The Use of the Large Group in a University Context

Introduction

I will share the experience of using the large group as a working format in a university context. It was born from my experiences in this field that began in the early 80s, when in Bilbao (Spain) the training courses in group psychotherapy supervised by representatives of the London IGA began to be organized.

The training in group analysis in Spain began to materialize as a result of the collaboration between the OMIE Foundation and the IGA London, resulting in supervisory visits that were organized from 1982 onwards, as well as the work carried out by Fernando Arroyabe with whom I collaborated closely during those years (Guimón, J. 2010). Since then, the Foundation, following the guidelines of EGATIN, has organized the training with the name “Group-Analytic Psychotherapy” and with the academic recognition of the University of Deusto. (Sunyer, J.M., 2015)

The training has varied, at least in terms of my part (Sunyer, 2018), from more orthodox to more radical positions (Dalal, 2020), which is evident in each of the venues in which it is taught: Bilbao, Barcelona and Madrid.

In this paper, I will explain how I made use of the large and small group in a university setting.

The context

Shortly after arriving in Barcelona in 1992, I joined the Faculty of Psychology of Ramón Llull University to take charge of their Counselling Psychology course (Ivey, AE; Bradford, M.; Simek. Morgan, L. (1980); Tudor, K. 1999; Corey, G. (2000); Corey, G. 2000; Scott, MJ; Stradling, SG (1998).There, I developed a modality of group work that was outlined over time (Sunyer, JM, 2005, 2008) .The context was that of a relatively young, private university, ideologically open to psychodynamic approaches. The very young students were more used to a school model than to the university itself. This came from the greater control and relationship that the teachers offered over the students, and the existence of spaces called “seminars” in which groups of about 12 students maintain a close relationship with the tutor.

My students were in their fourth and final year of study, and the subject was offered as optional among those given in the first semester, from September to January. Not being compulsory and the experience derived from the way of working made it especially attractive.

The group of between 120 and 140 students met twice a week for 90 minutes. This meant that in each course the students participated in about thirty sessions in small and large group formats. My objective was to create a space for learning and reflection on what a psychological intervention is, thinking of the participants not so much as students but as professionals. This way of working lasted until 2016 when I retired.

The language

Possibly the most difficult issue was the articulation of two almost antagonistic languages: clinical and psychotherapeutic with the university one; mine and yours. The first, beyond the use (and abuse) of diagnostic classifications, emphasizes the understanding of what happens to the patient and the development of psychotherapeutic processes that avoid a progressive marginalization of family, social and work environments of the patients. It is the one that takes place in acute care rooms, medium or long stay, in hospitals and day centres, in outpatient clinics and drug addiction centres, etc. My own clinical experience came from having worked in an Day Hospital that was part of the Psychiatry Service of the Hospital of Bilbao (with a basically psychoanalytic environment, with the group approach being common throughout its structure).

The second language abounds in general aspects, proposing a domain of diagnostic classification – not an understanding of psychopathology and much less in psychiatric phenomenology (Jaspers, K, 1966) – in describing and supplying a range of therapeutic resources, knowing some of the outstanding currents of psychological thought and, even, the promotion of research work. This language places more emphasis on academic training and the benefits of professional development.

In addition, being an academic centre involves exams and the preparation of work involved in the evaluation of students. I did not have, and I believe it continues like this, any formal contact with a psychiatric clinic in which anyone who wants to be included in the healthcare network can carry out practices supervised by a clinician and have them subsequently discussed by an academic. In any case, the training periods that were carried out are (or were) very limited.

There I perceived a significant dissociation between what is the care, understanding and support of human suffering, and what it means to complete a divergent academic journey within healthcare practice. The language itself and the teachers’ debates put more emphasis on organizational aspects than on the personal processes carried out by the students. And all this, underlining the symptomatology not as an expression of suffering but as a series of individual characteristics classifiable according to international criteria (DSM-V); that is, more homo clausus (Elias, 2010).

The proposal

The number of students who attended the groups ranged from 110 to 145 – 93% belonged to the clinical speciality. Each year, it welcomed students in a large group format. There the work plan was explained: we had to organize ourselves in stable groups of between 8 and 10 students. In group, and for 25 minutes, we would discuss some texts that would correspond to the topic of the day. Subsequently, we would form a large group with all of them. There, the objective was to share what was worked-on in small groups and open the discussion to other topics. In this discussion, clinical and social issues appeared that were linked with aspects of the here and now of the sessions within the academic context.

