Abstract
Billow’s article (a first one in a series of three) presents an approach to ‘relationally based group therapy’ as he defines it. It is aimed at providing a comprehensive view of the field, and to create a frame in which integrative ‘foundational principles’ of group psychotherapy will co-exist coherently, creatively and productively with each other. Billow’s scope is broad, encompassing major theoreticians in the field and bringing together diverse perspectives in psychoanalysis, group psychotherapy and group analysis. He draws his ideas from theories by Bion, Foulkes, neo-Kleinians, neo-Freudians, major relational writers and others. It is a welcome, timely undertaking that opens up many venues for studying key concepts which psychoanalytically informed group psychotherapy struggled with from the beginning of its creation. Billow’s large scope, the breadth and riches of his project are very impressive. As said, the first article in this series lays the ground for creating an integrative theory that is based on a variety of psychoanalytical concepts, which have been gradually changing the landscape of the psychoanalytical culture over the past 40 years. Since Billow’s view covers a wide range of central theoretical and clinical issues which deserve separate discussions, each in its own right, I will limit my comments only to a few aspects. Some of them are aimed at emphasizing the strength of his arguments and their relevance; in others, I will touch upon some controversial issues, including differences between Foulksian group analysis and Bionian concepts, which Billow presents as being the major principles that guide his thinking about group psychotherapy.
To begin with, the group psychotherapy literature in general and that of group analysis specifically, which draws on relational theories is still rather meagre. The few writers who explore group psychotherapy along these lines like Grossmark and Wright (2015), Schulte (2000), Wright (2004), Weegman (2001), Weinberg (2015) and others, agree that the intersubjective turn in psychoanalysis is most relevant to this field of study. They all believe that relational approaches contribute a vital dimension to its theoretical and clinical thinking; that the interconnectedness between them has not yet received the recognition it deserves, and that it requires further development. Hence, Billow’s work is a most welcome addition to these pioneering studies. It is a bold project which delves into various psychoanalytical sources that can enrich our thinking about the dynamics of therapeutic change. It aims at creating a frame for exploring in depth the many complexities inherent in our work. As such, it promotes meaningful discussion, opens up paths for new learning and enables us to sharpen aspects of similarities and differences between various theoretical approaches. Inevitably, it also evokes controversies over polemic issues in the field. As our clinical work ventures into new territories and is continuously applied to new problems, the act of re-examining our concepts and struggling to reach new understandings is a vital contribution to our practice.
Billow’s striving to think in an ‘experience-near’ mode is not to be taken for granted; therapists who make an effort to conceptualize their clinical experiences without resorting to the protective shield which the ‘blank screen’ concept provides them with, take upon themselves a difficult task; even today when the ‘objective’ stance of the clinician has lost its primacy in psychoanalysis, it is still easier said than done. Billow’s readiness to see himself as part of the process, rather than a neutral objective observer is a valuable reminder that our work is a reciprocal process; that as such, it has a significant ethical dimension which is mostly not dealt with explicitly. Billow’s definitions of being ‘experience–near’ are most probably different to mine; the stance of staying ‘experience–near’ is inevitably a subjective construct for anyone. The beliefs about what constitutes one’s authenticity at any given moment covers a wide range of private experiences. Nevertheless, Billow’s insistence on the idea that the therapist’s world is co-determining the reality of the therapeutic encounter is well worth re-emphasizing. It strengthens our rootedness in the intersubjective reality that the therapeutic encounter is embedded in. Consciously and unconsciously the therapist’s authenticity is born out of an emotional struggle to sustain the ability to ‘be oneself and to behave oneself’ as Winnicott (1965) felicitously defines the tensions which characterize this role. The therapeutic relationship, whether individual or group, is a complex emotional endeavour, charged with difficult feelings for all participants. Even today, when the professional culture is more open to consider the subjective world of the therapist as an essential part of the therapeutic process, it still takes courage to be in touch with one’s vulnerabilities; to transform them into explicit communication for the sake of creating a process of curative relationships with others.
