Abstract
Summary
Quoting Piaget, Vygotsky, Freeman, and Foulkes, the article suggests a format of dynamic group psychotherapy rooted in research on the “Dialogic Organization of a total social-psychosomatic Self”. The proposal is illustrated by cases of disturbed children playing in groups with a trained groupanalyst, in which are focused children’s initiatives and the adult’s systematic reciprocally contingent responses.
Introduction
According to the classical theory of “Psychoanalysis”, dynamic psychological therapy is based on the assumption that all emotional disorders and disturbed interpersonal relationships are produced by repressed and unconscious aspects of primal forces: oral, anal, and sexual impulses. Rehabilitation should result from retrieval of repressed aspects of those impulses which are revealed by free-association phantasies while the natural expression of emotions is expanded and understood in the context of the “transference relationship”.
Though acknowledging that only a small part of experience is exposed to awareness at any one moment and is capable of being put into words, “Psychotherapy” built on the theory of “Steps in the Development of the Dialogical Self” does not centre action on unconscious hidden impulses to be uncovered but relies on the observation of changing aspects of communication during the life-cycle - understood as pointing to an evolving social brain. Pre-symbols and symbols evolve, as emotion links perception and act through expressive co-action (an interpersonal reality) basically geared to self-contingency analysis - opening space for personality organization.
Psychotherapeutic intervention in terms of the theory of “Steps in the Dialogic Development of the Self”, so-called dialogic relationship proposal, is initially rooted in Pestalozzi’s and Herbart’s, “active education”, though standing on more recent research on the characteristics of the development of communication. It centres exclusively on the search for personal meaning by each child or adult.
In this account, ‘in-out-in-out’ manipulations of things (or narrated event sequences) is used as an analogue of turn-taking behaviours, constituting a back and forth game metaphor to be worked through in the relationship - as an “analogue” of the basic “metabolising” play activity of the two year old.
The mystery of things that go in and flow out of containers, as they are being manipulated, is easily understood in psychosomatic terms being a metaphor of alternating communication - showing or hiding contents, accepting or refusing the other.
In recommended psychotherapeutic play sessions which follow, imaginative play with miniature toys disposed in a large box (“World Play” material) is not observed, but only compulsive kneading together of coloured plasticine rolls, till they are transformed into one brown soft mass.
Pounding and wetting this (from a nearby jug of water) but never spilling, she now produces a sticky glue-like paste. In the beginning, her back to the therapist, she had peeped as if to see what she was doing, finding her smilingly attentive - She then turns to her, and continues face to face, all the time talking to herself (but not responding in any form to echoes or comments, or permitting alternating enactment of a sequence). She then asks to wash her hands.
In the third play session, the brown mass (retained under her orders from former meetings and now dry) is again wetted till it becomes an almost liquid paste. Almost the rest of the hour is joyfully occupied with playful acts of water made to flow from jug to container and back - while the therapist just underlines happenings: …“now in; now out; now in; now out.” At one moment the therapist is instructed to knead some paste, which she does - but little reciprocal exchanges ensue. When excitement bursts out of limits, it is easily contained.
This is an example of how a cognitively well-developed five year old had efficiently hidden her emotional immaturity and perplexities - here expressed in non-imaginative play-like activity reduced to energetic compulsive kneading, as well as repetitive ‘in-out-in-out’ manipulations, with no opening for real reciprocal intercourse.
Emerging in an accepting, non-directive play situation, behaviour could have been described immediately in psychoanalytic terms as “anal” - but may also be looked at in terms of evolving communication.
