Groups, Virtual Therapy and Chaosmic Psychism in the Viral Age
In this article I will expand on the history of understandings of group therapy, beginning with virtual therapy during face-to-face life in the consulting room and into the current context of the pandemic.
History of Group Psychotherapy
If we imagine four quadrants representing two axes of group therapy, the vertical line representing the group, with an administrative pole and a phantasmatic pole, and the horizontal line representing the subject that has an ego pole and an unconscious pole. Then four types of group therapy emerge that are captured by these statements:
• Therapy BY the group consists of working with the vertical line in its administrative pole (rules for belonging), with the group as the driving force and an idealised coordinator. An example would be Alcoholics Anonymous where each member offers a story without the intervention of the other members and the coordinator is a former alcoholic; it is not a psychoanalytic group.
• Therapy OF the group, originating with Bion, interprets the vertical line of the group towards both poles: the Task Group and the Basic Assumptions, but does not interpret the subject.
• Therapy IN the group as practiced by Argentine psychoanalyst Gerardo Stein as a kind of group psychoanalysis. It works the horizontal line of the subject in both the ego and unconscious poles but does not interpret group phenomena.
• Finally, Group Therapy that works with the four poles of the group and the subject, based on complexity and heterologous logic. Its representatives are the French school of Didier Anzieu and René Käes and in Argentina M. Bernard.
The Therapeutic Group: a sensitive, multiple construction
My theoretical scheme is in the line of Group Therapy. Multiple refers to subject-other relationships and the rhythm of intersubjectivity. Sensitive because it summons emotions and body movements captured by intuition. In virtuality it occurs in another way: the body exists beyond the screen. To be constructed by the uncertain future of each session that is enhanced by the variety of alternatives that are analysed together.
1) The relationship with the group is existential, created by exposure, in a field of desires it is about living the experience. As the group theorist Raul Usandivaras said, “at some point in the session a member takes the plunge” (personal conversations).
2) In the group there are links that imply an encounter with otherness in paired transferences. Otherness has several dimensions: identical / similar in narcissistic ties, different / alien in neurotic ties, and strange / sinister in ties with explicit violence that cannot be grouped together and where the other becomes an object whose social expression is femicide and genocides.
3) In the group there is a phantasmatic background arising from an anarchic set of fantasies that at some point acquire an organizer through signifiers or the dramatic, depending on whether speech or drama predominates. These climates are variable in each session and it is good technique for the therapist to ask, What is happening in the group today?
4) Multiplicity points to Spinoza’s second order of knowledge, which is the law of composition of links, a sense of rhythm, meaning that links with other links are composed, through common understandings. The opposite also happens: there are moments of decomposition of the bonds when the differences generate conflicts that disturb the group.
5) This means that at some point a member will show their miseries and take the place of a Lacanian remnant, a Pichonian (of Pichon Riviere) scapegoat or become the Jinn (in Kaesian terms): the bearer and spokesperson of all the negative and unbearable representations. Those are the moments when the dark and dense in each one emerges. The famous “dreaded scene” as named by psycho dramatists, and the therapeutic challenge is for the group to metabolize it and that this position is rotating. If it reoccurs with the same patient they will end up being expelled by the group.
6) The appearance of the ‘multiple subject’, the creation of each and every one in that group, is a subject-in-becoming that occurs at the crossroads of otherness present and overcomes false antinomies such as repetition-novelty or singular-plural, because both aspects add value. It enables pathways of transformation for each patient as aspects of the psyche emerge that were potentially in the subject or are unpublished inventions as a result of experience with Otherness.
7) A change in the fundamental rule, whoever wants to can speak, which means that others are silent even though their listening is another way of investing in the whole.
8) There is a horizontal level (work on the group) and a vertical level (work on the subject). Sometimes levels intersect when some group theme impacts on the history of a subject, whom I have called the “subjective indicator” because something goes from the group to the subject. This is a prime moment, the transferential equivalent of “mutative interpretations” (Strachey), when what happens in their life happens to a patient in the group, a uniquely powerful emotional experience.
9) On other occasions, brief individual sessions are produced in the Lacanian style, when the discourse of One specific subject predominates, because the whole group listens or provides comments. In these cases, it is important to observe the patient’s reactions, to see if he allows and is penetrated by the words of his peers or if he “plays tennis”, that is, he has a defensive attitude where everything that is said is bounced back.