In addition to the articles and other reading texts, stagings of all kinds were made in which clinical interviews, complex situations or feared scenes in a healthcare situation were simulated. On some occasions, actors were invited, or it was the teacher himself who represented a clinical case to be elaborated and worked-on by the students. Psychodramatic techniques were introduced to facilitate the understanding of conceptual aspects or clinical cases. Artistic activities and any other technique that served to introduce students to real situations and allow them to think and reflect on them were also encouraged.

Convinced as I am that all learning must go through written elaboration, we all had to develop our own “logbook”. The teacher wrote 2000-words daily that he sent to the students, a few hours after the class. They had to write a series of comments (around 1000 words) that they delivered to the teacher and were part of the evaluation of the subject. The evaluation criteria of the experience were shared and discussed with the students, contributing to 30% of their grade, reserving 70% for the teacher.

Assessment of experience

 Why did it go well?

1. The students had the opportunity to discuss for the first time among themselves and with the teacher what the compulsory reading of a series of texts related to counselling was suggested to them. This occurred in two formats, the small group and the large group. In the first, the discussions were limited to the texts that had been previously read to the class. In the second, it started from some of the topics debated in the child and expanded to experiences and situations that occurred in the subject or in other university spaces. In order to maintain a minimum level of work, the teacher visited each group to resolve conceptual doubts or other questions raised by the students.
2. Many of the debates were also transferred to other subjects and in a certain way involved their teachers. This confronted them with very different visions and realities: those discussed in the large group and those that came from the experiences of other teachers in the context of their subjects. What generated tensions or disparities in criteria between what happened and was discussed in the classroom, and what happened in other spaces with other colleagues. These differences delimited very well those coming from teachers with or without clinical experience. And in a way it enlarged the gap between my work proposals and theirs.
3. The transition from theory to practice was another of the relevant aspects. It is not usually the same what appears in some texts conceived by professionals of the psychological orientation to what emerges from the discussions between students as a result of experiences somewhat closer to their own life and that emerged in the large group. For example, the interpretation of the genogram of an anonymous patient described by an author is not the same as the interpretation of that of a classmate. The difficulties to do it, the fears and fears that are activated by an apparently simple exercise is a learning experience for anyone who is going to dedicate himself to working with more or less serious patients in a few months. That simple exercise confronted them with what someone may feel when the professional asks them for certain things, such as the description of their family pedigree.
4. The difficulties of approaching the intimate and personal. It was one of his great discoveries. Understanding what activates anyone when asked about personal and intimate aspects was quite an experience. Because they themselves, when questioned very slightly by their personal aspects, confirmed the effort that a patient must make when these and many other intimate questions are asked. I remember that after reading a story by the Grimm Brothers, they were asked to draw something. Some groups panicked as they tried to draw something in which nothing interpretable appeared. I think this helped to be aware of what it takes to enter a patient’s personal and intimate space and learn to respect them.
5. The understanding of what it is to theorize something. When diverse theories offered by more or less relevant or significant authors are studied or debated, there is a process of idealization of both the author and his conceptual proposal. When students are asked to develop their own theory about what is happening to them, what is achieved is that their abilities to think from their own experience are activated. That was important to them, accustomed as they were to assuming the truths of others without the slightest criticism. For example, discussing in the large group the information that came from a patient’s non-verbal language, or their delay to the appointment, involved comparing what is valued and what is not, and why.
6. When students have to make an effort to represent a certain situation, a self-unfolding process is activated, which breaks inhibitions and blockages. Helping them to play in the various situations that were created meant introducing a space of creativity about the academic experience itself, which, in many cases, is inhibited. This learning from the dynamics itself also helps to demystify the professional-patient relationship, being able to see it as a dance of intentions, desires, fears and inhibitions. It was very significant to see the relationship with the patient as the source from which to learn and not from which to pontificate.
7. I have always considered it very important to introduce creativity in clinical situations. Not so much that of the patient as that of the professional. By doing so, we open up the possibility that you will find alternative ways of approaching and understanding clinical cases, or situations that occur in the care relationship. Thinking about the dreaded scenes we all have in a clinical situation helps to review some of our ghosts, and see us as humans versus humans. Inhabited as we are by persecutory images of all kinds, playing with them -using dolls, Lego pieces, or ropes and wool- we were able to visualize many of the plots that paralyse our creativity.
8. Along with creativity, we must also recover the destructive elements so present in daily clinical practice. Many times it does not refer to the destructiveness of the patient himself but to that of the professional or that of the healthcare system. It seems relevant to me to introduce these elements into the academic discourse that tends towards asepsis, distancing it from daily clinical practice. For example, considering which destructive elements are activated as a countertransference response, is to introduce the ability to reflect on what certain clinical situations generate for us or what we can generate in them. Being able to understand ourselves -and accept ourselves- involves an increase in the maturity of some students in the face of a situation in which they will see each other in a relatively short time.
9. The analysis of healthcare and healthcare system. It was important to review the health structure of our region. Understand the various devices, what is intended in them and what is not. Also understand the internal structure of a service and grasp how the responsibilities of each professional are outlined in the workplace. It was important to know of the existence of different languages ​​that go beyond the professional orientation of each one and are related to the professional categories and the different classes. In this area, given that sometimes one of the students was a professional in a centre, it provided them with a more equal understanding that could come from the teacher.
10. It was also significant to be able to establish a view of the academic system itself. As important to see how each teacher defended her particular area of influence, how each orientation struggled to stand out above the others. And how this was reflected in the dynamics that occurred in the large group based on the affiliations and phobias that were established regarding some conceptual position.

