Abstract
In his written work, Foulkes never gave a systematic account of psychosis, psychotic disturbances and psychotic transference(s). Instead we find scattered remarks and reflections on the subject of psychosis throughout his writings. However, it is noteworthy that his first psychoanalytic article (Foulkes, 1930) was dedicated to Observations on the significance of the name in a schizophrenic (Foulkes, 1990: 3–20). Moreover, in his first group analytic article (Foulkes and Lewis, 1944), he mentioned and encouraged the treatment of psychotic patients in mixed groups (Foulkes, 1984, case 8, 10, 11 and 12: 30–33) but cautioned that in a group ‘psychoses should not be in the majority’ and ‘groups with psychotics only were a different matter’ (Foulkes, 1984: 35). However, some his most consistent statements on psychosis are given in his late articles. For instance, the view that ‘undoubtedly, the person who later develops a psychosis, is also conditioned by his early group, and vice versa’ (Foulkes, 1990: 276). And the conviction that ‘psychotic mechanisms are operative in all of us, and that psychosis-like mechanisms and defences are produced very early’ (Foulkes, 1990: 276). However, he cautioned that ‘later psychotic illness’ should not be considered as ‘regressions to these early stages as one might say that neurosis or neurotic reactions are’ (Foulkes, 1990: 276; cf. Wälder, 1937). And although Foulkes acknowledged that ‘early development produces many of the phenomena that are stressed by Melanie Klein’ (Foulkes, 1990: 276; italics mine), he posited that they were ‘being brought about by the interaction of the whole family on these primitive levels’ (Foulkes, 1990: 276). ‘Complicated emotions’, he wrote, ‘can be felt even by the small child as actually represented and transmitted, however unconsciously, by the parents, brothers and sisters and so on’ (Foulkes, 1990: 276).
Also, as a group analyst considering group dynamics, namely in larger groups, he argued that although ‘psychotic mechanisms (primary mechanisms in Freud’s language, very primitive behaviour and experience) are in evidence in such groups, these ‘individual mechanisms’ should be considered ‘as emanating from particular psychological situations which we can experimentally reproduce in groups’, especially in larger groups (Foulkes, 1990: 266; italics mine). Therefore, and by his emphasizing the concept and ‘the process of communication’ (Foulkes, [1948] 1983: 169; italics in orig.), Foulkes posited that ‘neurotic and psychotic disturbances are always linked with a blockage in the system of communication’ (Foulkes, 1984: 74; italics mine).
We have to keep this in mind when we read the article on ‘psychotic transference’, because conceptually Vollon, Gimenez and Bonnet oscillate between the psychoanalytic language ‘of libidinal investments’ (Vollon et al., 2019: 500, 501), a two-person concept and the group analytic language of ‘the variety of communications’ (Vollon et al., 491). However, arguing as a group analyst, Foulkes had abandoned such a dual use in favour of the primacy of the concept of communication. He wrote: ‘understanding by other members of the group can only occur when the energies (libido) invested into these symptoms can be retransformed into exchangeable value (cash as it were)’ (Foulkes, 1984). Moreover, to understand his approach to individual and group psychodynamics, another heuristic principle of his needs to be taken into consideration. Although Foulkes maintained that ‘all dynamics observed and known to us from psychoanalysis can be observed in operation inside the group situation’ (Foulkes, 1984: 97), he nonetheless insisted that their conceptualization and concepts cannot and should not be couched in the ‘well worn-concepts of individual psychopathology’ (Foulkes, 1984: 49). Instead, they need to be adapted to the group situation. Therefore, for each psychoanalytic concept a corresponding group analytic ‘equivalent’ needs to elaborated (cf. Foulkes in Foulkes and Anthony, 1984: 263–264).
