From an intrapsychic to an interpersonal symptom: Relations Training in Action

The development of the ‘symptom’ concept in psychoanalytic theory

The Cambridge dictionary defines a ‘symptom’ as: ‘Any single problem that is caused by and shows a more serious and general problem’. Classic psychoanalysis viewed the symptom as a phenomenon that represents unconscious conflicts and the attempt to reconcile them in the context of the individual’s psychological economy. Regarding the symptomatic action, Freud wrote: ‘. . . it was not a matter of chance but had a motive, a sense and an intention, that it had a place in an assignable mental context . . .’ (Freud, 1989: 307). Freud suggested that in everyday life unconscious material reaches consciousness in symbolic form through dreams, slips of the tongue, parapraxes and symptoms, all of which can reveal motive and meaning. Jones (1916) emphasized that ‘only the repressed needs to be symbolized’. In other words, according to Freud, the symptom is a psychological configuration that results from the return of the repressed. In accordance with this line of thought, the goal of psychoanalysis can be formulated in intrapsychic terms: ‘This is precisely the point at which psychotherapy has to intervene. Its task is to make it possible for the unconscious processes to be dealt with finally and be forgotten’ (Freud, 1900: 578).

Alongside this intrapsychic view that has been, and still is, dominant in psychoanalytic theory, even going back to the Freudian era, Ferenczi offered an interpersonal view of neuroses and symptoms. In his famous article, Confusion of the tongues between the adults and child—(the language of tenderness and of passion) (1949), Ferenczi argued that the development of neuroses is related to childhood traumatic interpersonal experiences. Moreover, Ferenczi claimed that a patient develops symptoms when the present interpersonal situation becomes a repetition of the early unbearable relationships:

without it [maternal friendliness] he feels lonely and abandoned in his greatest need, i.e., in the same unbearable situation which at one time led to a splitting of his mind and eventually to his illness; thus it is no wonder that the patient cannot but repeat now the symptom-formation exactly as he did at the time when his illness started. (Ferenczi, 1949: 227)

Over time, various psychoanalytic schools have begun to shift from an intrapsychic view to an interpersonal emphasis. Interpersonal psychoanalysis, with Sullivan as one of its leading theorists, positions the relationship as the field in which the human psyche resides. He defined personality as ‘the relatively enduring pattern of recurrent interpersonal situations which characterize a human life’ (Sullivan, 1953a: 110–111). Minuchin developed the structural family therapy, a therapy based on the assumption that a single ‘pathological’ member, the ‘identified patient’, stands for a pathological relationship within the family (Minuchin, 1974).

The object relations school also considers relationships to be the main element that drives the development of the individual’s psychological world, and proposes a view of personality as an internalized web of complex self-object relations. For example, Winnicott wrote: ‘ . . . the object, if it is to be used, must necessarily be real in the sense of being part of shared reality, not a bundle of projections’ (Winnicott, 1971: 118). Relational theories, which have grown more popular since the end of the previous century, emphasize the importance of the interpersonal field ² : ‘What these approaches [relational theories of the self] share is the belief that the human mind is interactive rather than monadic, that the psychoanalytic process should be understood as occurring between subjects rather than within the individual’ (Benjamin, 1990: 34).

The ‘symptom’ concept in group analysis

Foulkes (1898–1976), the founder of group analysis, developed a theory that views the interpersonal field as central to the essence and development of the subject. As for symptoms, group analysis considers all forms of illness as embedded in the interpersonal context: ‘ . . . all illness (‘mental’ and ‘physical’) and every disturbance involves social relationship’ (Foulkes and Anthony, 1957: 258). Foulkes’ understanding of pathological expressions as crucially related to interpersonal relationships is a view that attributes to the other a significant role in the health or illness of the individual. Foulkes, therefore, believed that group therapy is ideal for repairing what has been damaged in an interpersonal context (Foulkes, 1948). While Freud believed that the return of the repressed occurs as long as the repressed conflicts are not worked through, Foulkes thought that the group maintains its symptomology through repetition: ‘[The Symptom] mumbles to itself secretly, hoping to be overheard’ (Foulkes and Anthony, 1957: 259–260). Foulkes believed that through its diverse therapeutic components, group analysis can broaden the possibilities for human communication, and that open, rich communication can allow the troubled individuals to express their illness and be freed of symptoms (Foulkes, 1973).