The Intentional Structure of Personality
Communication is observed when the «proprius» searches for meaning for himself of everyday experiences and at the same time analyses the consistencies of interpersonal dynamic exchange movements, which become significant for the experiencing human when his spontaneous gestures are recognized and responded to - thereby laying down a matrix of reciprocal relatedness through mutuality in a critical social encounter. Understanding this in terms of the theory of a psychosomatic whole of personality organization leads to the need of unravelling the classical opposition between two relatively well defined lines of research on mental development and their distinct propositions:
Jean Piaget’s perceptual-cognitive line of questioning was centred on the individual as he “operates with things” (the “Umwelt” of Ethologists). His interests lay in the discovery of the universal mechanisms that underlie knowledge acquisition and reasoning as it moves through distinct cognitive stages toward maturation. Piaget’s “symbols” are direct ‘representations’ of factual things and events, building blocks for mental integration of sensory-motor images seen as independent of language meaning structure (semiosis). His later work does not contradict this basic tenet, though he states that «reality construction» occurs separately and in parallel to «personality organization», i.e. a field of understanding he delegated to Freud and psychoanalysis. (Genetic Epistemology, 1968)
Liev Vygotsky claimed that Piaget ignored the role of social exchange. He proposed that (cognitive) reasoning emerged through interaction in a social environment and argued that it was semiotically mediated, relying on cultural exchange and on language. Though having previously studied mostly behavioural response mechanisms, after 1924, he centred his inquiry on understanding how meanings are organized in personal experience seen as hinged on social communication in a specific group culture. (Thought and language, 1934).
(N.B. Recent research presents many objections against elements of the classic ’stage’ theory: For instance, Esther Thelen and colleagues (among other things), found that small weights added to babies’ arms during the first phase of an experiment affected their understanding of object permanence, proposing that observations could be better explained using a dynamic systems theory approach, pointing to the importance of the whole body image. (Child Development 77 (6): 1521–1538 - Retrieved from e-mail, 29 October 2011)).
Through exchanges between partners in mutual intercourse, language results as a meeting-point of reality (made up of things, events, people) with intentions. Thus, in his terms, subjective experience may be said to be “embodied” in a relationship, people, things, events (while also coded in sensory-motor terms) is moulded in the mind in terms of arousal, activation and evaluation of ‘interpersonal’ happenings carrying implicit meaning, i.e., being socially communicated, taking on implicit metaphoric or symbolic form.
Vygotsky provided the example of a ‘pointing a finger’:
Initially, this behaviour seems a meaningless grasping motion; however, as people react to the gesture, it becomes a communicative signal carrying meaning, serving as the context of language development.
Clarifying this observation, Vygotsky later stated: “With the passing of time, it is not so much the functions which change (as we mistakenly studied before): their structure and the system of their development remain the same. What is changed and modified are rather the relationships, the links between the functions. New constellations emerge which were unknown in the preceding stage” (1931 - Vygotsky’s letters to co-workers. In: R. W. Rieber & J. Wollock (Eds.), The collected works of L. S. Vygotsky). - Vol. 3. N. Y.: Plenum Press.).
Putting this into the modern context of neuroscience research, Walter Freeman states in 2001 that each brain has a private language, but each is also a unit in society, having what he calls an intentional structure - by which he means “the process of a brain in action, having the properties of unity, wholeness and intent, which is the tension of taking in by stretching forth”. (How Brains Make up Their Minds, 2001).
Researchers continue deepening our understanding of the all-encompassing realities of intrapsychic and interpersonal communication of personal meanings, held together by social brain structures, when studying psychosomatics anew (including more recent research on the dynamics of systemic exchange between brain structures, actively shifting in childhood, teen-age and still in adulthood (Freeman and Holmes, 2005) with their respective evolving pre-verbal or analogical (motor, visual and oral) and verbal languages (clothed in cognitive, socio-emotional, and immaterial changes). (See debate between theories that emphasize connectedness with and interdependence of particular systems to the entire brain. (http://sulcus.berkeley.edu/. - Access July, 2013)).
Communication is a given, which goes beyond mere interaction, and must be confirmed for the growing infant as well as in later situations: it is a two-sided signalling of behaviour revealing that an implication of mutuality is involved. An expectation seems to be signalled that the other shall complete one’s own actions. (J.S. Watson, 1979; Leal, 1975; 1980; 1982) Setting a pause between each behavioural utterance, the characteristic turn-taking behaviour emerges as dialogue found at least from the second month of birth, in the baby’s turning away rhythm.
