THEORETICAL APPROACHES TO GROUP COUNSELING
STAGE 8: LATER LIFE—INTEGRITY VERSUS DESPAIR (ABOVE 65 YEARS) The eighth, and last, stage of life confronts the individual with crucial develop-
mental tasks, such as adjusting to the death of a spouse or friends, maintaining outside interests, adjusting to retirement, and accepting losses in physical and sensory capacities. But the central task of the fi nal stage is reviewing the past and drawing conclusions.
According to Erikson, the successful resolution of the core crisis of this stage—the confl ict between integrity and despair—depends on how the person looks back on the past. Ego integrity is achieved by those who feel few regrets.
They see themselves as having lived productive and worthwhile lives, and they feel that they have coped with their failures as well as their successes. They are not obsessed with what might have been and are able to derive satisfaction from what has been. They see death as a part of the life process and can still fi nd meaning and satisfaction in the time left. Failure to achieve ego integrity often leads to feelings of despair, hopelessness, guilt, resentment, and self- rejection.
Implications for Group Work
Older adults are increasingly aware that they have a limited time left to live, and many of their issues can be productively addressed in a group. They realize that the joys associated with old age, such as wisdom and integrity, are limited in a way not recognized in earlier years (Henderson & Gladding, 2004). Themes prevalent with older adults include loss and grief; loneliness and social isolation; poverty; feelings of rejection;the struggle to fi nd meaning in life; dependency; feelings of uselessness, hopelessness, and despair; the inevitability of death; sadness over physi- cal and mental deterioration; and regrets over past events. Although these themes present major diffi culties for many older people, they also have a range of life experiences and personal strengths that are often overlooked.
Group work with older adults is one way to promote the positive aspects
THE PSYCHOANALYTIC APPROACH TO GROUPS
149 of aging as well as helping participants cope with the tasks associated with
this stage of life. The interpersonal nature of groups can be therapeutic for older persons, especially those who are isolated and lonely (Henderson &
Gladding, 2004).
The salient issues of this stage of life have implications not only for group leaders working with older adults but also for those who work with young or middle-aged adults. As people begin to see the years slip by, they feel in- creasing pressure to make something of their lives. Fears of being alone when they are old or of fi nancial or physical dependency on others begin to surface.
Group leaders can help these members prepare now for a satisfying life as they grow older. Asking “What would you like to be able to say about your life when you reach old age?” is a good way to start. What the members say in an- swer to this question (to themselves and in the group) can infl uence the deci- sions they need to make now and the specifi c steps they must take to achieve a sense of integrity at a later age.
Contemporary Trends in Psychoanalytic Group Theory
Psychoanalytic theory continues to evolve. Freud’s ideas were based on an id psychology, characterized by confl icts over the gratifi cation of basic needs.
Later, writers in the social-psychological school moved away from Freud’s orthodox position and contributed to the growth and expansion of the psy- choanalytic movement by incorporating the cultural and social infl uences on personality. Then ego psychology, with its stress on psychosocial develop- ment throughout the life span, was developed by Erikson, among others. Anna Freud, with her identifi cation of defense mechanisms, is a central fi gure in ego psychology although she is not particularly associated with the life-span inter- ests of Erikson.
Psychoanalytic approaches are being applied to both family systems therapy and group therapy, and some contemporary psychoanalysts stress the interpersonal dimension more than the insight aspects of therapy. This is true of both object relations theory and attachment theory. According to Strupp (1992), the notion of unconscious confl ict is still fundamental to psychodynam- ic thought. However, more attention is now being given to internal structures of personality that are signifi cantly infl uenced by experiences with signifi cant fi gures during one’s infancy and early childhood. Strupp notes that the Oedi- pus complex is no longer considered a universal phenomenon. Instead, there is an increased focus on disturbances and arrests in infancy and early child- hood that stem from defi ciencies in the mother–child relationship.
OBJECT RELATIONS THEORY
Psychoanalytic theory expanded to include object relations theory in the 1970s and 1980s. Object relations are interpersonal relationships as they are rep- resented intrapsychically. Although there is no single, generally accepted school or theory of object relations, this approach includes self psychology and relational psychoanalysis. Many theorists have contributed ideas to an evolving body of concepts that deal with object relations (St. Clair, 2004).
150
CHAPTER SIX
The term object was used by Freud to refer to that which satisfi es a need, or to the signifi cant person or thing that is the object or target of one’s feelings or drives. It is used interchangeably with the term other to refer to an important person to whom the child and, later, the adult becomes attached. At birth, the infant has no sense of separateness; self and other are fused. The process of separation/individuation begins when the infant perceives that pleasure and discomfort are related to objects external to the self. The infant at this stage will typically make an attachment to the mother’s breast before any recogni- tion of her as a whole person.