As an example of such an ‘equivalent’, Foulkes suggested considering the group analytic method of free group association as ‘the social equivalent of the psychoanalytic free association’ which originally was ‘a one-person-concept almost at a brain physiological level’ (Foulkes, 1984: 289; italics). Building on this (cf. Foulkes, 1990: 111), accordingly, Foulkes could rightfully claim that ‘from the beginning my endeavour has been to do justice to the essential unity of psychodynamics, whether they are studied or observed in a one–, two– or multi-personal situation’ (Foulkes, 1984: 180). Theoretically and clinically, this is the vantage point to study psychic disturbances of all kinds, including psychotic ones from a specifically group analytic perspective. In contrast to this, we shall see that Vollon, Gimenez and Bonnet in their article simultaneously use two-personal concepts (taken from psychoanalysis) and multi-personal, group analytic concepts. This is, of course legitimate, but also and quite often a source of misunderstandings. To avoid this (at least as far as possible) and to further the dialogue, I will limit my comment on their article regarding psychotic transference in groups to using mainly Foulkesean terms.
II
In their article, Vollon et al. propose the following hypothesis: In the early stages of a therapeutic group, the group psychotic transference oscillates between expansive movements and restrictive movements. It will be expressed by a tendency either to withdraw into themselves, or to exclude themselves, or to contribute in an undifferentiated way. (Vollon et al., 2019: 491)
Regarding the dynamics of psychotic transference, they mainly build on Bion’s early article on the Development of Schizophrenic Thought (Bion, 1956), namely the paragraph on transference (Bion, 1967: 37–38) but also refer to the work of Rosenfeld (1965), Bleger (1967), Searles (1965, 1979), Winnicott (1958 [1969]), (Green, 1980) summarized by Gimenez (2010). Moreover, with regard to the psychotic transference in the group situation and their origins Vollon et al. then discuss the contributions of Freud (1920 [1911], 1923 [1913]), Bion (1961), Foulkes (extensively), Anzieu (1972, 1975), Resnik (1999), Enjalbert (2001), Kaes (1994, 2005), Ivezić and Urlić (2015), which I will not consider in my comment.
As a clinical illustration of an oscillation between expanded and restricted transference in psychotic patients Vollon et al. present ‘the first two sessions’ of a psychoanalytic psychodrama group conducted in a treatment and re-admission unit, intended for psychotic patients by medical referral. The psychodrama, they write ‘unfolds in three stages’: first, the ‘construction of the scenario’, second ‘the play in the scenic space’ and third ‘allocated to review and to analysis with the whole group what has been played out’ (Vollon et al., 2019: 497). There are four female participants in the group: Lilian (68), Sarah (41), Nathalie (45) and Lydia (43), three of them diagnosed as paranoid–schizophrenic and one suffering from infantile psychosis. In the first session a pattern emerges out of the patients’ contributions. They all look at the therapist before they start to speak. However, they ‘interrupt each other’s words and avoid each other’s gazes while speaking. Accordingly, there is ‘no obvious connection’ between their interventions; a fact the therapist experiences as a ‘certain internal dissociation induced by this discordant cacophony’ (Vollon et al., 2019: 497). In terms of content, they talk about personal losses (Lilian, Nathalie, Sarah) and material losses (Sarah) so that ‘the group conductors record a lot of grief circulates in the group’ (Vollon et al., 2019: 498) until Nathalie says: ‘I am waiting for the doors to open’ (Vollon et al., 2019: 498) which is echoed by Liliane complaint: ‘But that one hasn’t stopped to talk about her room’ (Vollon et al., 2019: 498).
In their comment, the conductors note that the patients ‘do not appear to exist for one another as if they are excluding one another sensorially’; an exclusion they associate (with Bion) as ‘an expression of a weak investment between the group members’ and thus ‘marked by restriction’ (Vollon et al., 2019 498). At the beginning of the second session, Liliane expresses a wish to play: ‘I want to play a drama, where I am in my room and I pray’. Sarah ‘immediately reacts in echo’ and tells that ‘she feels the same’ (Vollon et al., 2019: 498 italics in orig.). On stage, then ‘both patients stand close to each other, motionless, face to face and look at each other intensively’ (Vollon et al., 2019: 498). In spite of the instructions to pretend, both take each other by the hand simultaneously assuring themselves of their everlasting beauty and love. The therapist internally associates ‘an image of Siamese twins’ and thus enacting a ‘symbiotic’ (Bleger) or ‘protoplasmic link’ (Vollon et al., 2019: 499). In their comment, the conductors interpret this dynamic in terms of a ‘tendency towards withdrawal and exclusion, and a tendency towards fusional abandonment and even undifferentiation’ (Vollon et al., 2019: 477).