Following this view, Friedman (2007, 2019) has proposed the concept of ‘relation disorders’ from an interpersonal perspective, which is complementary to the classical view of psychopathology. Relation disorders are categories of emotional patterns and mutual behaviours that can be observed in society in general, and in group therapy in particular. These disorders originate in deficient interpersonal patterns characterized by inability to contain intense feelings. Following Friedman’s concept, more has been written recently on relation disorders: pairing relation disorder (Doron, 2018) and authority relation disorder (Seidler and Friedman, 2019, personal communication). The main idea emphasis here is the interpersonal perspective on pathological phenomena that traditionally would have been conceptualized through a focus on the intrapsychic dynamics of the individual. Whereas in classic psychoanalytic treatment, the therapist’s interpretation constitutes a curative factor, in group therapy, the curative factor is the group members’ ability to communicate with each other: ‘Translation, that is the arising of communication from the inarticulate and autistic expression by the symptom to the recognition of underlying conflict and problems which can be conveyed, shared and discussed in everyday language’ (Foulkes, 1964: 68). This principle was succinctly formulated by Dalal: ‘When autistic meaning is converted into social meaning, then communication flows again and health is restored’ (Dalal, 2000: 58).

In this article, I will relate to symptoms that have a physical aspect. I chose this focus based on my impression that the study of physical symptoms in psychoanalytic writing (Mitchell and Aron, 1999) and in contemporary group analysis has been insufficiently dealt with (Hadar, 2019). Little literature exists on the body in the group therapeutic space especially when taking into account the centrality of the body in the interpersonal field. Even though the scope of this article does not allow a thorough consideration of the body as a central focus, I consider physical symptoms an expression of very low levels of communication, based on the conceptualization proposed by Foulkes and Anthony ³ : ‘Degrees from 4- to 6- correspond to bodily equivalents of emotions, organ language, conversions, and structural changes’ (Foulkes and Anthony, 1957: 260). Following this line of thought, the goal of group analysis is: ‘ . . . translation from one type of expression . . . from symptomatic and symbolic meaning to a clear understanding of what is at stake’ (Foulkes, 1975: 111).

To conclude this section, in accordance with the shift to an interpersonal perspective in psychoanalytic and group analytic theories, I suggest that a perception of the individual as established and residing in the interpersonal space calls for a reconsideration of the symptom’s meaning as an interpersonal phenomenon. The following is a clinical example that illustrates the main idea presented in this article, an example taken from individual psychotherapy. The interpersonal view on symptoms suggested here can affect the way we approach individual psychotherapy (for further reading considering group analytic approach to individual psychotherapy see: Nitsun, 2001).

The interpersonal symptom: a clinical example

Olga (pseudonym), a 55-year-old married mother of three grown children, sought therapy because of chronic frustration about feeling undervalued in many aspects of her life, despite her intense efforts to please her surroundings. The physical symptom that caused her suffering for many years was vaginismus ⁴ . Throughout the treatment, we worked hard to name her feelings by listening to her bodily experiences, since her ability to verbalize her feelings were limited. Most of the time I felt that we had established a positive relationship. However, I became aware that Olga had been trying to please me and that our relationship was stuck in a harmonious mode that provided an ostensible sense of security.

A year and a half into the treatment, our session slipped her mind and she did not come to the session. In the following weeks, she apologized over and over again, and all my attempts to encourage a more profound exploration of this incident were blocked by further apologies. My frustration with the fact that we did not manage to learn something new from this important occurrence grew stronger and stronger, until at a certain moment, I confronted her impatiently: ‘We won’t be able to really understand why you didn’t arrive, mainly because you cannot stop apologizing’. At that moment, the room was filled with feelings of fear and tension. Olga immediately took upon herself the role of restoring the harmony by starting a monologue on everyday matters, talking in a carefree manner, as if trying to relieve the pain of the conflict that had developed between us.

Later, when we began to explore this moment in which I had acted out the aggression in the room, we identified it as the ‘hot potato’ that neither of us wanted to hold. Despite the difficulty of talking about the therapy and about our relationship, Olga eventually managed to say that she was dissatisfied with the fact that even though she had been coming to therapy regularly, she was still feeling stuck, frustrated and exploited in her relationships with her family and her boss. I encouraged Olga to share more of these concerns and drew her attention to the connection between her bodily symptom and our interpersonal incident. Olga was experiencing the therapeutic relationship as frustrating and disappointing, but she could not admit these feelings to me (perhaps even not to herself), and in an unusual incident occurrence, our session had slipped her mind. In her physical absence, a symptom in itself, she embodied the void that could not be talked about between us. This rupture in our relationship opened a window to understanding the role of her bodily symptom in the context of relations: the symptom expressed the diminishment of subjectivity in our shared space. When I asked Olga whether the links that we made could help her understand her bodily symptom—vaginismus—she replied: ‘ . . . I have never told my husband how I want him to touch me. I can’t even imagine doing that, that’s so embarrassing’. The understanding of what had happened between us led to a realization that her vaginismus was an expression of a deep, long-lasting difficulty in her communication with her husband, and furthermore, represented her repeating self-deprecation in the various relationships she had developed throughout her life. This new perspective decreased her sense of loneliness and inadequacy and allowed her to continue to work on broadening her possibilities to communicate in her marital relationship, as well as in other relationships.

