seemed to be to do with his inability to bear anger and hate of the other so he would break off after a relatively short time though initially in our mutual work he was entirely unaware of this anger and hate.

So, a patient might be able to “manage” in a group but it may not be the best path for them especially in terms of a whole life or future.  Again, I think the matter of gaining a detailed history is important especially of early life if that is available.  However, it is not uncommon that a patient will have little to report on presentation in relation to their early life history.  I think that if someone has a background of their mother experiencing post-partum depression or psychosis or a history suggestive of the same then an individual approach may be very important.  As mentioned, a difficulty may be that such information is often not available at presentation.  The alternative is information available in the transference or countertransference.  So, a warning signal may be a patient seeming unable to connect with the therapist and feeling lost or unable to think about the experience of being in the session.  For the therapist it may be that an empathic connection may seem to be impossible to achieve or that one may experience the patient and oneself as on different “wave-lengths”.  Group therapy is not magic and cannot repair deep failures of connectedness or relational absence.

  Related to these matters is something that I have become aware of in the course of my professional life.  If someone presents with material that suggests difficulties in their attachment to their mother of a significant nature, they may well be better off starting in individual therapy.  We do know about the literature from the 1960’s and 1970’s and onwards (Scheidlinger 1974, Schindler 1966), that described how a maternal transference to the group is manifested and can be worked with.  However, I think that there may be insufficient space in a group to properly deal with these matters in a reparatory fashion.  It is not enough to be able to observe and understand such matters and one needs to be able to usefully bring about transformation and that may well take quite some time.  It can be achieved via a group but the opportunity to devote sufficient time and meet the need may not be available.

The Importance of Factors in the Patient, the Therapist and the Therapy: 

I do not think we can properly compare the outcome of a therapeutic experience unless we also consider a range of variables.  How does one properly compare the outcome of say formal psychoanalysis of 4 or 5 times a week on the couch for some years by a highly trained professional with a once weekly group experience of say 2 or 3 years?

In considering the patient one needs to take account of the nature of the patient cohort that is being treated.

It makes a profound difference working with say, a severely borderline personality disordered patient with a lifetime of personal and relational struggle and pain, possibly rooted in infancy, or someone presenting with a severe psychosomatic disorder, compared with someone presenting with a relatively simple and uncomplicated adjustment disorder or a grief reaction, not that these are simple matters to properly attend to!

I would also add that a diagnostic label or categorisation of a patient as say, anxious or depressed or bipolar or borderline and so on, is not sufficient.  Different patients who present with a similar clinical picture or diagnosis can have vastly different personality structures and hence treatment needs.  For example, a patient can present with an eating disorder that has as its basis a neurotic personality structure.  Such a patient may have difficulty in confronting and making their way through to a satisfactory adolescent sexual adjustment by virtue of oedipal difficulties earlier in life and regress to the oral phase, hence the eating disorder.  Such a patient might do well with some relatively superficial approaches.  This is not uncommon.  However, the presentation of an eating disorder can also overlay a more pervasive and serious psychotic adjustment.  This was a part of my experience as a child psychiatrist at the Royal Childrens’ Hospital quite some years ago, working with the Director of the Department of Child and Family Psychiatry, Dr. Winston Rickards (author, 1987).  Such a patient may well die or become chronically ill, and they do, without a deeper intervention.  The same applies to other diagnostic categories such as depression or borderline personality disorder.  This is where younger psychotherapists, psychologists and psychiatrists and others can strike trouble by assuming a diagnosis dictates the therapeutic approach and outcome.

If considering a group a further factor to reflect upon is the nature or character of the group being considered for a patient to join.  All groups are not the same.  A patient may do well in one group by virtue of the particular make-up of the group and how patients fit together including the therapist.  A patient, however, placed in another group may not do so well.  A corollary in the individual sphere is the fact that some therapists do better with some types of patients whether it be a function of personality, gender etc.

Something more can be said when it comes to the modality of treatment or the therapy, whether it be group or individual therapy, and the goals.

I think that there are some achievements that can be had via one modality that are much more difficult to gain via the other.  So, I will repeat what others have said, such as the Mexican psychoanalyst and group analyst, Juan Tubert-Oklander(for example, 2017 and in other publications).  It is much more difficult to access the social or group aspects of a patient’s life via an individual therapy compared with a group therapeutic approach.  Conversely, it is much more difficult to deal with the individual psychopathology, or internal world, of a patient in a group therapeutic context, compared with individual psychotherapy.

