Information about presenting Clinical Cases:
The Working Party on the Specificity of Psychoanalytic Treatment Today is a research method founded by Evelyne Sechaud, who developed the work of the clinical groups by widening the ideas of Johan Norman, Bjorn Salomonsson and Jean-Luc Donnet. The method is based on an analogical relation between the analytic sessions and their narration. The Working Party has found that owing to the associative thinking of analysts working together, the clinical research group functions as a magnifying echo of the transference-countertransference relation between patient and analyst. The small clinical groups are made up of 12 to 15 analysts from different analytic cultures working for a day and a half on the same clinical material (note 1). The presenter relates no more than necessary of the session content (speech, affects, and actions) without giving any indication concerning biography, the history of the analysis or the setting. He/she then remains silent without responding to the questions raised among the group. The fundamental rule of the group is to associate freely to the clinical material. The group thus 'constructs' the patient, each participant using his explicit and implicit theoretical references. Through the group work the gap between theory and practice (J.-L. Donnet) thus becomes reality and makes its exploration possible. The presenter then enters the discussion and lends his thoughts and feelings to the group work. This step enables the group to assess après-coup the constructions worked through during the preceding step.
(Ronnie Shaw and David Stevens, Co-chair.)
‘Weaving Thoughts’: A method for presenting and commenting psychoanalytic case material in a peer group, Johan Norman and Bjòrn Salomonsson
International Journal of Psycho-Analysis, 86:1281-1298, 2005
The authors argue that there are good reasons for seriously considering the dynamics of the peer group when discussing psychoanalytical case material. The setting and procedure have to protect and facilitate for the presenter and the group members to work together. The aim of this paper is to discuss the problems connected with presenting and discussing clinical psychoanalytical material in a (peer) group and to describe one such specific method, which the authors call the ‘weaving thoughts’ method. The design is primarily inspired by Bion's formulation ‘thoughts in search of a thinker’. The group participants reflect on the presented clinical material in a way that the authors metaphorically describe as creating a weave of thoughts that emerges from the material. The aim of the method is to facilitate a work-group climate that allows thoughts to wander about, and to avert group members from debating and compromising the integrity of its members by letting basic assumptions come into power. The method is described from theoretical and practical points of view, with two illustrations of seminars according to this design and finally a discussion of the advantages and drawbacks of the method.
One aim of this paper is to discuss problems that sometimes arise when a (psychoanalyst - note 2) presents clinical material to a group. Although our focus is the peer group, some of the problems are valid also for group supervision. We approach them with the help of a theory of groups developed from Bion's Experiences in groups (1961). The main question of the paper is the following: Is it possible to develop a method for handling the problems of the group? We think it is possible, and our paper's second aim is to describe such a method, which we call the ‘weaving thoughts’ method. It seeks to handle the problems sketched above and to promote a group situation, which facilitates the presenter and the group participants to reach a deeper understanding of the psychoanalytic process in the presented material. This is reached by a carefully devised framework for the group work, which we will elaborate in detail.
To present and discuss clinical psychoanalytical material in a group
Presentations of psychoanalytic case material in a group may have many different purposes. We will delimit our paper to those groups whose members take part in order to learn something about clinical psychoanalysis. In psychoanalytical training, supervision is a cornerstone (note 3). Sometimes, the supervision goes on in a group setting. A decisive aspect of supervision is that the supervisor is appointed by the institute and/or by the analyst. The aim is to bring into the analyst's awareness all aspects relevant for understanding the case and useful for the analyst's professional skill. In a weekly continuous supervision, the supervisor may choose not to comment on some aspects. He or she might prefer to wait until the next supervision to see how the analyst will handle the analytical situation. A consulting guest supervisor seeing the analyst only once, or after a longtime span, is not in the privileged situation to wait and see and may therefore try to knit together the loose ends in the presentation to create an all-embracing view of the case and the analyst's work with the case. This imaginative creation may sometimes be very interesting and useful for the analyst and may function as a ‘myth’ containing some central aspects of the case. An experienced supervisor usually protects the group's work. But, if the supervisor does not handle the group's dynamics carefully, malignant group processes risk influencing the discussion. If so, the value to the presenter and the other participants of the supervision might be seriously limited.