These significant moments that happened in the ‘here and now’ in therapy, demonstrate the relation disorder (Friedman, 2007) that was repeated throughout Olga’s life, a relation disorder that traps the participants in fixed and rigid roles. In this case, the repeated relation disorder had been a selfless relation disorder that was characterized by a ‘doer-done to’ relationship pattern (Benjamin, 2004), which describes a situation in which one party plays the role of the exploitative aggressor while the other is the weak, abused and apologizing victim. Olga’s forgetting session can be thought of as an interpersonal defence mechanism designed to avoid direct communication, since her absence from the session was in itself an avoidance of the relationship and does not allow true coping with what had been happening between us. In a process in which the therapeutic relationship allowed each of us to own the ‘hot potato’, we could come to recognize the aggression that until that moment had been a ‘not-me’ part (Bromberg, 1998; Stern, 2009). The practising of communication skills in the here-and-now of the relationship, including the ability to express wishes and desires, anger and disappointments, allowed the ventilation of difficult feelings and cleared room for new shared experiences. Such communication decreases the need for the symptom and allows one to be in a shared reality even if it involves conflict or confrontation, since even healthy aggression ⁵ does not exist alone but in a relationship context.

Relations Training in Action

The interpersonal view of the symptom leads one to regard group analysis as a suitable therapeutic space also for patients presenting with symptoms. In the next section, I will demonstrate group analytic work with a patient suffering from a body-focused OCD. I will show that this therapeutic work is based on the concept of Relations Training in Action, which I intend to develop following the vignette.

Development of the ‘Relations Training in Action’ concept

As part of his consideration of the therapeutic process that occurs in the analytic group, Foulkes (1964) formulated a process that he called ‘Ego Training in Action’:

‘Action’ here does not mean doing, or, literally, acting or role playing; nor is it the equivalent of ‘acting out’ in psychoanalysis. The group provides a stage for actions, reactions and interactions within the therapeutic situation, which are denied to the psychoanalytic patient on the couch. (Foulkes, 1964: 82)

Drawing on the interpersonal perspective that suggests that the subject is structured and established through a continuous process within a complex social matrix, I would like to claim that it would be more accurate to talk about relations training, rather than ego training ⁶ . Therefore, I propose the concept of ‘Relations Training in Action’ that refers to a process in which repetitions of familiar pathological relationship patterns appear on the group matrix stage, and on that stage, the group can work to develop new, healthier communication patterns. The perspective that views symptoms as located (Foulkes, 1948) in the interpersonal space, and as a symbolization of interpersonal dynamics, leads one to propose group analysis as an appropriate space for their treatment.

It is my understanding that the symptom plays two significant roles in the interpersonal space. Firstly, the symptom constitutes a symbolic voice that expresses painful interpersonal contents that cannot be spoken of; I call this part ‘the voice of the symptom’ ⁷ . For example, in Jacob’s case, the symptom involved an avoidance of physical contact, pain and cleansing after contact, and symbolized the repetitive movement between a desire for intimacy and the anxiety and pain that are part of an intimate relationship. The physical contact symptom represents at the same time the part that desires the contact and the part that is anxious about it. I argue that the person who carries the symptom in his body and mind expresses the pain/difficulty/anxiety not only for himself, but also for his social environment. For example, when Jacob said: ‘. . . the group had given up on me from the moment I arrived’, he spoke of the relation disorder ⁸ that had been characteristic of the group. In this sense, the repetitiveness of the symptom reflects the insistence to keep seeking the right contact, one that is safe enough for the individual engaged in the relationship.

I would call the second function of the symptom ‘interpersonal defence mechanism’, since the existence of the symptom in itself has a role as regulator of the proximity-distance of the relationship. The symptom constitutes a real phenomenon that causes physical and psychological suffering, and the attempt to avoid suffering is, in fact, also an attempt to avoid direct communication, since this communication is perceived as too threatening or impossible. In this sense, the symptom represents not only a solution to an intrapsychic conflict but also has an interpersonal function of regulating the relationship. In the two clinical examples presented above, the symptom acted as a regulator by achieving distance and avoiding contact; there can be, however, other pathological forms of regulation, such as over-anxiousness that can lead to clinging behaviour or tantrums that create a certain hierarchy in the relationship and so on. The defence mechanism is interpersonal, since the encounter with the other is experienced as threatening. The challenge of contact is replaced with a too distant or too close relationship that cannot maintain the healthy enough mutual movement between the individual and group—dealing with the questions of sameness and difference, of strangeness and familiarity.

