Talking through panic. De Maré and the Exhaustion Units

I

Pat de Maré was a witness of nearly all stages of the Northfield ‘experiments’. He enlisted in the Royal Army Medical Corps in 1942, and was trained for army psychiatry by John Rickman and Wilfred Bion at Northfield Military Hospital. Due to this, he not only witnessed the First Northfield Experiment conducted by Rickman and Bion (cf. de Maré et al., 1991: 168) but also participated in the Second Northfield experiment undertaken by Bridger, Foulkes and Main (which according to Tom Harrison really was the third (cf. Harrison, 2000; Hinshelwood, 2017).

Regarding this latter experiment, he criticized that, due to the fact that no ‘large inter-group meeting per se’ was established at the time, it was left to Foulkes (like a Shaman) ‘to act’ as a link ‘between the different groups’ involved and thus ‘to represent the large group in his person’ (de Maré et al., 1991: 12). As a consequence of this, for de Maré ‘to that extent, Northfield did not directly represent itself’ (de Maré et al., 1991: 12). Foulkes in his first book Introduction to group analytic psychotherapy (1948) referred to the cooperation with de Maré several times (Foulkes, [1948] 1983: 60, 117, 120, 121, 125, 126) and thanked him as an ‘old Northfieldian’ for his contributions he made to the book (Foulkes, [1948] 1983: 151).

However, whilst Foulkes remained at Northfield from 1943 right until the end of the Second World War (in Europe and in the Far East), de Maré in between left the hospital to run so called Exhaustion Centres throughout the European campaign, most probably first in Italy and subsequent to the allied landing in Normandy attached to the sector of Montgomery’s 21st Army Group. Only afterwards, he returned to Northfield at the time of the second or the third ‘experiment’.

By setting up so called Exhaustion units, the British army responded to one of the crucial lessons of military psychiatry during the First World War; namely that if acutely traumatized soldiers were once removed from the battle zone for being treated in its hinterland, they usually did not return to there. Confronted with the high rates of psychic casualties among the American Expeditionary Force in France due to ‘shell-shock’ and ‘traumatic neuroses’—’one seventh of the fighters were discharged for disability’ (Davoine and Gaudiellière, 2004: 195), the US Government in 1917 sent an observatory commission to Europe.

Led by Thomas Salmon, a general practitioner formerly working at Ellis Island, its task was to collect and to synthesize the British and the French experiences and to design an overall programme for the prevention and the treatment of what was now called the ‘war neuroses’ (Salmon, 1917). Based on interviews and his personal experience, Salmon formulated four core principles of what was now called ‘foreward psychiatry’, i.e. of the treating of acutely traumatized soldiers near the battle zone; namely ‘proximity, immediacy, expectancy and simplicity’ (cf. Salmon, 1917). Proximity for opening ‘a new space for trustworthiness amid chaos’; Immediacy for creating ‘a living temporality in contact with urgency’, Expectancy for constructing ‘a welcome after the return from hell’; and, finally, Simplicity for emphasizing ‘the obligation to speak without jargon’ (Davoine and Gaudillière, 2004: 116).

According to Francoise Davoine and Max Gaudillière, two Lacanian psychoanalysts and professors at the Ecole des Hautes Études en Science Sociale in Paris, these principles are ‘four pillars /to/ define the space-time of a new language game for an experience which is not so much unspeakable as inaudible’ (Davoine and Gaudillière, 2004: 116). Accordingly, they conceive the Salmon principles ‘as a rigorous foundation for the dynamics of a transference aimed at the creation of a new social link on the ruins of loyalty and hence of speech’ (ibid, italics mine); a link giving rise to ‘a kind of minimal society emerging from the absolute aloneness’ on the battlefield and thus ‘the only way out of a situation in which men have become things and in which all otherness that is not murderous has been banished from the death zone, sometimes for several generations’ (Davoine and Gaudillière, 2004: 116, italics mine).

As noted by Jones, de Maré was in charge of Exhaustion Centre 31 Field Dressing Station with 100 beds in France and later on in Holland (Jones, 2004). To meet the challenge of this task, the practising of the Salmon principles must have been equally important as his group experiences in Northfield with Rickman, Bion, Foulkes and others. Taking this into consideration, it is my contention that de Maré’s experience of Exhaustion centres should be considered a relevant and important context for his later group analytic work with large(r) groups, and especially his conceptualization of ‘group dialogue’ (cf. de Maré et al., 1991) and the conviction that ‘the only answer to mass violence is collective dialogue’ (de Maré et al., 1991: 31).