When a group of colleagues meets without a supervisor, with the aim of discussing a presentation of clinical material, there is one distinct difference from supervision. No one in the group is appointed to be the leader, and from that particular point of view all are equal. Therefore, this kind of group is often called ‘a peer group’.
The purpose of peer-group discussions is wider than for supervision. In many psychoanalytical societies, it is seen as a way to develop and keep up a good professional practice by offering help to reflect on the analyst's blind spots and peculiarities in technique, and to share opinions on difficult experiences. These peer groups are often composed of colleagues choosing each other on the basis of a mutual personal trust. The groups are often small, meeting regularly and over a long time.
Problems with traditional models of peer-group presentation
However, the situation is different and more risky when the group is composed of members who have not chosen each other, as when a psychoanalytical society has a local conference. Sometimes the members of the group may not even know each other. This is often the case at regional and international psychoanalytical conferences. Nowadays, case-presentation seminars may play a prominent role in conference programmes. The members of the group might be equal from the point of view that none is appointed leader. But from many other points of view the members are not equal, since they may have different professional experiences, reputations, aspirations, demands to be recognized etc. We will now illustrate the kind of problems to which we refer, using vignettes and clinical illustrations based on our own experiences and cases.
Vignette 1: One of the authors was invited to present a few analytical sessions from an adult case in a small group of training analysts at an international conference.
The conference was held in a city far away from my own country so I didn't know anyone except the moderator whom I trusted as a reliable person. After my presentation, there were a few short questions. Then one of the members made a long comment and questioned whether this was psychoanalysis or not. I responded as well as I could. The other members were silent at first but asked the colleague about some points in his comments. He elaborated further, then turned to me and called into question different aspects of my presentation. I felt there was no place for exchange of thoughts, and that it was more of an interrogation. This continued and I had to defend myself and my work. At the end of the session, the commenting colleague surprised me by praising my work as really very solid.
This group experience was a condensation of all the worst things that can appear in a group presentation. The commenting member saw himself as an authority with the right to interrogate, denigrate and idealize the analyst and his work. The other group members joined in their roles of pupils asking for the commentator's wisdom. In the next paragraph, in which we put forward Bion's theory on basic assumptions in groups, we will discuss how one can understand such experiences from a theoretical point of view.
Vignette 2: One of us presented a session from an analysis with an adolescent boy.
I knew it was difficult to understand this boy and that the dialogue, which each group member could follow via a transcript of the analytic session, was very odd. After my presentation, the members of the group seemed rather lost and nobody tried to go into the presented text of the session or the dialogue. The group members talked about what could be the diagnosis of the boy. One of the more prominent members of the group said this boy must be suffering from schizophrenia and I confirmed that he had been in a mental hospital when we began the analysis. It was evident that this member would never take such a case in analysis. A long discussion on diagnostic problems followed. Some other members tried to understand the details of the session, but with a sense of hopelessness. The comments turned to dealing with unrealistic thoughts concerning psychoanalysis and the omnipotent wishes of analysts. It was as if the members regretted and implicitly criticized me for my wish to work with this case.
Luckily, I had presented this case in a similar way in another group, which had led to a very interesting discussion. My wonder now turned towards the group dynamics. Something had happened during my presentation and the discussion afterwards which divided the roles into one authoritative and dead certain (the prominent colleague), the others fumbling, and myself feeling deserted and criticized.
We have brought these two vignettes to illustrate that there are many problems in presenting an analytic session (cf. Tuckett, 1993) and especially to a group. First, the presented session is not an unequivocal chain of indisputable events. Rather, the analyst presents his filtering of what he remembers from the session. Second, the analyst's remembrance is affected by the setting in which he presents his case. Third, each group member filters impressions into clusters of understanding that arrange themselves consequent on the group's emotional state. Thus, the group climate affects not only the atmosphere during the presentation but also how the group receives and interprets the clinical material. For example, in vignette 1, the commentator did not consider this as the analyst's presentation of his work in the session. He rather treated it as ‘the’ session, which he scrutinized without compassion.
In vignette 2, no explicit link was made between the developing group climate and the analytic work with the boy. Therefore, the group climate was left free to influence the discussion, which became vague and subtly critical of the analyst.