It may be observed how communicative interaction is structured when an adult conforms to these rhythms, and accepts the meaning-giving potentialities of contingent responses, “thickened thin data” (K. Kaye, 1979) through the exercise of thing-word exchanges. Later, in time, children’s repetitive play with material forms reveals their innate skill in taking up things and events as metaphoric material for interpersonal exchanges or “conversations”. (Shands, Harley, 1980).
Referring to observations of the development of primeval symbolic structures, Stein (Leopold Stein, 1957) coined the word “metabole” (from the Greek Metabolon, i.e. ‘thrown together’) to signify a ‘pre-symbol’ formation, designating the most primitive equation of feelings and fact encountered in interpersonal relationships, reality being transformed mentally as organizer of ex-changed experience.
Mediating Mental Organization
Going back to psychotherapy and communicative structures of the brain, a specific form of action may be envisaged when planning any form of rehabilitation, as illustrated:
Twelve play-therapy sessions at the ‘Psychological Intervention Unit’ follow (11-1973 to 5-1974), based solely on “contingent responses” to Sérgio’s gestures and movements - in accordance with the theory of “Steps in the Development of the Dialogical Self”.
Dramatic changes are seen: Sérgio starts crawling freely, and may remain standing without support; handles playful material emitting different sounds, communicates gestually addressing people, and points out things or places to them. (Unplanned interruption of sessions sees no further change in the following year).
In March 1975, a second series of meetings are made possible, and he is now placed in a group setting with four other children suffering global retardation. Sérgio soon starts walking more freely, this making him very happy.
Psychotherapy in an adequate peer group setting was indicated, to mediate meaning formation, multiple mutual exchanges being stimulated, to be understood as the basis for spontaneous personality growth.
More than “cerebral-palsied”, so called “atypical” children awaken a feeling of incongruence in the attending staff. Theory underlying work with these at the ‘Psychological Intervention Unit’ (led by Nurse M. Janeiro, 1979), was based on the information that those children had experienced early development disturbances in some format, though signs of neurological insult were negligible at the time. In theory, it was stated that they might have lost the opportunity for experiencing reciprocal exchange in communication - because caring adults had difficulty in responding contingently to their unusual formats of expression, thereby inhibiting the possibility of an intentional dialogue and thwarting personality organization.
On one occasion, two adults and three (of the five) members of the group are present, all of them with motor deficiencies.
Suzy (4 years and a half) stands on one side, both arms wide open in a rather stereotyped gesture, advances slowly and hesitantly in direction of Nurse Maria, nearing, she recedes again, while M. opens her arms wide. She approaches again, and the game is repeated (after two years of contact, and one year of school integration, having formerly rejected any relationship, reacting even to being looked at). In the meantime Telma and Paula (both 5 years) take up miniature kitchen utensils and come together. Telma watches M. and Suzy as they exchange gestures (Telma presented profound retardation and mutism, two years ago, when first seen, but no symptom of cerebral palsy. Integrated in the group six months ago, she now communicates though in a rudimentary form).
Paula now sits near T., her back to the group. (Three years ago, Paula refused participation in any interpersonal context. Being immersed in the symbiotic relationship pattern, she accepted contact with one adult but only in terms of being cuddled).
Telma approaches M. with a mixer in her hand, showing clearly her need for attention by pulling her face to look in her eyes. Suzy then pulls M.’s face back in her own direction. Both start playing with the mixer with M.’s active participation. In the meantime, one can see Paula and T. beginning a ‘conversation’.
Both sub-groups sustain animated exchanges in which everyone seems involved. Telma fetches a baby doll and feeds her with the bottle (Telma had been compulsively fed and formerly vomited her food systematically). One can see that T.’s hands are also holding the baby doll (at Telma’s request), sort of supporting Telma’s gesture.
One may observe that the three children are, in a certain fashion, resonating to each other in their respective play: as preparing food and giving food are complementary activities, and the group play atmosphere is emotionally gratifying.
This feeling is echoed by T. in so many words.
The group now risks new activities, and multiple contingently alternating exchanges evolve - with corresponding evidence of individual global development.