10) It is interesting to establish here the differences between group events and individual psychoanalysis, what is said and what is kept silent in each context, but we must not forget that the group is a device for treating the subject. While in individual therapy the patient usually organizes the session before arriving in the consulting room, in the group one never knows what is going to happen, and even though a patient brings a speech, often he is interrupted by the spontaneous scene that takes place at the moment. The negative effect of this is that the member feels displaced and positive at the same time because listening can also transform the subject.
11) Two key moments that are exclusive to group therapy are: the arrival session (new patient) and the farewell ceremony (patient who leaves having agreed to do so with the therapist and the group). In the new virtual culture, these forms have varied and others have retained their style: in the opening session, the patient either presents himself with his problem or asks who are these strangers with whom he will share the group. Aspects of psychic structure are played out in these choices; for example, it is common that in hysteria (male or female) they prefer to go first or if obsessive traits predominate, they decide to listen to others. In clinical situations such as anxiety there is an urgency for the ‘newbie’ patient to speak. In all cases virtuality arises because at the end of the session they ask for the mobile phone number and include it in the WhatsApp group.
Regarding the farewell ceremony, it is usually very emotional, the patient talks about each one including the therapist and everyone talks about him, including the therapist. Then the technical part consists of excluding them from the WhatsApp group because they no longer belong to the group.
12) Clinical work is complex and I do not aim to convey an idyllic vision of groups. There are situations where failure appears and when conflicts are repeated and it is not possible to metabolize critical situations of great hostility that do not enter the circuit of the spoken word and elaboration and sometimes end with patients leaving.
Each session is unique, but it can also be the last. The reasons that can end the group are varied, but a decisive factor is the tendency to bureaucratization, as M. Bernard pointed out. It happens when belonging predominates over the task. An unconscious pact is created between the members where everyone repeats the same thing and no one interferes with these discourses, and the group becomes stagnant and becomes a paid space rented to the therapist, and the analytic aim is lost and boredom prevails. Other reasons are clinical, relating to the capacity for transformation of patients, which in times of social crisis can be difficult for the therapist or the institution to sustain.
13) The therapeutic group is a set of links that has a symbolic-imaginary origin in the desire of the analyst or in the institution that chose them (and could be described as a paternal or maternal imago). The fantasy generated by this origin will reappear every time a patient enters, even though the group changes members and although the therapist does not function as an oracle, because the group’s exits depend on the group and each member, but the incomers are up to the therapist and the father-genitor bias marks the transference, that is to say that the oedipal question is present in the origin as in the beginning of life, and later it becomes secondary, as the group is not a family or a fraternal clan. The analyst can be a hypnotist (leader of the masses according to Freud) or hypnotized if working from Bion’s basic assumptions. In practice, both things take place, and sometimes the therapist produces a scene with his intervention, and at other times he is prompted to play a dramatic one and generally oscillates between these positions, but the important thing is that he perceives where the transference dynamics place him. The therapist fulfils several functions: they choose patients for a certain group, their desire supports the task, establishes the framework in terms of space, time and fees, they decide admissions with each one or works through with the group the abandonments, and is responsible for the continuity of the task while their presence underlies the viability of the group as new members join.
14) When the session begins, that is the moment of greatest uncertainty, what is not planned, how they arrive (in a cluster, sometimes together) who will speak, who will be silent, where they will sit when in the room (sometimes they repeat places), who will interact with whom. At the moment of invention, every therapeutic group is a creation supported by the frame (time, space, analyst or institution) that provides consistency to the group and keeps it together. The underpinning is perhaps the most specific and supportive of the group, it consists of the feeling of belonging that the group offers. There are moments of organized polyphony when everyone assembles an associative chain from identification and difference, which is another way of thinking about fusion and lack, creating the multiplicity of linking that allows the transformation of the psyche of each member of the group. This ‘multiple group’ is different from the couple and family multiple because there are no prior pacts and agreements, only those established by the group culture.
In my opinion, another way of thinking about the group is as a small community that, paraphrasing Freud, “if all psychology is social”, implies that the notion of “healing with others” means every personal cure is a collective cure. The community aims to promote a hospitable attitude among human beings by including different social, cultural or gender representatives in the same group. In this sense, a plurality circulates that enriches and is favorable for people who live in very closed contexts. The experience of Virtual Group Therapy has broadened this horizon. Although this does not affect an admission criterion focused on the characteristics of the psyche, so, for example, it is not convenient to place unstable psychotics or more than one borderline in a group with a predominance of neurotics.