There are thus good reasons to consider group dynamics seriously and ensure that the setting and procedure protect and facilitate for the presenter and group members to work together. Some analysts seem reluctant to problematize the way psychoanalytic case material is presented in a group. A ‘dismissive’ view holds that, whatever problems arise, they issue from the case and therefore do not originate in the group. A contrasting attitude exalts the group process to the status of a ‘royal road’ to understanding the presented material. Finally, some hold a ‘nihilistic’ view that, since group processes vary uncontrollably, no pre-defined framework can restrain them. Sometimes a group functions well, sometimes not, and one can only hope for the best! These views do not take sufficient account of the risks of presenting case material in a group. Nor do they appreciate the potential inherent in a well-thought-out method of presenting case material.
Although our two vignettes are taken from groups created ad hoc during a conference, we do not say that a peer group composed of colleagues who know and appreciate each other will be exempt from problems. What problems might a psychoanalyst encounter when presenting case material in any peer group? We will start with a table based on our own experiences over the years. The analyst may encounter:
Elitism and the building of factions in the group
Interrogation of the analyst instead of curiosity in the work
Narrow-mindedness in the discussion instead of open-mindedness
Authoritarianism towards analyst and group members instead of mutual respect
Belief in authority among group members instead of free and egalitarian thinking
Competitiveness among group members instead of friendly exchange
Helplessness of the analyst or of the group instead of hopefulness
Idealization of or by the group instead of accurate perception of its assets and limitations
In order to get theoretical tools for approaching the problems of the peer group, we now turn to group theories.
Application of psychoanalytic group theories on the clinical peer group
Basic assumptions
As soon as one enters a group, one is involved in group processes. Anzieu states, ‘By immersing themselves in group life human beings sometimes rediscover their creative powers and sometimes share a bewitching self-destructive illusion’ (1975, p. 159). The unconscious of each group member ‘interact[s] and produce[s] phantasized constructions that may be short-lived or stable, paralysing and stimulating’ (p. 134). Bion formulated that, even when the group has specific aims and tasks,
‘these aims are sometimes hindered, occasionally furthered, by emotional drives of obscure origin … emotionally the group acts as if it had certain basic assumptions about its aims’ (1961, p. 188).
Basic assumptions are patterns of unconscious group functioning that establish themselves in a group and that hinder it from working optimally. Bion formulated three such assumptions: ‘Dependence’, ‘Pairing’ and ‘Fight or/and Flight’. With the help of these assumptions, we can characterize patterns of malfunctioning. There are also distinct potentials in group presentations. Here, Bion's theory of work group functioning is applicable.
The first basic assumption is when the group orients itself towards Dependence, ‘baD’. The members search for a leader. If nobody is assigned that role, the group tries to find one among its members. As disappointment in him or her inevitably appears, the group tries to recruit another. baD fits in with authoritarianism and authority belief in our table. In case-presentation groups, a member who is famous within the psychoanalytic culture, or the moderator, seems prone to be endowed with such characteristics. This was the case with the ‘prominent members’ in both vignettes above. Interestingly, the presenting analyst rarely acquires such a role, probably because of his position as help-seeker.
The second pattern is called ‘baP’, where P stands for Pairing. Two participants establish a community with erotic overtones, that is, in the minds of group members. baP can be at work when competitiveness reigns in a group. A pair, allegedly equipped with psychoanalytic perspicacity, arouses idealization and jealousy, and competitiveness spreads to the group members. The atmosphere makes the presenter feel that the group is no longer trying to work on the presented session. Expectations of getting new perspectives on one's analytical work are thwarted and one feels helpless. A special instance of baP is a general idealization of the group. The opinion is spread that the group does a very good job and gets to the roots of the case. The analyst, who ‘really’ knows how to tackle this difficult case, is said also to do a very good job. This is a pairing between the group and the presenter, with the underlying assumption that people outside the group fail to understand the case, that is, they have become the victims of de-idealization.