Another notable aspect in the article is the importance Billow ascribes to the group as a major human construct. Human ‘groupishness’, our essential socialness with the infinite implications it carries is a major theoretical and clinical subject. It needs continuous acknowledgment and renewed affirmation with every turn. It is not a given: the therapist can easily and unknowingly slip into a mode defined as ‘one person psychology’, and lose sight of the ‘two person psychology’ culture which marks the relational tradition in psychoanalysis. One of the problematic outcomes of this ‘slipping’ is a denial that some significant dynamic aspects that take place in this process are born out of social power structures inherent in the therapeutic relationship; more often than not, those tend to be ascribed to unconscious resistances and transferences in the inner world of the patient.
Having said that, I would like to relate to some of the difficulties I perceive in the article. Billow brings together into his comprehensive view psychoanalytical approaches which, to me, are incompatible with each other. This creates tensions and inconsistencies in a number of issues throughout the article. I will point out some of them:
Billow’s proclaimed emphasis on the key role of the ‘leader’ as he defines the group therapist is an intriguing statement phrased in a bold manner ‘it’s all about me’. He sees the group therapist as a main symbolic figure for transference projections and for processing what he considers to be the all-important dynamics of resistance. However, this notion seems to me to be at odds with the idea that the therapeutic process is co-determined by all participants in the interaction. The centrality of the group leader goes against the grain of the relational emphasis on mutuality and reciprocity as key concepts. It is worth remembering that the connotations of defining the group therapist as ‘leader’ are different from those of the Foulkesian ‘conductor’. The concept of ‘conductor’ symbolizes the sensibilities inherent in group analysis: namely, the group ‘orchestra’ is made up from individual players; each one of them introduces his own distinct musicality, to be heard and responded to by the distinct musicality of others in the group. The music of the group analytic group, its ‘web of communications’ is a collective product of the multi-directional process woven through the ever-growing exchange between all individual players of the analytic group; including the conductor.
Following this line of thinking, relational concepts are inconsistent with Kleinian/Bionian arguments in many ways. One of the major points of difference pertains to defining the seeking of truth as a basic motivational force in human life. As I see it, this purely Bionian notion has little to do with the intersubjective idea of the fundamental reciprocity which human relationships are based on. It is also very different from the basic premise group analysis postulates, as spelled out clearly by Foulkes:
The first and foremost aspect with which group psychotherapists are usually concerned and according to which they form their concepts is that of belonging, of participation. Being a respected and effective member of the group, being accepted, being able to share, to participate, and to belong are the basic constructive experiences in human life. No health is conceivable without this. This happens throughout life, but the need for psychotherapy arises when this participation and sharing are disturbed. (Foulkes and Anthony, 1965: 27)
This idea is closely related to the centrality ascribed to communication in group analysis. As far as I can understand, the attempt to bring together the search for truth and the search for belonging, participation, and communication creates ‘a confusion of tongues’.
In a similar vein, the well-known Bionian alpha function that the group leader is supposedly endowed with is definitely a one-directional process. Despite claims to the opposite, it is yet to be understood why anyone would be motivated to develop this transformative alpha function for the benefit of containing others, he has taken upon himself to be their therapist. This thought is connected with a number of pertinent issues concerning the therapeutic relationship, whether individual or group, such as the idea of mutual change that both patient and therapist undergo throughout the therapeutic process. It touches upon questions like; what is the contribution of the patient to the development of the therapist? What does the therapist ‘gain’ from this relationship? What motivates us in this role? These questions constitute the professional and personal underside of relational approaches. However, they are not really part of the Bionian or Kleinian spirit.