Mahler (1968) believes the individual begins in a state of psychological fu- sion with the mother and progresses gradually to separation. The unfi nished crises and residues of the earlier state of fusion, as well as the process of indi- viduating, have a profound infl uence on later relationships. Object relations of later life build on the child’s search for a reconnection with the mother (St. Clair, 2004). Psychoanalytic practitioners believe there is continuity in the development of self–other relations from their infantile origins to ma- ture involvement with other persons. Thus, object relations are interpersonal relationships that shape the individual’s current interactions with people (St. Clair, 2004).
The contemporary theoretical trend in psychoanalytic thinking centers on predictable developmental sequences in which the early experiences of the self shift in relation to an expanding awareness of others. Once self–other pat- terns are established, it is assumed, they infl uence later interpersonal relation- ships. This infl uence occurs through a process of searching for a type of experi- ence that comes closest to the patterning established by the early experiences.
These newer theories provide insight into how an individual’s inner world can cause diffi culties in living in the actual world of people and relationships (St. Clair, 2004). Psychological development can be thought of as the evolution of the way in which individuals differentiate themselves from others.
Object relations therapy is based on the premise that early in life the in- dividual has drives that are satisfi ed through attachment to specifi c people, primarily parents. These early interactions lay the foundation for relationship patterns later in life (Marshall & Fitch, 2009). In group work, participants can experience how they are bringing very early patterns into their present in- teractions. For example, a group member who appears closely involved with others at one meeting may seem distant and removed at the next, leaving ev- eryone wondering what happened to the level of work that seemed to have been achieved. This pattern might repeat what Mahler (1968) calls the “ambi- tendency” of an infant who goes back and forth between wanting to be held by its mother and wanting to be left free to roam and explore. In a therapy group, the participants work through self-destructive interactional patterns. The pri- mary goals in a therapy group are to create a corrective emotional experience and change self-defeating relationship patterns (Marshall & Fitch, 2009).
ATTACHMENT THEORY AND GROUP PSYCHOTHERAPY
John Bowlby (1988) studied the importance of attachment, separation, and loss in human development and developed attachment theory, one of sev- eral extensions of psychoanalytic theory. Attachment involves an emotion- al bonding with another who is perceived as a source of security (Pistole &
Arricale, 2003). According to Bowlby, the affectional bonds that the infant has
THE PSYCHOANALYTIC APPROACH TO GROUPS
151 with others, especially the mother (or another “attachment fi gure”), are es-
sential for human survival. Infant attachment relationships can be broadly classifi ed as secure or insecure. The quality of care an infant receives is relat- ed to the quality of that individual’s relationships in later life (Peluso, Peluso, White, & Kern, 2004).
According to Marshall and Fitch (2009), a therapeutic group experience helps members meet their needs for being involved with others, for feeling attached, and for feeling appreciated. Attachment theory, which can be considered an offspring of object relations theory, is a part of the newer relational models within the psychodynamic approach. Flores (2008) believes that this theory synthesizes the best ideas of psychoanalysis, cognitive sciences, child develop- ment research, and neurobiology. He states: “Attachment is a primary motiva- tional force with its own dynamics, and these dynamics have far-reaching and complex consequences, not just for development but also for the importance of the relationship and alliance in treatment” (p. 128).
BORDERLINE AND NARCISSISTIC PERSONALITY DISORDERS
Perhaps the most signifi cant developments of recent psychoanalytic theory in- volve borderline and narcissistic personality disorders. The essential features of the borderline personality are an unstable view of one’s self and instability in relating to others. With borderline individuals, relationships are dominated by the need to defend against the fear of abandonment or rejection. The es- sential features of narcissistic personality disorder are a pervasive pattern of grandiosity, hypersensitivity to the evaluations of others, and a lack of empa- thy. Every relationship with a narcissistic individual requires adulation and perfect responsiveness from the partner (Masterson, 1997). Both of these per- sonality patterns begin by early adulthood. Among the most signifi cant theo- rists in this area are Kernberg (1975, 1976) and Kohut (1971, 1977, 1984). Kohut maintains that people are their healthiest and best when they can feel both independence and attachment, taking joy in themselves and also being able to idealize others.
Object relations theory sheds new light on the understanding of person- ality disorders. According to St. Clair (2004), borderline and narcissistic dis- orders seem to result from traumas and developmental disturbances during separation/individuation. However, the full manifestations of the personality and behavioral symptoms tend to develop in adolescence or early adulthood.