The third pattern, ‘baF’, concerns itself with Fight and Flight. A group tries to flee from a disagreeable topic, leaving the leader to tackle it. The ultimate goal is to preserve the group at any cost and condemn opposition. Elitism and the building of factions are instances of baF. The same is the case when inquisitorial interrogation replaces constructive curiosity. This paves the way for narrow-mindedness instead of open-mindedness. It is possible that both vignettes contain instances of baF. An atmosphere developed which probably made more people than just the presenting analyst eager to escape from the group.
Often, one basic assumption reigns while the other two exist in the group's ‘proto-mental’ levels (Bion, 1961, p. 102). They exert their negative influence and produce ‘group diseases’. The individual cannot avoid being afflicted and influenced by the ‘group mentality’, that is, the unanimous expression of the will of the group, contributed to by the individual in ways of which he is unaware … It is thus a machinery of intercommunication that is designed to ensure that group life is in accordance with the basic assumptions (p. 65).
Basic assumptions are ‘formations secondary to an extremely early primal scene worked out on a level of part objects, and associated with psychotic anxiety and mechanisms of splitting and projective identification’ (p. 164).
The challenge of the work group
The peer group thus faces a challenge, which can be formulated negatively: how can the group avoid being engulfed or fragmented by the archaic proto-mentality? We can also formulate it positively as a challenge: the group can be inspired by the archaic mentality provided it finds ways to counterbalance it. How can the group find these ways? A peer group meeting for the specific purpose of sharing clinical experiences intends consciously to form a work group. Such a group is characterized by: participation by all, curiosity, open-mindedness, mutual respect and interchange, free and egalitarian thinking, hopefulness, perception of the group's and its members' assets and limitations. In Bion's words,
Certain ideas play a prominent part in the work group: not only is the idea of ‘development’ rather than ‘full equipment by instinct’ an integral part of it, but so is the idea of the value of a rational or scientific approach to a problem (1961, p. 99).
This requires that the group accepts ‘the validity of learning by experience’ (p. 99).
When we discuss group functioning along the lines of work group and basic assumptions group, we do not wish to conjure up a sterile categorization into good and bad. ‘Work-group activity is obstructed, diverted, and on occasion assisted, by certain other mental activities that have in common the attribute of powerful emotional drives. These activities spring from … basic assumptions …’ (p. 146). The pressure from the basic assumptions proto-mentality is always present. How can it be transformed into, and assist, work-group functioning?
Our solution is that the group must have prescribed rules of procedure, which must be recognized by the group members in order to execute their function. Rules of procedure can be seen as a containment, which safeguards that the clinical material is treated with respect. The rules facilitate an atmosphere in which everyone feels free to turn the attention to one's own thoughts, images and imaginative conjectures (Bion, 1987) and yet remain tactful. The clinical material assumes the form of an aesthetic object (Meltzer, 1988) in the participants' minds, to which they can relate with passionate interest without disrespectfully penetrating into it.
We will now describe and illustrate a method that considers these aspects. We call it the ‘weaving thoughts’ method. Thereafter, we will present two sessions carried out according to the method.
The ‘weaving thoughts’ method procedure
The method was developed and introduced in 1997 by Johan Norman to a clinical seminar in the Swedish Psychoanalytic Institute's child psychoanalytical training. This seminar has been a regular occurrence since 1990 and is still going on every second week.
One inspiration for the method came from a seminar at the Bion Conference in Turin in 1997, where a group of Brazilian analysts together with the audience worked with their associations to an antique myth (Camargo et al. [internet]). The ‘weaving thoughts’ method is also used in combination with technical discussions in the clinical seminars of the Institute's adult training. Since the start of the Annual Nordic Conference on Child and Adolescent Psychoanalysis in 2001, the method has been used there. In 2002, Björn Salomonsson introduced the method at the child analytic pre-conferences of the European Psychoanalytic Federation's annual conferences. By now, we have experience of the method from more than 200 sessions in different settings. It has been used by analysts from different cultural, linguistic and geographic areas, different psychoanalytic cultures and theoretical views, and for sessions with both adult and child cases.
The Aim
The aim of the method is to create a framework for peer-group presentation of clinical case material. It shall protect the analyst's integrity and self-reflection and take advantage of the subtleness of psychoanalytical clinical material, so that the group session will be characterized as a work group that learns from experience.