15) I tend to think of the transference as what happens in the session. It was Bejarano, a pioneer of the French School, who proposed four types of transference: to the group, to the Therapist (central), to the others (lateral) and to the world, establishing the central one to the therapist as the main one to interpret. In my opinion this has changed: the most important transferences are between peers and the transference to the group (moods, imaginaries, dramas) which constitutes a defense against the world, while the transference directed to the therapist loses the relevance that it has had on the couch, although the word of the analyst has a special effect.
Continuing the ideas of the clinical link (description-interpretation-intervention according to Janine Puget) towards the groups, the therapist’s resources consist of perceiving the atmosphere and the state of the group in the here and now of the session, interpreting the associative chain of the subject or the whole and intervening when the analyst gives an opinion as an other-subject. This often happens with questions related to social subjectivity, where the therapist fixes a position, for example agreeing with marriage equality or questioning corruption.
In the transference between peers we observe:
A) a cross of ghosts (Lacanian reading) when the ghost of one member is attached to the ghost of the other by means of identification, or a new fantasy is produced that has never been present before arising from the differences in the group, enhanced by involving several members;
B) the relativization of the conflict itself when listening to others and the impact of a member’s word said “raw” without analytical timing, when anyone can intervene with the speech of another and express a comment or produce a scene where emotions are at stake;
C) in the continuous-discontinuous axis, the patient generates a story about his external links that does not coincide with his way of relating to the group members and on other occasions, repetition impacts.
16) In the course of the group, the original Freudian fantasies (primary scene, seduction, castration) are expressed on another level: they are fusion, seduction and lack, which constitute the magma of multiplicity. As M. Bernard suggested, these fantasies are rotating and permutative between the members and produce group dynamics. Someone speaks and occupies the centre in an active role of libidinizing the whole (seduction), some make full identification with that discourse (fusion) and others are in difference (lack). From psychodrama we would say that a ‘scene’ (free energy) is presented where desire circulates with drama as an argument (linked energy) on a contingent group climate that engages the therapist’s intuition and leaves an unrepresentable remainder.
17) The concept of “healing with others” also implies that the changes are produced by the emotional effects of listening and of the ‘scene’. Sometimes an anecdotal account involves practical aspects of solving everyday questions in a colloquial language between the members that I don’t undermine; and sometimes they bring information, a signal that is useful and produces relief, not everything is phantasmic circulation.
Virtual Therapy
I began to work online (virtual therapy) in 2008 as a Research Project that was accepted at the private University in Buenos Aires where I am a professor and teach therapeutic groups. For four years (2009-2013) I coordinated a virtual group with Spanish-speaking patients from all over the world that gave rise to the book: Virtual Group Therapy: Healing over the Internet published in 2014. At the time I used Skype to observe what it has in common and how it differs from face-to-face therapy. It is possible for patients to record the sessions after written agreement not to broadcast them on the web and ensuring the privacy of the group. This allows a continuous record of the group sessions, something like a “shared clinical history: as opposed to the face-to-face sessions where the chronicle is only held by the therapist, and remain a legally inaccessible document. All members can go to the file at any time and check what happened in a session …six months ago. What do the patients do during the session? They can pause the camera, be absent, go to the bathroom, eat, mute and talk on the phone, and as one member said ironically, when an exciting topic comes up, masturbate. How do you know if someone else is not watching or listening to the session? I think that these “traps” come undone, as those who try to play with the medium soon abandon the attempt as it is difficult to sustain a deception over time. The web cam has in common with face-to-face the possibility of seeing the patient’s face, to hear the tones of his voice, laughs, cries, etc., with an image but without a body.
Unlikely and specific elements of this technique include that being on a web cam looks like a Bergman film of close-ups, the patient’s face always on the screen, which we can observe in detail in all its expressions and in greater depth despite, what a paradox, of not being “physically present” , while the rest of the body remains in the background and out of reach of the camera; that prevents the free movement as can occur in classic group therapy, for example, the exchange of chairs, places or visits to the bathroom. It is a therapy of faces that speak. Another issue is the relationship between the public and the private, the access to the home of the patient and also of the therapist, exposing intimacy to strangers who will never be face-to-face. What thus arises using the web cam is what I call “Multiple Mirror Therapy”. This idea arose from the comment a patient made: “I started the group with a frown and now I look relaxed, talking was good for me.” So I thought that with the camera on we all look at each other simultaneously, for example I can observe my own face when I interpret or listen to a patient’s speech, it is an unprecedented situation specific to this technique and all patients are observed in a mirror during the session.