It is of note that this aspect has been an ongoing point of discussion for many decades now.  At Northfield in England, during the Second World War, during the Bion, Rickman, Foulkes and Main era, the question was raised in terms of being able to achieve a social readjustment of some sort for soldiers in group treatments, but not necessarily an individual adjustment, that is, working to resolve internal neurotic difficulties.  Bion and Rickman, via the group, were at least initially aiming to bring back emotionally traumatized soldiers to a condition or state of adjustment that, if not able to go back to the battlefield, at least could attain some sort of social and community adjustment (author 2020, 2019).  A question can be put as follows:  To what extent can an individual, with a personal neurosis in the classical sense, attain a social adjustment through individual therapy alone?  Or can a patient with what might be called a social neurosis benefit with individual therapy alone?  I think there are limits in both directions.

I have not been able to find many papers that deal with these issues directly at least in the group literature thus far.  I think the problem is that group therapists tend to submit papers to group journals and that individual therapists tend to submit papers to individually oriented journals each attesting to their own bona fides and worth.  Also, the key journals of repute internationally will not tend to accept for publication papers outside their jurisdiction so to speak.  One exception here is the British Journal of Psychotherapy.  There is not a lot of inter-penetration of ideas.  Each category of psychotherapist tends to preach to their own as though the benefits are a forgone conclusion.  In addition, there are powerful institutional forces that can lead to isolation and rejection of those expressing interest in alternative approaches.

Robi Friedman contributed a paper (2013) that has examined these issues.  He calls on S.H. Foulkes and Y. Agazarian and speaks of “Relation Disorders” that may best be treated in the setting they developed, as is claimed, that is, in a group.  The implication is that one may be entirely missing the point by managing a patient with such a relation disorder via an individual approach and his claim is that the small group or even median group are therapeutic contexts of choice.  So, what are defined as relation disorders?  Friedman defines relation disorders as “multi-personal dysfunctional patterns of emotion and behaviour manifested in group settings”.  Also, they are “co-created inter-personal dysfunctional patterns being the result of the failure of all involved parties”.  These might include matters to do with separation, aggression of one sort or another, rejection experiences and more.

I will now address the impact of factors to do with the therapist as we examine the choice of therapy.

I have already mentioned the importance of training earlier in this paper in the sense that without an appropriate training how can the therapist properly refer, with care and understanding, a patient for a particular therapeutic intervention.  However, on the other hand, Neville Symington, psychoanalyst, has clearly stated that psychoanalytic training itself is not enough and may in fact work against development of the human capacity to connect and heal (1996).  I can recall Bill Blomfield, one of the founding members of the AAGP, a psychoanalyst and group therapist, in a personal supervisory discussion, saying many years ago that training is for monkeys not psychotherapists and so there is a tendency to use the term “candidate” instead of trainee in some circles.  But, of course, the simple substitution of a more neutral term for trainee does not say anything for what experience the subject may have during the training.

The stage of career of the psychotherapist or analyst is important and also their competence which is something we sometimes seem to not want to face.  Experience is important in terms of providing, if we are fortunate, sufficient clinical wisdom.

Now I think that one of the problems in considering these issues is that the individual context, be it individual psychoanalytic psychotherapy or psychoanalysis, is sometimes assumed to be in some ways non-relational.  It might seem strange to some for this to be said but I think it is the view in some quarters, nonetheless.  This may hearken back to the time of Freud and instinct theory and the idea at the time in the early 20th century that psychopathology was individual always.  The fact is that psychoanalysis and psychoanalytic therapy have moved on especially in some circles.  Although, there are some fields of analytic endeavour that can seem stuck in the past or fixated.  Developments occurred with Fairbairn, Klein, Winnicott, Bion and others and seemed to be stimulated by both the first and second world wars and included the evolution of Object Relations Theory.  Further development allowed the relationship between analyst and analysand to be the absolute central matter and in that sense became relational.  By the way I am not talking here about so-called Relational Psychoanalysis, more popular in the U.S., as it is a different matter.  Nor am I speaking of so-called Inter-personal psychotherapy although both of these may be a reaction against an analyst-centric ideology.  It seems to me if one wants to be critical of psychoanalysis one goes back to the early papers and asserts that there is the evidence of a non-relational theory and practice and that Freud and his followers said, in a sense, “it’s all about instincts” [sic].  We do know, however, that the social was rejected by Freud early on and certain other early analysts and we are familiar with the marginalisation of Trigant Burrow in the early years for pursuing a group approach (Pertegato 2013, Author 2014).