The size of the group. The group works at its best with about 10 to 15 members (note 4). It is important that group members sit in a circle making eye contact possible.
The length of a presentation. Usually one and a half hours. Sometimes the whole session is used for presenting two analytic hours, sometimes only for one. In continuous case seminars, we try to work on the same case for two consecutive weekly/second-weekly group sessions. This is of course not possible at congresses.
The presenter. The analyst is asked beforehand to prepare a typewritten detailed presentation of a piece of psychoanalytic case material, usually two sessions. All group members should get a copy at the meeting. Thus, everybody can follow the text when the presenter reads it out. The copies are given back to the presenter at the end of the meeting.
The presentation
The aim is to provide the members of the group with fresh material, on which they can reflect with as little memory and desire as possible, and to which they can associate with as much evenly suspended attention as feasible. The presentation should include the details of the to-and-fro of the session, i.e. what the analysand and analyst said and did. Sometimes, the presenting analyst prefers to include what he felt and understood in the session. Information should be given about setting, frequency and weekdays of the sessions, age and sex of the analysand, and when the analysis started, for example, ‘The patient, whom I call Don, is a boy of 5 years who is in analysis with me four times a week, Monday to Thursday, for two and a half years. Here follows a Tuesday session’.
No further background material is included. Anamnestic, diagnostic or other information, however valuable, circumscribes the listener's psychoanalytic perception and directs the attention towards factual information. Biographical data tend to spuriously ‘explain’ events in the session. They direct the evenly suspended attention and reflection. If background data are not revealed, the listener's mind must stay with the impact of the presentation and work out its imaginative conjectures. If, for example, the analysand is an adopted child, the adoption will of course be a very important fact in his life and it will probably be surreptitiously present in the session. But if and how the adoption is present in the child's mind is best studied with an unfocused attention. Were we given the information beforehand, we would be tempted to use it as an overinclusive explanation.
The comments on the presentation
After the analyst has submitted one session without being interrupted, the group members browse through the text and reflect. Anyone who wants to comment gives the moderator a sign. The presenter remains quiet and follows the group's associations to the material. This may involve the presenter deeply in thoughts and emotions. They can be disturbing, for example, when people's comments are critical or based on factual misunderstandings. But the presenter can also feel understood and enriched.
The presenter might presume it easier to handle the emotions by responding to the group. However, we have found that the best way to contain emotions and learn from the experience is to remain silent as the group questions, comments, reflects and perhaps praises, misunderstands or criticizes the work. Our argument is that, in the analytic situation, the analyst is well aware of how to refrain from giving the analysand factual information in order to further the flow of unconscious material. Similarly, in the ‘weaving thoughts’ setting, a non-reply by the submitting analyst will enable further associative material to surface in the group. It might seem paradoxical that non-information about relevant facts would increase knowledge. However, we must bear in mind that, just as in the analytic situation, what we specifically look for here is meaning and psychoanalytical knowledge. We hope to discover unconscious processes at work in the transference and countertransference.
While listening to the presentation, the group members have already become aware of thoughts, images and feelings connected with a piece of the dialogue or a course of events. In our experience, the group session is most fruitful when the members' comments are tied in detail to the presented analytic session. The written text provides a support for going back and looking more closely at the passage that awoke the listener's attention. We regard it as evidence of the link between the analytic and group processes when group members associating to the presented material develop a reflective, contemplative speech, for example, ‘What strikes me about the end of the session is how utterly sad it is’. It often signifies that the group functions on a work-group level when the participants start speaking of the analyst in the third person: ‘I feel the analyst is overwhelmed by the analysand's stream of words, I think especially there on page three in the text’. This change is often accompanied by a redirection of gaze. Group members look less into the eyes of the submitting analyst and more at each other or in the air. It is as if the group temporarily forgets the analyst's presence. This indicates that the group's psychoanalytic understanding of the material is deepening. The group now functions as a working analyst at his/her best.
Different members are receptive and attentive to different aspects; the minds of the individuals are simultaneously set in work by the impact of the presentation. The uncontained thoughts of the session can be envisaged as searching among the group members for thinkers that are receptive to them and who can think and transform them into a verbal comment. Because of the list of speakers, it may take some time before one can present one's comment. In the meantime, other comments have been formulated and still more are waiting on the list. There will be no conscious effort to organize the comments; they are just threads in the weave. As the weaving goes on, the patterns stand out.