Conducting the group

Although what I learned at the time (following the model proposed in my training) brought about movement towards very Bionian positions (Bion, 1976) and that we could classify as a psychoanalytic or “orthodox Foulkes” orthodoxy, experience indicated to me that I had to change this approach. Since the conductor is part of the group, he should show himself not as a “fly on the wall” but as “the one that flies around the room”. This means having an attitude that allows students to get out of passivity and enter into dialogue with others.

But arriving at this port meant a radical change in my style after the reflections that gave rise to my work in 1996 and 1998. Indeed, relative passivity fosters regressive situations that do not benefit young students of a psychology faculty at all. The reason why I assumed a role closer to the conductor who sets the rhythm, gives entrance to the instruments, modulates their intensity, marks the silences… so that the generated music offers coherence and proximity to its performers.

This change led to debates that allowed them to think about their own university experience, their proximity to the end of the academic period and their fears about the professional world. In general, they were moving towards what their profession was going to be in a few months, drawing parallels between what was happening in the classroom, what happened to the patients they had interviewed and what was happening in the social and political environment in which we were immersed.

However, the academic structure itself, as well as the objectives of these types of institutions, does not make it easier for students, the majority of whom are young, to feel comfortably in doubt, exploring alternatives in the interpretation of data, and less with movements that lead to personal reflection and insight. The mechanisms of intellectualization, rationalization, and denial prevail, which are activated very easily in situations in which projective identification and projection were evident (not to mention projective identification and introjection), dissociation and splitting.

Before these reactions, the conductor must be present. He is forced, to take care of the psychic balance of the students – at least some of them – to enhance those aspects that facilitate an identification with him that ensures the stability of the group and that the phenomena of splitting and dissociation are not significant. The use of psychodramatic resources, the stagings, the representations of clinical vignettes, the use of creative material, etc., is a guarantee of the maintenance of balance in the students.

Transferences and countertransferences

The characteristics of the environment in which we worked meant that any comment that moved through a somewhat more transferential area was easily denied and led to intellectualization – typical of the university world -. And even, in those circumstances in which the  elements projected on the group or the topic of conversation were very evident, any movement that approached the emotional tended to be rejected or derived towards rational thought.

The “authority figure” that the teacher represented clashed with the authority they had to question or deny. My personal, close style also generated confusion in that what was expected (distance) was what they were used to: they found it difficult to match proximity with the authority of experience. This generated affiliations and phobias among them, which translated into their attitude towards debates, work and participation in small or large groups.

Internally, I felt a great contradiction: on the one hand, I understood their fears and contrary reactions to accepting my contributions; on the other, I wanted to convey something that came from my clinical and group experience and, at the same time, allow criticism, doubt, chaos. The only way to avoid that internal tension was to stick to what they could figure out for themselves. This meant that the figure of transference that easily develops in clinical contexts and to which they were accustomed, was modified by academic reality. Accustomed to the teacher maintaining a somewhat distant position from the student and not accepting questions not so much about what he says but about what happens in classroom relationships, that other image distorted expectations. You could talk, debate, contradict, and not only with the authority figure but with colleagues. And with the peace of mind that everything that was said or expressed did not intervene in the assessment of the subject.

When students could not or could not find a way to express themselves to their classmates, they found in the logbooks another way to express, and now more clearly, their emotions. Indeed, most of the days more than one made personal contributions related to their personal or family life. This pushed me to respond to them so that, without leaving the role of teacher, they could capture the part of psychotherapist that lived in me. On some occasion this led to seeking some extra time to reassure, advise or redirect a student who was going through a complex family or personal situation

Parallel to this transference situation, they were in a duality, in what we could call a clash of loyalties (Boszormenyi-Nagy, I; Spark, G.M. 1983) that was related to the teaching structure.