Narcissistic and borderline symptoms, such as omnipotence, grandiosity, and splitting (a defensive process of keeping incompatible feelings separate), are behavioral manifestations of developmental tasks that were disturbed or not completed earlier.
Borderline Personality
A borderline personality disorder is characterized by bouts of irritability, self-destructive acts, impulsive anger, and extreme mood shifts. People with borderline dynamics typically experience extended peri- ods of disillusionment punctuated by occasions of euphoria. Interpersonal relations are often intense and unstable, with marked changes of attitude over time. Splitting is a term often attributed to the tendency of people with border- line characteristics to think in “either-or” categories. For example, a formerly valued group member (or therapist) may suddenly be seen as worthless if he or she angers the member who exhibits borderline features. Impulsive and152
CHAPTER SIX
unpredictable behavior frequently can cause physical harm. A marked iden- tity disturbance is generally manifested by uncertainty about life issues per- taining to self-image, sexual orientation, career choice, and long-term goals.
Kernberg (1975) describes the syndrome as including a lack of clear identity, a lack of deep understanding of other people, poor impulse control, and the in- ability to tolerate anxiety. In recent years a great deal more clarity about indi- viduals with borderline dynamics has emerged, especially due to the work of Kernberg and other theorists. They may be more disorganized than neurotics but more integrated than psychotic individuals. People who manifest border- line dynamics have not fully achieved separation/individuation and tend to have a chaotic, primitive personality structure.
William Blau (personal communication, March 1, 2009) points out that the diagnosis of a borderline personality is being applied rather broadly in clini- cal settings. Some authors describe individuals with borderline personality disorder as being characterized primarily by the inability to effectively man- age emotional intensity, which is a less pathologizing view. Blau believes peo- ple with borderline characteristics are amenable to treatment, although their problems may be more diffi cult to resolve than simple neuroses because they are embedded in relatively permanent personality patterns. He also prefers to refer to borderline “dynamics” rather than borderline “personalities.” Blau’s view is consistent with that of Yalom (2005), who contends that borderline per- sonality disorder does not represent a homogeneous diagnostic category. Ya- lom states that diagnosing whether a person has a borderline personality dis- order depends on the characteristics of the individual being screened rather than on a broad diagnostic category.
Implications for Group Work
According to Yalom (2005), the core problem of individuals with borderline features lies in the area of intimacy, and a group setting offers the therapeutic factors of cohesiveness and reality testing. He contends that if these individuals can accept feedback and observations pro- vided by other members, and if their behavior is not highly disruptive, the group can offer them supportive refuge from daily stresses. Although indi- viduals with borderline dynamics may express primitive, chaotic needs and fears, they are continually confronted with reality through the group process, which helps keep these feelings somewhat under control. Yalom writes that people with borderline disorders are referred to group therapy not because they work well or easily in a group but because they are so diffi cult to treat in individual therapy.Clients with borderline personalities may be treated with a group format developed by Linehan (1993b), which is based on dialectical behavior therapy (DBT). DBT includes some psychodynamic concepts in a cognitive behavioral framework. DBT skills training groups should be used with borderline clients in conjunction with individual psychotherapy. DBT groups validate the cli- ent’s behavior “as it is in the moment,” confront resistance, and emphasize
“the therapeutic relationship as essential to treatment” while teaching clients skills necessary to change (Linehan, 1993b, pp. 5–6). This topic is taken up in more detail in Chapter 13 on cognitive behavior therapy.
For those interested in learning more about treating individuals with bor- derline personality disorders from an object relations perspective, see Clarkin, Yeomans, and Kernberg (2006). There is a excellent discussion of working with
THE PSYCHOANALYTIC APPROACH TO GROUPS
153 people with borderline and narcissistic disorders in psychodynamic therapy
groups in Rutan, Stone, and Shay (2007).
Narcissistic Personality
Children who lack the opportunity either to differen- tiate or to idealize others while also taking pride in themselves may later suffer from narcissistic personality disorders. This syndrome is characterized by an exaggerated sense of self-importance and an exploitive attitude toward oth- ers, which serves the function of masking a frail self-concept. Such individuals tend to display exhibitionistic behavior. They seek attention and admiration from others, and they tend toward extreme self-absorption. Narcissism may also present itself as very low self-esteem and an overreadiness to idealize others (see Gabbard, 2000).Kernberg (1975) characterizes people with narcissistic dynamics as focus- ing on themselves in their interactions with others, having a great need to be admired, possessing shallow affect, and being exploitive and at times estab- lishing parasitic relationships with others. He writes that individuals who are narcissistically oriented have a shallow emotional life, enjoy little other than tributes received from others, and tend to depreciate those from whom they expect few narcissistic pleasures.