The moderator
One of the group members is appointed beforehand to moderate. The moderator opens and closes the session, introduces the presenter and contains the discussion. Containment here essentially implies seeing to it that the presenting analyst and the group respect the framework, a task not always easy. Equally important, and a prerequisite for the moderator's containment, is that he actively takes part in the receptivity and reverie and turns towards the images and thoughts evoked by the presentation. But the moderator does not take part in the group's verbal exchange on the clinical material. When the presenter has finished, anyone inclined to speak gives a sign to the moderator. The moderator should keep a list of speakers to avoid people breaking in on each other.
The moderator thus plays an essential role in minimizing the risks of the discussion turning from a working-group climate into one of basic assumptions. One of the most perplexing ingredients of this procedure is that questions to the presenter or the group members are left unanswered. Questions are treated as any other thought surfacing during the group session. The moderator helps preventing a non-response turning into a basic assumption in the group and instead supports bringing about work-group functioning. If necessary, the moderator may do this with a comment that upholds the method's framework, for example, ‘This material seems to invite the group to ask for factual information. I suggest we just look upon the questions as thoughts arising out of the clinical material’. This is normally enough to inspire the participants to look behind their questions. If anxiety arises both in the submitting analyst and in the listeners, it can be taxing on the moderator's containing capacities. But, if the situation can be managed, the reward often comes rapidly in the form of a deeper understanding of the unconscious levels of the material. When the moderator protects the participants from forcing information from the analyst in order to ‘penetrate’ the case, they can continue to give free reign to their associations and imaginative conjectures. The moderator is thus the watchman of the aesthetic object.
Another instance, which may provoke anxiety and actualizes the moderator's role, is when the group's dialogue turns into oppressive silence. Of course, silence might signify the group's need to contemplate, but it can also mean hostility and confusion. The moderator's task is not to decide which kind of silence reigns, but solely to contain the situation as anxiety waxes and wanes. When the participant analysts gradually discover the method's kinship with the psychoanalytic situation, silence often loosens its frightening characteristics. On the other hand, situations do arise where silence is a sign of uncontained unease in the group and in the analysis.
This could be due, for example, to the persecutory processes, in Bion's terms typical of baF. The group wants to flee anxiety-provoking material and leave the moderator to handle it. Since this is not group therapy but a method of understanding psychoanalytical material, the moderator can do nothing but describe, on a phenomenological level, the silent climate of the group and ask if it could be related to the material.
Sometimes, group members base their ideas on twisting what was factually reported in the presentation. This could herald the formation of a basic assumption. If someone says ‘I wonder why the analyst all the time talks about X …’, and the text contradicts this, it may be necessary for the moderator to ask the member to point it out in the text. Basic assumptions tend to be formed from nuclei of projective statements, and when the comment has no anchorage in the text it needs to be clarified. For the presenting analyst, it is a matter of decency. For the group, it signals that some material is handled through projection rather than reflection.
If the presenter wants to present a second session, the moderator decides when it is time for it. Usually this is at half-time, and the same procedure is repeated. When a few minutes are left, the moderator announces that time is out for the comments. The moderator does not make any summary, nor invite the submitting analyst to judge the value of the comments, but only asks if the presenter wants to say some words about the experience of having listened. The moderator sees to it that this will not start a discussion in the group, since this could easily turn into basic assumptions functioning. Finally, the moderator may invite the other group members to reflect a few minutes on how the group has worked.
One final comment on the procedure. There can be situations where the moderator feels it is necessary to allow the presenter to correct a factual misunderstanding arising in the group. Thus, all rules must be handled with human judgement and it is the moderator's role to adapt them to the present context.
‘Weaving thoughts’ session
Illustration 1
We have chosen this session to illustrate how the analyst can get help to become aware of a very serious problem through the impact of the presentation on the group members. The presenter, who is one of the authors, reads out the following text.
‘Bill’, an 8-year-old boy, has been in analysis four times a week, for two years, Monday to Thursday. The following is taken from a Wednesday session.