What some psychotherapists have called “acting out” has been designated as resistance to cognitive mental development, thereby eliminating interest in emotional meaning structures (in turn depending on the use of body image and phantasy, as distinct from reasoning). On the contrary, in groups, action is considered an important form of communication to be reflected and understood as an indicator of messages wanting to be understood - not expecting to be set aside as having little to do with the scene of enacted emotional relations.
During the last three meetings, children had been occupied producing various coloured thick paints (washable) with the ingredients furnished, then decorating large posters. The activity soon evolved to spreading big brown blobs, varying in consistency and tone.
On one of those occasions, the Group analyst underlines: “This always turns into something brown”. Immediately the setting changes. One of the children declares she wants to leave and starts putting her coat on. The Group analyst echoes the child’s need and then (observing a change in her intention) follows up, helping her to take the coat off, and mediating a return to the scene. The sequence is repeated three times, without any form of criticism, while the others just look on. She shall remain in the group till the end of the session, occupying herself with drowning human figures (miniature doll family) head down, in small receptacles (yoghurt cups which she fills with liquid colours, some vivid, others dubious. While playing, her lonely game her back to the others, she peeps sideways, seemingly watchful of happenings. Two other children begin playing ball. After a few moments, these two boys leave the room and play football outside very energetically (anxiety is expressed in the form of fight/flight?).
The Group analyst remains inside but visits them from time to time, speaking of the threshold which limits the play-room and separates it from the outside territory and the other building. She underlines that they play outside because inside brown things always appear anew. One of the boys contradicts her, saying that here they have more space to play. The Group analyst answers she does not agree and gesturally compares the two areas in detail. After this short dialogue, the Group analyst accepts the fourth child’s non-verbal request, to help her in putting a little order in the play-room. The other two come in, look around, and go out - then come back to play freely in the room, probably expressing non-verbally that family disorder and life space impositions were their real problem of inner control. (Though also seemingly preoccupied with “brown stuff”, in view of her training, the Group analyst always centred her attention on mutual communication, thus holding the group together, and contributing to mental organization). One of the boys makes an attempt to begin painting again, but is called upon lightly by others to continue to play the ball - which they do with relative subtlety due to constriction in space. The meeting nears and attains its end without more ado.
The session, chosen from many others, describes a moment of non-verbal decision: the theme being “to leave the situation behind”, a criterion that gives a new substance to the term ‘acting out’ - clearly expressed and accepted in the described situation.
In the said example, it became clear that children were not ready to confront their expressed needs for gratification - seen as forbidden and dirty by their real mothers (here the group analyst), to be retained forcefully. Psychotherapy became dangerous because painting materials were made available which awaken banned dirty impulses - consequently, the room had to be abandoned. The autonomous initiative of their small companion (supported by the mother/group analyst), to clean up and put the room in order, makes them feel safe again.
More than the ambivalent fight/flight reaction seen as an “acting-out” resistance to growth, expressiveness here evolves as a feeling of the group: “We are capable of controlling the situation!... Dr. (so and so) understood!.. We are not forced to grow yet - and, thank God we are safe!
Perhaps that is why this play-session was followed by great progress in integrative mental organization of these four children (found mainly in three of them).
In play, the child projects emotional meanings on things and persons, attempting to master the perplexities, confusions and conflicts witnessed in the world of grown-ups. In phantasy play the child uses his gift of continuously experimenting with his intuitions of an inner self, handling pseudo-reality situations through manipulating miniature imaginative miniature materials which may be used to display events and people in a relatively carefree and not involved context. He may discover himself when acting with things, led by its exploratory impulse, learning to review and reconstruct his image, “as if”, and experiencing new forms of relating with others outside the stereotypes he has learned and their repetitive sequences.
A group of four nine to ten year olds coming from disrupted families are invited to meet with the group analyst once a week in a large play room: a big table in the middle of the room; a carpet on one side depicting a city with streets and gardens and a drawing board on the other side. At their disposal are varied large building blocks, a collection of miniature play figures including a family, soldiers and vehicles, outside clay, drawing and painting materials.
Several activities succeed each other. Communication is mostly one-to-one or with the group analyst - who echoes movements and emotional expressions, as required, and often participating in activities.