I suspect that the Salmon principles provided an inspiration and a starting point for what de Maré many years later described as the passage From Hate, through Dialogue, to Culture in the Large Group (cf. de Maré et al., 1991). Moreover, as Davoine and Gaudillière explain in their book on History Beyond Trauma, these principles were also ‘closely associated with the beginnings of the psychoanalysis of the psychoses in the United States’ (Davoine and Gaudillière, 2004: 117). They were not only taught at the Washington School of Psychiatry founded in 1930 by Harry Stack Sullivan but they also and crucially informed Frieda Fromm Reichmann’s intensive psychoanalytic work with psychotic patients in Chestnut Lodge (cf. Fromm-Reichmann, 1946; vgl. Davoine and Gaudillière, 2004: 104–105). Mentioning this, the contours of a professional network become visible across continents. Having been the first woman to be granted a university degree in German psychiatry, Fromm-Reichmann (somewhat earlier as S.H. Foulkes) had been Goldstein’s assistant and in this function had treated brain injured veterans of the First World War (cf. Davoine and Gaudillière, 2004: 105). Accordingly, there are connections between Gelb and Goldstein’s early neurological studies (cf. Gelb and Goldstein, 1920), the development of German psychiatry and psychoanalysis in the 1920s and 1930s and even links to American and British military psychiatry throughout the two world wars (including the contributions of Foulkes and de Maré). Taking this into consideration makes it useful to review de Maré’s work on larger groups through the lens of his war experiences, particularly in the Exhaustion centres. To explain this in more detail, I will now outline some clinical aspects of large group experience as de Maré conceptualized them.

II. Group dialogue according to de Maré

‘Large groups’, de Maré wrote ‘provoke phobic responses, and since panic is indigenous to crowd situations, it is not surprising to discover that people sometimes take the opportunity to talk their way through panic’ (de Maré et. al., 1991: 89). ‘It has been our experience’, he wrote, ‘that panic occasioned by public speaking and also the traumatic neurosis can appropriately be treated in the larger group’. ‘The same’, he added, can be said of problems of expatriation, of social persecution, of the survival syndrome’ (de Maré et. al., 1991: 83).

Building on Fairbairn’s theory of object-relations, namely his clinical view that ‘the core of neuroses is the panic of separation anxiety’ (de Maré et. al., 33), de Maré argued that ‘the central anxiety in the larger group takes the form of panic (a major issue in separation anxiety) manifested in individuals as phobia, the extreme form of mental anguish’ (de Maré et al., 1991: 18, italics mine). Collectively, panic gives rise to processes of ‘massification’ (de Maré et al., 17), namely ‘mass formation and packing (as in wolf pack) and the intense revenge motif of mob violence’ as ‘the group’s equivalent of counter-phobic measures’ (de Maré et al., 1991: 18). For de Maré, these forms of mass formation represent ‘a flight away from the attempt to develop conscious laterized thinking (dialogue) back into a mindless dyad of leader and led’ as a ‘return to binary relationship between two parties’ (de Maré et al., 1991: 19). Moreover, since the large(r) group is by its very size is frustrating, it not only occasions panic but also ‘generates hate’ (de Maré et al., 1991: 18, italics mine). Due to this, he argued that ‘the primary problem of the large group centres around primal hate’ (de Maré et al., 1991: 114).

To fully understand this, we need to comprehend though that for de Maré ‘hate provides the psychic energy for the mental processes of seeking objects’ (de Maré et al., 1991: 120, italics mine). This search can only come into being if and when ‘hate can be organized through dialogue’ (de Maré et al., 1991: 18, italics mine). It is only due to the ‘structuring of hate through dialogue’ (de Maré et al., 1991: 108) that endo-psychic energy may become ‘liberated’ and ‘gradually transformed into the impersonal fellowship of Koinonia’ (de Maré et al., 1991: 18, italics mine). In other words, the passage from hate to culture for de Maré crucially depended on the symbolization of traumatic affects; namely that ‘panic (the ultimate in mental pain) and hate (the ultimate in mental energy) have to be contained in some form of symbolic currency, so that they can be transformed and structured out of their biological subsystem and become functional for intellectual purposes’ (de Maré et al., 1991: 91, italics mine). Therefore, he posited, that the essential ‘function of the larger group method’ and its principal aim consists in the attempt ‘to transform hate into dialogue and eventually to arrive at a culture of fellowship and Koinonia’ (de Maré et al., 83, italics mine). As such, dialogue for de Maré ‘can be seen as an extension and expansion of the free-flowing discussion of group associations’ (de Maré et al., 1991: 17), as Foulkes described it; an expansion however ‘in which interpretations are arrived at in a rounded fashion through dialogue itself’ (de Maré et al., 1991: 147).

However, although as a method it is no less rigorous, dialogue nonetheless differs from the Foulkes’ original method of access to unconscious processes in groups (Foulkes, 1949; 1971). In contrast to the unconscious, ‘familio-centric’ meaning of group associations, it ‘has to be learned like a language’ (de Maré et al., 1991: 17) and ‘functions without final truths’ (de Maré et al., 1991: 47).

Although both advocate what Foulkes had called ‘communication under reduced censorship’ (Foulkes in Foulkes and Anthony, 1984: 56), they do this in different ways, with different aims, and by employing different interventions. According to de Maré, in larger groups it is not the conductor ‘who is the main receptacle for projections of parental authority figures’ but the group itself ‘which constitutes the canvas on which the superego is projected’ (de Maré et al., 1991: 35). As a consequence of this, de Maré emphasized that to facilitate group dialogue, the group ‘convener’ in contrast to the small group conductor, ‘gives support to the role of individuals at an ego level, encouraging freedom of dialogue and interpreting the nature of social and cultural pressures’ (de Maré et al., 1991: 35, italics mine). Moreover, what the convenor furthers is not insight into unconscious family dynamics but an ‘investigation of consciousness (through outsight)’ (de Maré et al., 1991: 145, italics mine). This clearly marks a difference from conventional small group technique.