Bill is dressed in black. He says that he is supposed to be a magician from the Harry Potter story. He looks a bit bizarre. He is excited, talking in half-sentences, and names and events seem to be muddled up; I feel that Bill and I have a relationship to each other that is very odd. I can't understand any meaning and I think Bill is aware of this.
I say to Bill, ‘I can understand that you are telling me a long story that is hard for me to understand. And, you know, this is the situation when you can feel misunderstood by me’. Bill continues with an artificial storytelling voice, ‘Yes, that's right, and then …’
He continues his story, making gestures, as though they were secret, magic signs, very affected. At this moment, when he is making all these gestures, I am reminded of a fear Bill had when we started the analysis. He was afraid of getting caught by something, which he tried to push away in order not to get stuck. This image of
being totally controlled by an external power disappeared after one year of analysis, but I think it is here now again between us. Bill makes magic signs directed towards me. He radiates power and a desire to be admired in a self-glorious manner. I say, ‘You can make a fool of me, and it is true that I cannot understand very much of what is going on between us today, that I even misunderstand you, and that you feel angry and hurt and left alone, and that I am very stupid who understands nothing’.
Most of the session has passed and Bill just goes on making magic gestures very energetically, as if he is trying to identify himself with a destructive and evil power.
A [As if to myself, thinking aloud]: ‘I wonder why this is happening just exactly today’.
P: ‘I wanted a magician's costume and I got one from Mummy. I thought it would be fun in school and also here with the costume’.
Bill walks over to the table where I am sitting and rearranges some coloured pencils on the table, so that they lie parallel, a bit apart from each other.
A: I see that your pencils are supposed to lie close to each other but not too close.
P: They have to be that way. I am very, very angry with Daddy. I hate the football training because it makes me miss the children's' program on TV. But I can't give up the football, Daddy has decided it, it is Daddy's fault. It takes so much time that I miss everything fun.
A: Your daddy has been working away from home for a long time and you feel angry when you feel left alone without him. And that is the way you sometimes think about the analysis. The analysis also takes a lot of time, and still you feel deserted by me.
P: But I have to come here. Mummy and Daddy have decided.
A: It is difficult for you to handle that it is, in fact, you and I who have decided to continue. If Mummy and Daddy no longer decides that you must …
P: Then I wouldn't need to come—and … [shouts] a spider! Take it away! I'm afraid of spiders!
Bill runs over to the other corner of the room, makes a big scene over what is an almost dead spider dangling from the ceiling. He breathes frenziedly, as though he is having an anxiety attack.
My impression is that he is not at all sincere. There is obviously something that is disturbing him and his emotional link with me so that I cannot reach him.
P: Oh, it's probably not so dangerous.
A: You are trying to escape when you are afraid and you can't trust me. Now we can talk about it sometimes instead, and that is better.
Session ended.
Now, the group starts to comment (the analyst's own thoughts are placed in brackets). The first comment is that ‘sometimes it is difficult to be a child analyst. Bill seems to be overwhelmed and is using the Harry Potter story; he brings confusion into the session in order to get help to sort it out’. (I feel myself more confused than that, it was very difficult to reach him.) The second comment is that ‘the analyst can't grasp any meaning as there are two currents—a wish to be understood that is ruined by a contrary wish not to be understood, he is scared to be understood’. (Yes, this comment picks up something important for me: that I must not understand.)
Many comments are on the same line: ‘Isn't there a problem with symbolization, in the sense that Bill can't distinguish between self and object, internal and external. The use of language and words can be a possible way to help him to develop symbolization’. ‘My feeling is that Bill can't stand to be who he is. He tries to find a magician, to be invaded by a Harry Potter and get an omnipotent self, but this is a solution that brings no safety. The analyst tries to help him to begin dealing with what really matters. (Bill is really invaded—by me? By his mother? Is the omnipotent magician self a defence against us?) ‘I have the thought that Bill is invaded by/is invading the Harry Potter magician. He is inside the object in a claustrum. The analyst, though, is not enclosed in the magic claustrum; he is staying outside trying to open up a dialogue. But, as long as Bill has this tendency to invade or to be invaded, a dialogue could mean that there is a threatening inside of the analysis and of the analyst, full of spiders and helplessness. Then, Bill wants to leave, but is confronted by his fear of being thrown away’. (Yes, I really feel outside and Bill is afraid of me; he is invading and invaded by the mutual threat.)