By the same token, the idea that people are profoundly and intensely dependent upon each other in every sense, which is the cornerstone of relationality, is not really an essential part of Bion’s approach, even though he is considered to be ‘relational’ in some way. Billow’s adamant conviction about the centrality of truth as an existential necessity, which is brought about by the Bionian alpha process, is not questioned. It is a given, we are supposed to take for granted, as a universal human reality. However, as said, the existence of such metaphysical entities is neither part of relational thinking, nor is it part of Foulkes’ approach; these diverse approaches cannot be reconciled with each other and woven into one seamless fabric. Some concepts just do not fit in with others; hence they create a number of inconsistencies and even confusions along the whole article: Billow allots a central place for Kleinian/Bionian conceptualizations and regards them as the ‘fundamental key concepts’ on which he bases his version of group psychotherapy. As said, some of the intersubjective approaches Billow refers to, (like those of Foulkes, Mitchell, Bromberg, Renik or others), just cannot be reconciled with Bion without over-straining all of them. It appears however, that Billow considers all of them as having a common denominator; they are all presented as part of one continuum forming a homogenous baseline. As said, Billow binds together diverse psychoanalytical perspective such as self-psychology, intersubjective concepts, attachment theories and others. He takes it for granted that they can all be somehow incorporated seamlessly into one unified view. He works under the assumption that Bion’s emphasis on seeking or avoiding truth and the needs for meaning making are the primary motivations for human behaviour he defines them as being the ‘primary organizers’ of human relationships. These are all-encompassing powerful statements.
However, I feel that Billow’s arguments would gather more strength if he would substantiate them more fully. Granted, it is not easy to offer viable hypothesis about human relationships in our relativistic culture, which tends to avoid sweeping generalizations; basic beliefs in our field can gain some more credibility and depth, when they are offered as hypothetical constructs to be considered for careful explorations. As it is, we all tend to hold many professional convictions which are put forth for re-examination through exchange and dialogue with our colleagues and patients alike. Since I am a group analyst, I am probably biased, when I say that this is one of the main contributions the Foulksian culture offers: namely, regarding the reciprocal, multidirectional, communicative exchange we create with each other, as a transformative resource; thus, each truth is re-examined via the truth of the other.
Group psychotherapy is not a unified field; it draws on a variety of different premises, personal persuasions, professional beliefs, social traditions and cultures. For me, it is more productive to understand Billow’s concerted interest in Bion/Klein theories, as an excellent opportunity to refine our understanding of this field.
In this sense, it can be more productive to juxtapose Bion’s ideas about groups with those of Foulkes’ before suggesting they are basically similar. Such a comparative mapping out of different approaches could be a valuable contribution in the best tradition of group analysis. It can sharpen our theoretical ideas, whatever they may be, and provide us with a sort of compass to navigate in the complex waters of our task, more accurately. Acknowledging differences as well as similarities is an essential part of learning. It goes without saying, that Bion is a major contributor to group psychotherapy, as well as to psychoanalysis in general. His ideas have been most influential theoretically and clinically. They are often part of our professional identity, even unknowingly, as it often happens with many of our formative ‘fathers’ in psychoanalysis. This is more of a reason to make a special effort to study the finer differences between the approach of group analysis and group psychotherapy, which is based on Bionian/Kleinian fundamental principles. Billow’s broad perspective provides us with an excellent frame for struggling with vital issues that group therapy is imbued with. I can identify with a passionate desire for constituting a unified vision of our field, that I sense in Billow’s approach to the subject; the ambiguities, inconsistencies, confusions, complexities and multiple perspectives we have to contain in our role as therapists are a continuous personal and professional challenge. At times, the strain is overwhelming. In this context, it is helpful to remember that Bromberg (1993) defines mental health as ‘the ability to stand in the spaces between realities without losing any of them’ (1993: 166). I find this statement captures the essence of our daily struggles.
I look forward to Billow’s next articles in this series to learn more about the way he develops his concepts and weaves them into the practice of group psychotherapy. Whether we accept his comprehensive views about what constitutes the fundamental principles of relationally based group psychotherapy, or question them, Billow’s project is a major contribution. It enables us to re-examine our theoretical assumptions along with their various clinical implications.