In contrast to this, group dialogue as a method indeed widens the scope of the classical formula of ‘communication under reduced censorship’ (Foulkes in Foulkes and Anthony, 1984: 56). Due to this, clinical facts and phenomena become observable which are denied to psychodynamic ‘interpretation’ of psychic facts. In the words of de Maré: ‘If the small group situation mainly evokes interpersonal experiences first known within the family, the large group context contains a different range of meanings for the individual’ (de Maré et al.,1991: 17); meanings which he emphasized are ‘not only intrapsychic and interpersonal but also contextual, including the impact on the individual of contextual traumas and mass impersonal forces (de Maré et al., 1991: 17–18, italics mine), and thus bring into focus ‘traumatic experiences of all kinds and their after effects: from war and revolution, persecution and oppression, to job loss and redundancy, moving house and moving country, the impact of cultural change and threats to cultural identity’ (de Maré et al., 1991: 18).

Considering the ailments to be treated in and by the large(r) group returns us to Northfield, reminding us that large(r) groups ‘provide a setting in which we can explore our social myths (the social unconscious)’ (de Maré et al., 1991: 10) as well as a setting to address and to treat contextual traumas and traumatic states of all kinds. Consequently, we may assume that the Salmon principles were both elevated and preserved, aufgehoben as Hegel would have it, in de Maré’s notion of group dialogue. In so far, it can be seen as an elaboration of what the Salmon principles in their time anticipated and aimed for, namely the attempt to (re-)create what Davoine and Gaudillière referred to as a ‘new social link’ on the ruins of loyalty and speech and a ‘minimal society’ (Davoine and Gaudillière, 2004: 116) emerging from the wastelands of war and other social catastrophes.

III. Northfield re-visited

Finally, I will re-visit Northfield by quoting from the notes of a staff meeting led my Major Foulkes. According to Jones (2004), Foulkes in Northfield understood a soldier’s traumatic breakdown in combat ‘as a function of failed unit cohesion’. Although as a Freudian psychoanalyst, Foulkes kept a distance to concept of trauma, he did not as a clinician. In a staff meeting in May 1945 he argued that:

breakdown in combat followed the fracture of links with peers so that these relationships became a source of strain rather than mutual support. The group itself was designed to restore a soldier’s self-confidence and social tolerance of army life by re-introducing him to positive communal functioning. (Jones, 2004 quoting the Wellcome Library for the History and Understanding of Medicine, PP/SHF/C3.8 Notes of staff meetings led by Major Foulkes 24 May 1945: 2, italics mine)

This passage clearly indicates that at Northfield, despite the existing differences, rivalries and tensions between the various subgroups of the hospital staff, there must have been a kind tacitly agreed ‘common clinical ground’ among those who participated in the Northfield ‘experiments’. This common ground I suppose was the assumption that psychopathology and ‘communal functioning’ are closely related if not intertwined. Foulkes adhered to this view even in the 1960s when he emphasized that ‘all illness is seen as interpersonal and as involving the community’ (1984: 296, italics mine).

Therefore, he argued that ‘the analytic group is a token community with access to the social, interpersonal unconscious’ (ibid, italics mine; cf. Hopper, 2003a), a fact that in his view was ‘experimentally confirmed at Northfield’ (Foulkes, 1984: 206, italics mine). As an illustration, he referred to the predicament of the ‘hospital band’ (cf. Foulkes, [1948] 1983: 48, 51, 102, 114; Foulkes, 1984: 211–214). Regarding group analytic theory, he drew (at least) two important consequences from this.

Firstly he felt compelled to extend the four group ‘specific therapeutic factors’ (cf. Foulkes, 1984: 33–35) he and Lewis had outlined in 1944 by a fifth; i.e. the function of the group as a public ‘forum’ symbolizing ‘the community as a whole’ (Foulkes, [1948] 1983: 167–168). Secondly, he claimed that psychopathology is ‘essentially comparative’ (Foulkes, 1984: 296, italics mine), and thus a ‘social psychopathology’ (Foulkes, 1984: 199, 296–297, italics mine).

De Maré as I hope to have shown built on this when he conceptualized ‘group dialogue’ as the ‘royal road’ to investigate the social unconscious (or its equivalent, ‘collective consciousness’ according to Durkheim) (cf. de Maré et al., 1991: 145) but to also to treat social psychopathology. As such, I see group dialogue as a necessary supplement to Foulkes’ original method of ‘free group associations’ (Foulkes, 1984: 285). Taking all this into consideration, for me to re-visit Northfield today is to re-consider and to re-evaluate these propositions in the light of the current society and our present clinical and theoretical knowledge.