These matters can be considered to intersect with our views of our work and a particular chosen context of work: whether it be individual or group.  We all, I could expect, understand that there are forces operating in daily life, society and politics that go beyond an individual orientation.  Does a decision to work with and consider the wider importance of the group, prevent the possibility of also valuing the individual orientation?  And the same question can be asked in relation to a group orientation:  does the pursuit of an individual context for our work prevent the possibility of also valuing a group focus?  Vamik Volkan, an American psychoanalyst, born in 1932, migrating to the US as a young man from Turkish Cyprus, and still working as a psychoanalyst, but in a more limited fashion, comes to mind.  He was a previous Melbourne Freud Conference Lecturer.  He has written extensively of how large group identity determines how an individual experiences or expresses one’s inner self.  He has discussed extensively, and for many years, how such factors determine the inner experience of refugees and immigrants and the development of perennial mourning (Volkan 2017).  Included here is his examination of the phenomenon of transgenerational transmission of trauma from individual to individual but more importantly from one group in history to another down the years.  A key example here is the massive trauma of the holocaust but also the terrible plight of first nations or indigenous peoples.  However, so far as I am aware, he has not and does not claim that large groups can offer what we could call a cure or a therapy.  They can, however, help us understand how the wider context of one’s large group can influence one’s inner experience.

I think there is also something to be said about the matter of access.  I mean how much access does a particular mode of therapy allow us to have to the individual versus their group habitus, as the case may be?  Habitus is a term used by sociologists such as Norbert Elias (2010, 1987).  It refers to how the cultural history and nature of a social group, particularly its customs and ways of living, come to structure the psyche (author 2019), or in other words, sociogenesis determines psychogenesis or individual psychological development.   What I mean here is that psychoanalysis may allow deep access to the underlying strata of individual personality and hence a corresponding deepening of self-understanding and repair.  Indeed, that is its aim.  To a lesser extent individual psychoanalytic psychotherapy can also allow such access but it is more difficult to achieve.  Less frequent individual psychotherapy may not give access or sufficient opportunity to fundamentally bring about substantial repair.  In a similar way group therapy may be limited in what it can offer in the way of fundamental repair.  Nevertheless, a group intervention may offer profound help to individuals and lives can be changed for the better.  Symington (1986) has spoken and written of the importance for persons to have the opportunity to experience a communion with the souls of others, as he puts it, or to experience being part of a community and I think this is possible at a deep level in a group.

Group analysts take their moniker from S. H. Foulkes and have elaborated and reinforced it in the UK and in some parts of Europe and elsewhere but by no means is it accepted as the only theoretical basis for understanding and working with groups worldwide.  I refer here also to the terms analytic group therapy or psychoanalytic group therapy which are more a part of our local and Australian history.  But the AAGP, historically has not insisted that there is one unitary form of offering therapy in the group context.  In some places it is much more contentious and argued for strongly in a partisan sense.  In Australia we have tried to maintain the existence of a broad umbrella or large tent, as Volkan might say, to provide a home for all.  There are ramifications that flow from these matters.  In the group that identifies strongly with the term “Group Analysis” and consider themselves “Group Analysts” they follow particularly, Foulkesian recommendations, and those of the descendants.  A practical consequence is the oft recommended advice that individual sessions concurrent with group sessions is not advised and in some circles is actively discouraged.  However, this has not been, and is not, universal amongst those that prefer that label.  For example, a significant paper by Dorothe Turk (2019), published in the journal Group Analysis, is relevant.  The title of this paper is “Combined and Parallel individual and group therapy-still a red rag?”.  She is qualified as a psychoanalyst and group analyst in Germany.  She makes a strong case for the combined modality for certain cases as do I.  Historically, I believe Robyn Skynner, former London Group Analyst, also practised in this way and there are occasional papers published in the journal Group Analysis over the years that suggest the same.  But I am aware that there is a strong push in some trainings to proselitise the purity of the group context only.  It reminds me of the arguments in the psychoanalytic field and, originally, the “Controversial Discussions” of the 1940’s come to mind, between the Kleinians and the Anna Freudians or what came to be known as the Contemporary Freudians and then also concurrently the Independent group.  But I think there has been an absorption of Bionian and Kleinian views amongst the general psychoanalytical community but splits can be evident from time to time.

Many Australian group therapists historically practised a combined group and individual therapy.  A number of these were psychoanalysts in their training originally, although not all, and clearly valued the exploration of the inner world of the individual.  For myself, I cannot see the point of maintaining work within the group context solely, when from time to time, it is clear certain individuals need and will benefit from an individual attention as well, or even, instead.  My first duty is to serve the needs of the person, come what may, rather than be an adherent to an ideology.

The influence of Bion instructed a school of group therapy at the Tavistock Clinic, latterly represented by Caroline Garland and includes Philip Stokoe, past Freud Conference Lecturer.  This form of group work can be considered as Psychoanalytic Group Therapy.  Garland (2010) edited a book entitled “The Groups Book” which is a comprehensive account of this important approach.