In virtuality, Winnicott’s transitional space is missing: the coffee that marks the meeting before or after the frequent session in face-to-face therapies, but there is a point in common in all the techniques which is the use of WhatsApp. When a patient entered the face-to-face group everyone asked for his mobile number and included them in the WhatsApp group that was administered by a member of the group and where the analyst did not participate. When the patient left the face-to-face group, he left the WhatsApp group at the same time. What was the relationship between the two groups? Did it amplify or interfere with group therapy? It so happens that the virtual and the face-to-face were in different registers, which had different codes and different management of time and space. While in the room the bodies prevailed with their gestures, smells, positions, in a defined space, the consulting room, and in the limited time of the session. In the virtual version there were no limits to space (any) and time (continuous) in the absence of the transference to the analyst who was paradoxically the creator of the group – or did this mark another form of transference to an absent leader?
It had the advantage of installing a special sense of belonging to the group because someone always responded and everyone felt “the group thinks about me”, but this kind of absolute availability threatened to become, as René Käes said, an immortal and eternal Archgroup beyond or in replacement of face-to-face therapy. In this dynamic, castration was put on the electronic failure of the object or on the departure of the member of the in-person group if this rule was fulfilled. My technique is to work with it and raise the stories that cause ripples in the group but we can argue about the rights and wrongs of it. Following Bion, I think that the Basic Assumption of dependence would be located in the computer, while the therapist would be in this aspect one more member of the group subjected to the laws of technology. Let us remember that the continuity of communication does not depend only on the rules of the group, since any unforeseen event (failure in the virtual system, power outages, etc.) can cause the abrupt interruption of the session: we are under the control of a tyrannical superego and it is clear then that it is machine mediated therapy.
In this sense, the machine can transform itself into the non-castrated Other, that is, if in the game of generations, parents are the bearers of their children’s lives and these in turn are the guarantors of their death in the human universe of finiteness and castration, then the machine would be immortal in its perfection and always renewable by a superior specimen, as is currently the case with computers. The man-machine relationship generates various events: it supports the development of the Cyborg (half human-half machine) as it already happens in the subjectivities of the 21st century: we are the extensions of our cell phones, of laptops, we are going through the era of implants: genetic, organic, etc. Although this mobile phone culture has become global, there is a risk of creating Cyborgs as a superior race through genetic selection, body transformations and the installation of objects in the psyche. Another dreaded variant is the autonomy of the computer over humans that we saw in science fiction films, as in Kubrick’s Space Odyssey. The machine transmits certainties and the questions it produces function within a previous system, that is to say, the computer, according to Heidegger, is a Being that cannot question itself about the meaning of Being.
I am put in mind of Argentinian writer Julio Cortazar when he wrote, “a bridge is a man on the bridge” – a computer is still a man with a computer. I do not believe in the existence of computers without people. Is the assumed knowledge of the analyst, needed at the beginning of all treatment, devalued by this great Other, the machine? Or does the analyst awaken the phantom of the mad scientist? It may happen that there are patients who disappear from the system in the best phobic style, and although this occurs in face-to-face therapies, it seems simpler to disconnect the computer. The basic assumption of attack and escape usually occurs due to the leakage of information generated by the webcam, where anyone could share the session over the internet. This paranoid climate is possible when communication moves towards a more discriminating stage, where personal stories and the current conflicts of each member appear. It will be necessary to emphasize the “we”, referring to the commitment and ethics of confidentiality and to deploy a system of preventive control of messages outside the group; this leads to establishing boundary criteria already mentioned as a prerequisite to carry out therapy.
Hypothesis and Questions
What is gained with virtuality and what is lost with the dilution of the body? Does the absence of self-skin or body contact neutralize containment or are other forms of support generated? Turning to Foucault, how is the understanding of the Self affected when intimacy is exposed to a continuous image? The risk is to fall into a subjectivity of continuous recycling, with automatic substitutions and without specific anchors. Will this therapy be a variable of the neologism “extimacy”, an intimacy that is exhibited, or is it another form of intimacy? Do the cultural, geographic and ethnic variables favour the understanding of the problems posed or hinder them? What happens with sexuality in this therapy with the machine, especially WhatsApp that enables a clandestine attitude towards the drives, so for example the patient can open a window and watch sex while in therapy or, in a conceptual way, what does it mean for the register of the real? Does virtual therapy accelerate the psychic times of the self? What happens to the unconscious in virtuality? What if the patients meet in reality? Would another exchange take place? Or does it make sense that they know each other, is this idea not an old way of thinking? If it is feasible, should we alternate online therapy with a face-to-face session?