After this, I. and N. begin painting on paper, while P. goes to the white board and paints people, two girls and two boys standing on grass, and lighted by a large sun, a huge butterfly floating over them under the blue sky. Standing between the three children, the group analyst underlines it is a beautiful scene, and says that she is going to copy it on paper. P. comes to sit at the table and takes up a sheet, doubling it up: on one half he draws a boy in a garden and (having asked the group analyst to paint his open hand), he presses it on the other half of the sheet. I. who had been experimenting with colours on her sheet, now becomes animated and draws animals and hearts, while N. also experiments with blobs of colour. Most of the time he tries to rob paint from the others and to spoil their paintings. The others tell him several times to stop. I. exchanges N. and P.’s names but admits this when confronted.
Observing N.’s concentration, the group analyst smilingly comments that when N. jutted his fingers into the other’s paintings he seemed to have been saying that he is back - maybe meaning that he had felt their loss. At the end of the hour, drawings to be kept in their box are selected consensually, it also being agreed that the rest may be taken home.
Starting from the general hypothesis on the modifiability of personality structures, and given the relative flexibility of systemic brain organization, when describing distinct play formats, Eric Berne (1964) was specially centred on what he designated as the «borderline» personalities of our time, describing cases in which a solid core regulator is lacking to deal with fluctuations in the inner world between “self” and object representations (Malcolm Pines, 1978; 1980).
All too often, today, the classical three of “inattention, hyperactivity, and impulsivity” are being pointed out for help by burdened teachers, repeatedly receiving from psychiatrists the title of ADHD - a disorder in neuro-development held to be rooted in biology, which focuses on traits assumed to have lagged behind in their central organization since early childhood. (N.B. – In spite of refined diagnostic procedures, key observations are difficult to place, because it is hard to draw the line where normal levels lie, or where clinically significant levels of disorganization begin to require medical intervention, in parallel to educational investment).
To accommodate observed “bipolarity”, S.H. Foulkes’ concept of “ego-training-in-action” may be quoted here anew offering psychotherapy as an alternative instrument to medication. Both in individual therapy (instituted as early as possible) and in group analysis, intense oscillations of humor may be held in a network of communication in which an opportunity is offered for experiencing reciprocal exchange between involved partners and needed space and time is furnished for cerebral integration to evolve, as the triad of self-regulation is modelled (… giving time for oneself; pausing to predict outcomes; opening the mind to alternatives in phantasy. – (D.J. Leong, E. Bodrova, 2008)).
In one such case, psychotherapeutic intervention was proposed to the medical practitioner, and circumscribed as an educational project, advancing that spontaneous communication of acts and things between persons in a relationship setting becomes instrumental in furthering systemic brain organization - if and when it takes on a form of accepting exchanges in which reciprocity may be experienced time and again.
G. is a nine year old child of divorced parents, apparently presenting learning difficulties without cause. Living with his grand-mother, he had been sent to a psychological unit by the school with the request for evaluation and possible medication - indicating alternating signs of deep sadness and impulsiveness, accompanied by violent behaviour. Psychotherapy is initiated and taken up anew after the summer vacation.
Toward the end of the session, all three begin building towers on the table, each one trying to make a tower higher than the other. At the end of each construction, participants throw objects from a distance, trying to hit it and throw it down, enjoying this immensely. (The Group analyst takes part, but, at the same time remains outside, by putting actions into words: “now the tower is being built” - “now we destroyed it”). After this, having repeated the whole scenario various times (each time being underlined by : “built – destroyed”), the group analyst asks what had been more fun, building or destroying. Surprisingly, both children answer: “building!”
The hour having reached its end, goodbye takes on the form of: “See you next week, maybe with the others who are absent today.”
CONCLUDING REMARKS: In the last part of this paper I am presenting the more important element of my reasoning, namely, the suggestion that systemic brain organization and behaviour regulation evolve when intra- and inter-personal communication circuits become enriched as impulsive behaviours are integrated in reciprocal act sequences.
Applying this rationale, psychotherapeutic intervention may be centred solely on the functioning psychosomatic whole of persons, new meaning construction and a new beginning becoming set in a network of reciprocally contingent responses.