Some Concluding Thoughts

I want to finish with a few words about psychoanalysis that may be of use.  There are many ways to define the aims and means through which psychoanalysis operates and here I only mention what is helpful in considering the nature of this paper. I have found that Neville Symington, psychoanalyst, has offered a very helpful way of understanding what may occur in psychoanalysis.  I say what may occur because, as he so well describes, in his several publications, for example, “The Analytic Experience”, first published in 1986, it may well not occur.  However, this matter is not unique to psychoanalysis in the sense that a mode of therapeutic intervention may not achieve its goal.  We all know this somewhere in our deep selves but can prefer to deny this “truth”  The whole book is a collection of lectures he gave in London, many years ago, under the auspices of the Tavistock Clinic.  The introductory chapters of this book are a wonderful explanation of how analysis is to do with the pursuit of a truth but a truth that can never be arrived at.  Further, that such truth can only ever be approached by the analyst and analysand in a joint experience (1986, p. 18).  In this way he emulates the work of Wilfred Bion and his concept of “O” or the “thing in itself” or perhaps some sort of essence of the person.  Indeed, the Symingtons (1996) made a significant contribution to an understanding of Bion’s oevre describing his “clinical thinking”.   Symington adds to truth, the importance of understanding and insight.  But insight is explained in a very different way to that which most of our profession describe it.  It is not insight that the psychotherapist or analyst sees, that the analysand or patient cannot, and is gifted in a passive way.  Instead, there is the possibility of a mutual creative flourish.  Finally, he emphasises the importance of the development of meaning and that interpretations are to do with finding new meaning through the deep connectedness between the two (or more) persons and the growth of integration of the fundamental fragmented nature of personality.  Again, meaning is not offered to the passive analysand but in successful work may be arrived at through a deeply mutual encounter.  I would add to these that suffering is both a part of the experience if things go well and an accompaniment however paradoxical that may seem.  Further, that suffering is required to thrust a person into this pursuit.  In passing I feel I cannot fail to mention from the group perspective a possible relation to the development of insight at an individual level.  “Outsight” is referred to in the concept of “Mirroring” in groups by Malcolm Pines (1982, and personal communication 1987).  Pines died this year (2020) almost 40 years after his paper on Mirroring was published and this paper is a powerful resource that should be on the reading lists of psychoanalysts, psychotherapists and group therapists because of its power, insight and wisdom. The concept outsight refers to the importance for a person in coming to understand how they perceive and experience others, and how they are perceived and experienced themselves by others, in their social network, or in an analytic group.

So, to what extent are these aspects of a psychoanalytic experience capable of being achieved as part of a small group experience may be a question to consider.  Related to this may be the matter of goals.  The reader may want to consider on the one hand the pursuit of symptom relief, versus on the other hand, a deep seated and thorough-going change in the self, and how this may determine the nature of the recommended therapeutic intervention.

Note:  A version of this paper was read at the Melbourne Conference of the Australian Association of Group Psychotherapists on 20 th November, 2021.

References

Author (1987) “Some Thoughts on the Psychotherapy of the Eating Disorders/ Anorexia Nervosa” Australian Journal of Psychotherapy, 6 (1) 1-13.

Author (1995) “Glimpses of a Cassel Hospital Outpatient Group”, Australian and New Zealand Journal of Psychiatry, 29: 309-315.

Author (2014) “Book Review. From Psychoanalysis to Group Analysis: The Pioneering Work of Trigant Burrow”, Australian Journal of Psychotherapy, 32 (1).

Author (2019) “Civilizing and De-Civilizing Influences: Refugees and the Disincentives Towards Relating Humanely to our Global Relations”, Australasian Journal of Psychotherapy, 37 (1) 32-51.

Author (2019) “The Northfield Experiments 70 Years On” Australasian Journal of Psychotherapy, 37 (2) 8-27.

Author (2020) “The Northfield Experiments-A Reappraisal 70 Years On” Group Analysis, 53 (2) 162-176.

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Pertegato, Edi and Pertegato, Giorgio (Eds) (2013), “From Psychoanalysis to Group Analysis: The Pioneering Work of Trigant Burrow”. London: Karnac.

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Dr Paul Coombe is a psychiatrist and individual and group psychoanalytic psychotherapist in private practice.  He was the Overseas Senior Registrar in Psychotherapy at the Cassel Hospital, London 1990 to 1993.  He is a member of the AAGP (including as a past President) and the VAPP.  He has published in local and international journals including in the areas of family therapy, psychoanalytic aspects of eating disorders, small and large analytic groups, Munchausen’s Syndrome by proxy (also included as a chapter in a book), the works of William Shakespeare, Epistemology and the nature of Truth, and the Northfield Experiments of World War 2.

pdcoombe@bigpond.net.au