VIRTUAL THERAPY IN PANDEMIC
The effect of the Covid19 virus has been to bring Virtual Therapy to the fore. Questioned by the psychoanalytic orthodoxy that saw it only as an auxiliary technique, compensating for the inconvenience of attending face-to-face sessions, or overcoming the inevitable geographical distances. It did not achieve the status of gold standard as occurred with group psychoanalysis and ‘linking’ psychoanalysis, which took twenty years to be accepted. The proof is that with any frame or technique, the unconscious can be interpreted if the analyst works with transference and free association in addition to signaling.
According to a Greek adage and a book by René Käes, all crisis is rupture and overcoming. Anguish in the face of the unknown creates an opportunity. The pandemic effect of virtual therapy acquiring massive visibility overnight made all platforms Zoom, Jitsi, Skype a radical novelty. The moment of the Copernican turn occurred, a change from the classical paradigm in less than a week, as surprising as it was impossible to symbolize.
These changes transform the world as the ways of inhabiting it change and they are here to stay. In this techno-digital context I will deal with the ‘jewel’ of current therapy that has altered the psyche and the concepts of space, time, body and language that I have mostly described in previous paragraphs. Where is the body in virtuality? If we leave the classic dichotomy presence-absence, we can think of “corporeality” as experiences of inhabiting the virtual scene or vibrating body (Rolnik). The body exists beyond the screen and connectivity, it produces sensory-perceptual, gestural, shared semiotic effects, of which perhaps virtual sex is the easiest example to understand. The time oscillates between the Greek Aión or continuous time – eternal, and chronological time. It is an instant or a transitional state where the other may or may not be or be someone else. The space is no longer homogeneous, it is a fold without borders, the consulting room lost its walls, therapy can happen anywhere and at any time. All these variables confirm in the psyche the fourth register mentioned together with the Real / Symbolic / Imaginary that Freud and Lacan could not work with because there was no internet then and I will call Chaosmic (a cross of order and disorder, a subjectivity made up of the objects installed in the psyche, which broadens the structure of the Borromean Knot in the psyche).
Now we turn to clinical practice. Even very experienced analysts feel beginners or somewhat clumsy when faced with platforms that are complex to access and operate. Questions arise: what transference is at stake? What about the beginning of the session? Who calls who? I can tell you about my own experience. There is a problem between desire and technique if at the time of the session the patient does not appear, we do not know if it is due to technical difficulties or resistance. What to do? After ten minutes I set my status to “I am online”, but I do not call the patient. There is a risk of reversing the demand, and that it is the desire of the therapist who wants to do the session. Some patients have dropped out, especially those who were used to the couch, because they cannot bear the virtual face-to-face that hinders free association. With those who have continued, I suggest using only the sound without activating the video system, to regain the analytical frame.
I draw on Bleger’s ideas that the psychotic part of the personality was deposited in the symbiotic nucleus of the frame, the one that has exploded and also affects us. Accustomed to the bustle of the consulting room, we are surprised by the slow pace of virtual sessions with an inevitable need for technical adaptation. Reality feels flattened. The absence of life outside the home, the reduction of the outside world, impoverishes the themes of nourishing linking. This generates a climate of repetition, of boredom; in one group the movie Groundhog Day was mentioned, we are paralyzed, there is no news to tell, there is a risk that the plague will settle among us and destroy the therapy. How to inject life, desire, projects when we do not know how long it will last and what existence will be like after, which will remain in force? As a group analyst, I will find it difficult to bring the groups into the consulting room after lockdown because how do we observe one and a half metre distance if there are six or eight members and distrust prevails, a certain persecutory tone: where has each person been? How do you know if you are an asymptomatic carrier? Virtual groups may continue for an indefinite period. What happens to us as human beings? We are also afraid of contagion, but even more so of unemployment, which in our case is somewhat hidden because we do not know how many patients we have or do not dare to say. Going from the face-to-face to virtual without elaboration, and immediately, is like a migration so real that we flee from the consulting room to our homes, unless we already worked there.
For the vast majority, the consulting room has become an inaccessible and nostalgic place. When will we return? The change in the transference that is mediated by the software that decides when the connection works and absorbs a large part of the dialogue during the session has been accentuated. There are several paradoxes – the therapist can be an excellent clinician but if he has a computer that is not up to date, the noise and interference will influence the session that can lead to a crisis in the treatment. The same is true for groups, it is enough that one patient has an obsolete system so that the whole group cannot work, it quickly generates exclusion fantasies, the patient becomes the scapegoat of the group. The continuity of the treatments can depend on the algorithms and the connection, and in this way virtuality generates a symmetry between analysts and patients.
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Carlos Pachuk
Translated by Marcela López Levy