III
What can be said about these two sessions from a group analytic perspective? What comes to mind here is Foulkes’ notion of ‘relatedness’ he referred to in one of his characterizations of the ‘group matrix’. ‘Relatedness’, he wrote, ‘seen as taking place within a basic, all embracing group matrix, is the cornerstone of our working theory’ (Foulkes in Foulkes and Anthony, 2014: 219) 1 . Taking this into full consideration, it is easy to realize that what is at stake in the clinical example of Vollon et al., is relatedness as such, as a capacity grounding actual relationships. Accordingly, the polarity involved here is one between a basic relatedness versus ‘total disconnection of external perception and internal sensation from the world’ (Britton, 2015: 94). Obviously, for Foulkes this capacity was a liminal point with regard to group matrix. In the clinical example of Vollon et al., this is highlighted by a particular pattern of interaction and communication. In the first session, all patient communications are directly addressed to ‘the therapist(s)’ and only indirectly to the fellow group members. As a consequence of this, there is no ‘free floating group discussion’ at all (as it is in a group of neurotics) but only a ritualized exchange of disassociated messages. Graphically we have the pattern of dyads rotating around the central figure of the therapist. It is the therapist who is both ‘massively invested’ as an address (Gimenez in Vollon et al., 2019) as well as completely excluded as a person—more latently in the first session and manifestly in the second where the dyad is a horizontal one between Lilian and Sarah. Nathalie’s hope: ‘I am waiting for the doors to open’ (Vollon et al., 498) applies to both configurations because the dyadic pattern remains to be closed and enclosing. Viewed from a modern developmental perspective, it seems to be organized around the ‘gaze’ of the (m)other which for Amaniti and Gallese ‘represents the most activating form of preverbal communication, and the perception of facial expressions is one of the most salient channels of communication’ (Amaniti and Gallese, 2014: 125). However, it is as if for these patients the normal ‘tendency to follow mother’s gaze to an external target in order to see what she is looking at ‘seems to be blocked for some reason’ (Meltzoff, 2011: 60) so that the ‘window’ remains closed. Hence the wish to open it some day.
To summarize we might say that what the French colleagues following Bion hypothesized as a psychotic transference (of expanded or restricted libidinal investments), can also be viewed (with Foulkes) as a pattern of ritualized group interaction and severely restricted group communication.
IV
How would we conceptualize this dynamic in terms of ‘group analytic theory’ according to Foulkes? Together with Vollon et al., he would have agreed that, ‘the phenomenon of transference is of fundamental importance for all psychotherapy’ (Foulkes, 1984: 177). For Foulkes, this is because ‘transference is a compulsive repetition of the most relevant and unresolved conflict-situations’; a repetition ‘still active at the time in the current life of the individual’ (Foulkes, 1984: 177; italics mine). Due to his Freudian legacy Foulkes considered the compulsive nature of this repetition as an expression of Freud’s notion of ‘the repetition compulsion’ and thus as ‘the essence of transference’ (Foulkes, 1984: 157, italics mine; cf. Foulkes, 1990: 212). (Freud, 1920g; cf. Nasio, 2012) 2 . Although ‘members can transfer, corresponding to their own unconscious phantasies, not only to the therapist but to each other’ (Foulkes, 1984: 74; 177), Foulkes also and again line with Freud emphasized that ‘in respect to transference, we may do well to differentiate between the classical repetition of infantile, incestuous fixations and transference in the wider sense and symbolize them as TR and tr respectively’ (Foulkes, 1984: 293; italics mine).