Organizational dissociation

In effect, the emotional ties, the identifications and projections that each student, or groups of students, develop with other teachers introduces a complex matrix in which coherence between what happens in the classroom and outside it does not always prevail. That reality activates something of what I already pointed out in 1997, or of what Nitsun calls the organizational mirror (1998a, b). The warp of relationships contained a more intimate or close part that developed in the classroom. It was born from the links between all of us around a group experience seasoned by contributions from the clinic. But such a communication network was inevitably expanded by being in contact with other members of the faculty, in their classes and seminars, and who introduced into the plot aspects not always consistent with what had been worked on in the groups.

In this expanded matrix, other types of power dynamics were cooked that were associated with the credibility that each teacher generated, with the distorting elements of the relationship stemming from rivalries, and with the relative position of each member of the faculty with respect to their peers. And if the first was related to the tension between clinicians and theorists, the other two were related to the affiliations or phobias that they generate in students. In reality it was adjusted to the projections and identifications that the students deposit; but at the same time, the reciprocal occurred while the members of the university structure deposited, projection and mediating identification, their own expectations and desires.

Invisible loyalty games were very evident in some cases. The sympathy that a companion could feel for me was evident in that “her followers” also felt it. And similar in other feelings. The logical rivalries between the teachers were also evident in the large group; and also the envy that I involuntarily generated in them. On more than one occasion I was warned by a classmate about the noise that was generated in the classroom when changing from small to large group, but also some situations generated by the debates of that group, or the protests about not finding the chairs properly when another teacher was entering, etc.

I accept that I have never pretended to have a “university career” in the sense of choosing to position myself in a place of power with respect to my fellow professors. My only concern was to pass on my clinical knowledge to students. I reported annually to the Dean on the progress and progress of my students (Sunyer, 2020), and the results of the classroom atmosphere measured through the Moos questionnaire. I never got an answer. This accounts for the recognition that my efforts had within the University. Nor did my classmates make any comments, being interested in the experience, even though the students themselves transferred what was happening in the classroom. That split, to which I surely contributed even passively, made classroom work more complex. It was evident through the split between supporters and critics of the way of working; dynamic phenomenon that tried to counteract through the clinical activities that were dramatized in the classroom. And it complicated conducting.

Transferentially, the difference in age made it easier for them to be seen more as children taught by my daily work, explaining the pros and cons of that profession, rather than health professionals who came to learn. But countertransferentially, he perceived the pressure, as if he had the obligation to demonstrate that what he said corresponded to clinical reality; and to which emerged from the dynamics that had been established in the classroom and not from a delusional montage or interpretation.

This tension highlighted two things: the great disconnection between what is explained and the healthcare experiences with more or less serious patients and, on the other hand, the split that occurred in the cloister itself between a majority of theoretical professionals and a few clinicians.

In my text on the dynamics that occur in the clinic (1997), I emphasized the role of the healthcare team that acted as a mediator between the more or less exaggerated needs and desires of the psychotic patients with whom I worked, and the limitations that came from of the hospital structure. For his part, Nitsun emphasized the need to elaborate these anxieties on the part of teams and that, if they were not metabolized, they moved to other higher structures. In the case of the students and most likely due to the disconnection that the University has with the healthcare world, my role was more to explain to them that “children do not come from Paris”; something like an approach to healthcare reality as opposed to theoretical or conceptual reality. A job basically of re-establishing organizational dissociation.

All this was still a way to mitigate the fright that most had when they saw that their training period was ending and that in a relatively short time they would have to establish links with people with high rates of suffering. Most likely what is at the base of all this is no stranger to what you see on a daily basis. The difficulty in accepting that all psychiatric symptoms is nothing more than the expression of large areas of incommunication among the members of any human group, and not that of a defective homo clausus for basically biological reasons.

Most likely, all of this is very much in line with a social debate in which it is debated whether the role of health professionals should be limited to alleviating symptoms through operative and evidence-based techniques -which does not exclude the use of medication- Or we must be people who develop systems that improve the levels of communication between everyone, activating group work in all healthcare devices so that the development of symptoms is not required as a cry in the face of lack of communication.

Again, homo clausus or homines aperti.

Epilogue

The experience was certainly unique and innovative: a large group of students participate in an educational format in which group work — in a small and large group format — is the focus of their discussions. The topics of conversation, sometimes very active, addressed what the readings and their own experiences in the classroom suggested. They were able to begin to conceptualize from their own experience in what can be understood as an elaboration of the affective and intellectual processes that are born around the texts to be debated and their own life experience.

There is no doubt that all this generated tensions in the group of teachers that could not be addressed because, among other things, academic structures are not the same for the work of incorporating the affective processes derived from their own teaching practice. This indicates the enormous field of action that has been postponed. Most likely because the unitary conception of the individual prevails over the collective. 

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José Miguel Sunyer
josemiguelsunyer@gmail.com