The treatment process described by the concept of ‘Relations Training in Action’ thus includes:

The process of ‘Relations Training in Action’ resembles, to some extent, the process described by Schlapobersky (2016) in his consideration of three interacting dimensions in the process of group therapy, the three Rs: Relational, Reflective and Reparative. The ‘relational’ moments, similar to the first stage ⁹ of ‘Relations Training in Action’, are moments in which there are significant events among the participants, whether conflictual or otherwise. In the clinical example, the image of the ‘wall’ emerged in the context of the relation disorder that had been repeated in the group, characterizing, ‘diagnosing’ and distinguishing Jacob from the rest of the group. In this sense, the image, as well as the way it was used by the group, was a ‘symptom’ of the pathological relations. In deficiency relation disorder, the group casts one of the participants—Jacob in this case—in the role of the inadequate, anxious and weak member, while all the others are positioned as healthy and strong. Jacob was familiar with this role from previous experience with various social circles in his life, as well as from the therapy group, and in response, he felt anger and even despair.

The reflective dimension, according to Schlapobersky, becomes possible when the group engages in inquiry that gives meaning to the occurrences, through the developing self-awareness and ‘ . . . discovery of symbolic meaning and the way in which idiom and metaphor have a purchase on the psychic . . . (Schlapobersky, 2016: 66)’. Likewise, the second stage of ‘Relations Training in Action’ includes discovering the symbolic meaning of the symptom, so that the symptom with which the individual is preoccupied is connected to the interpersonal dynamics of the group. As evident in the above example, it seemed that the willingness of the group to meet their own personal ‘wall’ and to share it with the group weakened the split between the ‘ill’ and the ‘healthy’ and broadened the common zone (Foulkes, 1964). When the participants agreed to crack the ‘walls’ in the room, even if only for a few moments, their pain coalesced into a common experience, and the experienced contact was appropriate, comforting and soothing. The articulation of the symptom as a symbol of a common anxiety and pain focused on relationships contributed to a transformative process in the group. The image of the wall acted as a mutative metaphor (Cox and Theilgaard, 1987) in the group process, when the use of the metaphor changed from a separating wall into a common wall on which the group participants could reflect together.

The reparative dimension in Schlapobersky’s model refers to reparation processes that allow the experiencing of new feelings towards the other (for further reading see Schlapobersky, 2016: 65–67), which I see as parallel to the continuous working through and training processes that are expected to develop and to broaden the capacity to take part in a real relationship in the Winnicottian sense: ‘ . . . real in the sense of being part of shared reality’ (Winnicott, 1971: 118). As Benjamin (1990) writes, experience in a common reality is an expression of the capacity for mutual recognition. In group analytic terms we can speak of a relationship with a good enough communication level (Foulkes and Anthony, 1957) enabling a sense of ‘weness’ (Brown, 1994) and connectedness (Nitsun, 2001) that enhance the mental health of each participant.

The above vignette is a fragment from a spiral, continuous process in which the group worked over and over again to move forward in ‘Relations Training in Action’. When the work focuses on the relationship and not only on the symptom, new forms of communication gradually become possible, forms that are based on a common capacity to play, which allows contact with the other while remaining connected to feelings such as empathy and identification, as well as differentiation. According to Foulkes (1975), the focus on the meaning of the symptom is, to begin with, the role of the group analytic conductor: ‘He (the conductor) should be ahead of his patients in this, should hear the “voice of the symbol” (Foulkes, 1975: 132)’. Thus, we could say that the role of the conductor, along with the group members, includes translating the symptom into the language of relations, or, in other words, seeking the voice of the symptom that resonates in the group space, waiting to be heard.

Summary

This article proposes that a symptom expressed through the individual’s body and mind is in fact a symbol of a relation disorder that exists in the interpersonal space. From this perspective, the concept of ‘Relations Training in Action’ is presented and demonstrated, along with a description of therapeutic work in this spirit. This process is relevant for individual therapy as well, but appears more intensely in the group space, since the latter provides rich interpersonal opportunities that occur in the ‘here and now’. It seems that the group, in its essence as an encounter among people, generates action that constitutes a foundation for training towards reaching significant transformations in the relationship sphere. Unique to group therapy, relationship disorders are repeated in a way that maintains the group in familiar patterns, but also allows the possibility to be free to experience new forms of relations in the group. The transition from the language of the symptom, which is characterized by feelings of loneliness, inadequacy and shame, to an interpersonal language that is focused on communication and its development, enables a reality that emphasizes the relationship dimension and enlarges the areas of communication.