Consequently, throughout his work, he distinguished between ‘true transference’ and ‘transferences in the broader sense’ or ‘transference reactions’, i.e. ‘responses to current impressions and experiences’ (Foulkes, 1984: 285; italics mine). These reactions include ‘so-called actual neurosis and psychotic, narcissistic disturbance’ (Foulkes, 1984: 108). However, heuristically what needs to be highlighted again is that Foulkes did not just ‘apply’ the psychoanalytic concepts of unconscious transference of unconscious conflicts. Due to this, he insisted that in contrast to psychoanalytic treatment, in the group situation, ‘the individual’s neurotic conflict appears in the therapeutic group situation in a dynamic, and even dramatic form’ (Foulkes, 1984: 156; italics mine). To re-create these intrapsychic conflicts in the group situation, the individual group member unconsciously ‘uses other members of the group including the conductor’ by endowing them ‘with properties of persons in his real life, past and present’ (Foulkes, 1984: 157), in other words as personifications of inner objects, fears, reaction-formations’ (Foulkes, 1984: 157; italics mine). Conceiving dramatization and personification as group ‘equivalents’ of mental mechanisms (cf. Foulkes, 1984: 119; italics mine) ‘known to us from psychoanalysis’ (Foulkes in Foulkes and Anthony, 1984: 263), he generalized that ‘unconscious conflicts can be represented by persons’ (Foulkes, 1984: 289). Consequently, from a group analytic point of view unconscious intrapsychic conflicts are (i) externalized, (ii) dramatized, (iii) personified and finally (iv) (re-) enacted. Moreover, due to group situation there is an interplay of multiple unconscious conflicts. Taking this into account, Foulkes spoke of an ongoing ‘spontaneous re-enactment’ (Foulkes, 1984: 157; italics mine) of multiple unconscious conflicts in the group (cf. Grossmark, 2016). Vollon et al. well noticed that this view has important implications for their treatment (2019). In contrast to psychoanalytic treatment, where unconscious conflicts can and should be systematically, timely and tactfully explored and interpreted, this is not possible in group analysis. In groups, Foulkes noted ‘transferences are not received by impartial technicians, but reacted to by other emotionally disturbed people, met by counter-transferences of considerable charge’ (Foulkes, 1984: 125; italics mine). Due to this, ‘any programmatic procedure would interfere with this process’ (Foulkes, 1984: 157). This is the reason why Foulkes discouraged any attempt to systematically analyse individual transferences in the group situation 3 .
V
Notes on resonance
Wrestling with the problems of conscious and unconscious group communication, Foulkes eventually discovered what he called ‘the secret mechanism by which the participants without being aware of it, were prompted to move as they did, as if all controlled from a central switchboard’ (Foulkes, 1984: 169). This mechanism, he wrote, is the phenomenon of ‘resonance’. Regarding group communication, he realized ‘not only is there an unconscious communication between individuals, but that this unconscious communication is highly selective and specific’ (Foulkes, 1984: 290; italics mine). Due to this it is ‘as if the individuals knew the whole of psychoanalytic psychopathology and reacted accordingly’ (Foulkes, 1984: 290; italics mine). In other words, each individual, unconsciously ‘resonates in the key to which it is attuned, in which his specific personality structure is set’ (Foulkes, 1990: 298). Therefore, the concept of ‘resonance’ (cf. Foulkes, 1977), provided the key to conceptualize how unconscious multiple individual conflicts and transferences are being processed in the group analytic situation. As a consequence of this, he argued that ‘all individual communications can be considered as unconscious associations to a shared theme, reactions against a shared theme or interpretations of a theme of others’ (Foulkes, 1990: 243). Moreover, in terms of resonance, all of these communications unconsciously resonate with each member’s individual psychopathology. Building on this, we would have to say that this also applies to the clinical example provided by French colleagues. In terms of Foulkesean theory, what we see here is ‘a chain of resonance’ (Foulkes, 1984: 168) operative between psychotic patients, a chain we might presume is revolving around a ‘shared theme’, namely the theme ‘to open—or not—the window. In 1994 Pines pointed out the relevance of ‘resonance and levels of psychic organization and experience’ (Pines, 1994: 138), a subject which so far has not been picked up, really. With their article on the psychotic transference in groups, Vollon, Gimenez and Bonnet provide us with an excellent example to further the dialogue about the vicissitudes of psychotic transference in groups: regarding both the clinical facts as well as differing theoretical views and approaches to them.