There is also a growing trend to see narcissism as a striking lack of self- esteem. Kohut (1971) characterizes narcissistically oriented people as being highly threatened in maintaining their self-esteem and as having feelings of emptiness and deadness. These individuals are typically searching for some- one who will serve as an object to feed the famished self. Kohut uses the term selfobject to refer to a person who is used to foster the narcissist’s self-esteem and sense of well-being. These clients look for people whom they can admire for their power because they see themselves as worthwhile only if they are associated with such selfobjects. Yet their inner void cannot be fi lled, so their search for confi rmation by others is never-ending. Because of their impover- ished sense of self and their unclear boundaries between self and others, they have diffi culty differentiating between their own thoughts and feelings and those of the selfobject.
Implications for Group Work
Yalom (2005) discusses the problems that arise when individuals with narcissistic dynamics enter group therapy. They typi- cally have diffi culty sharing group time, understanding and empathizing with others, and forming relationships with other members. These clients have a constant need for center stage. They often assess a group’s usefulness to them in terms of how much time is devoted to them and how much attention they receive from the therapist. They are likely to be bored and impatient while other members are working, and they also tend to divert the discussion back to themselves. These individuals have unrealistic expectations of the other mem- bers. They feel that they are special and deserve the group’s attention, yet they are not willing to give attention to others. According to Yalom, a major task of the therapist is to manage such highly vulnerable members in the group. The leader must focus on the way members who display narcissistic traits relate to others in the group.In Interactive Group Therapy, Earley (2000) provides an informative discus- sion about the challenges of dealing with members who exhibit borderline and narcissistic tendencies. One of the main problems for group leaders is the
154
CHAPTER SIX
potential countertransference reactions that are stirred up in them. The in- tense anger and splitting defenses that people with borderline disorders often display can result in a leader becoming intimidated by the client’s anger or by becoming angry in return. The grandiosity, self-centeredness, and demeaning comments of a member displaying narcissistic tendencies can also elicit in- tense feelings of anger in both the leader and the members. Earley states that members with borderline and narcissistic disorders tend to provoke intense reactions in group therapists. This makes it particularly important for ther- apists to become aware of their reactions toward certain members, to avoid acting on their feelings as much as possible, and to seek supervision when needed.
According to J. Michael Russell (personal communication, January 16, 2010), countertransference reactions can be of value in understanding group mem- bers with borderline and narcissistic characteristics. Traits that initially might elicit negative reactions can be treated more therapeutically if the group lead- er’s feelings are understood as resulting from members trying to communicate something about long-standing styles of interaction. For example, a member’s moodiness might be seen as an attempt to communicate the moody nature of some early parental relationship.
The spirit of psychoanalysis requires taking the time to form a deep rela- tionship with a minimum agenda in a carefully structured frame. Some of the most powerful tools for understanding borderline and narcissistic personality organization have emerged within this tradition. This way of working draws from the developmental models of Mahler and the competing visions of trans- ference and countertransference put forward by Kernberg and Kohut.
THE FUTURE OF PSYCHOANALYTICALLY ORIENTED THERAPY
In 1992 Strupp wrote that the various modifi cations of psychoanalysis “have infused psychodynamic psychotherapy with renewed vitality and vigor” (p. 25).
In his forecast, he suggested that this approach would undergo further revi- sions and that it would maintain its prominence in individual, group, marital, and family therapy. Although contemporary psychodynamic forms diverge considerably in many respects from the original Freudian emphasis on drives, the basic concepts of unconscious motivation, infl uence of early development, transference, countertransference, and resistance are still central to these new- er psychodynamic therapies. Strupp also noted a decline in practices based on the classical analytic model, due to reasons such as time commitment, ex- pense, limited applications to diverse client populations, and questionable benefi ts. He acknowledged that the realities stemming from managed care would place increasing emphasis on short-term treatments for specifi c disor- ders, limited goals, and containment of costs. Strupp identifi ed the following trends and predicted some future directions that psychodynamic theory and practice would take:
• The emphasis on treatment has shifted from the “classical” interest in cur- ing neurotic disorders to the problems of dealing therapeutically with chronic personality disorders, borderline conditions, and narcissistic per- sonality disorders.
• There is increased attention on establishing a good therapeutic alliance early in the course of psychodynamic group therapy. A collaborative