Further comments follow: ‘The spider, doesn't it mean that Bill can't think his own thoughts, and therefore creates the enactment?’ ‘I am reminded of Bion's formulation “the absent object is the place of the present persecutor”.’ ‘The object is a frightening, persecutory and lifeless spider-analyst, but it is transformed and taken care of in the emotional relationship with the analyst.’ (I feel that the comments often are helpful, but the problem is that I do not feel that his fright is taken care of by me. There is something so evasive in Bill.)
Another line of comments is about the parents: ‘I feel really angry with the parents, they seem to be unpredictable’. ‘When they can let Bill go with the costume at school and at the analysis, they can also interrupt the analysis.’ (Really true, an interruption is always hanging in the air, and this is another kind of omnipotence. In spite of what has been said that Bill and I have to decide, I feel very upset by their insincerity.)
After the session, I was full of thoughts about ‘who is doing what to whom?’ I felt critical against my own work with Bill; I felt that it lacked depth. I was reminded that nobody had commented on when Bill organized the pencils at equal distances. I thought that he has to keep things together and apart, and I discovered I was furious with the balance permanently going on between me, Bill and his mother. I got a visual image of Bill as the omnipotent guard over this balance. I became aware that I was standing in front of one of the most difficult problems we meet in child analysis—a folie à deux. Bill had developed a skill to make his mother annoyed with me by telling her something critical. He would tell her, ‘My analyst has said …’, which were often his own thoughts, and then tell me, ‘My mother is angry with you …’. Her rejoinder would originate from his own thoughts and from his mother's response to his thoughts. It took more than a year in the analysis to understand the mental functioning of this system and then it was possible to talk more sincerely.
In cases of folie à deux between the analysand and a partner outside the analysis, as in this case between Bill and his mother, the presenting analyst and the group encounter a difficult problem. The theory of the ‘weaving thoughts’ method assumes that thoughts arising in the group from the presented material issue from an intersubjective communication between analysand and his analyst. In a case of folie à deux, a psychic field is created outside the analysis, which functions as a communicating vessel with the analytic field. Every word by the analyst and the analysand and every event in the analysis is also going on between the child and the mother, and the mother and the analyst, and vice versa. As long as the analyst has not discovered that the child, and indirectly the other partner in the folie à deux, are the real masters ruling the analytical frame and the analysis, the group cannot handle the presentation of a psychoanalytic situation of such immense complexity and leakage of the frame. This is so even if every effort is made to safeguard the method's framework.
A similar process as in a folie à deux may evolve in the group when a psychotic part of the personality is at work in the analytic session. The group members tend to leave the text and the task of weaving thoughts out of the presented material. This was the case in vignette 2 above when the participants let go of the text and started a diagnostic discussion. In place of thoughts emerging from the presented session, the comments will be based on what another participant has said, or on psychoanalytical theory. Thus, there will be a web of comments on comments. This is the group's way of handling the patient's and the analyst's unbearable psychic pains and the ruptures in the analytical frame. Evidently, the less the analyst has acknowledged these pains and difficulties in his presented work, the greater is the group's tendency to cluster around basic assumptions.
Illustration 2
Here, we have selected a theme from an analytic session which was discussed during a ‘weaving thoughts’ meeting. We want to illustrate how the procedure helps the analyst to avoid being trapped by what he feels to be some critical remarks. We will follow how the framework prevents them from developing into basic group assumptions. We will argue that the group members' comments can inspire the analyst to reflect on his work in a way that a traditional group setting would have been incapable of. We include the analyst's silent thoughts on the group members' comments to illustrate our points.
The case is of a girl of 3 years. The analyst has asked the mother to attend the sessions because the girl was so distressed while she was alone with him. This, and the length and frequency of the analysis, are the only things he tells the group before submitting the session. He tells of how the girl in the session inadvertently tears her mother's bag and coat down from their hook. She refuses to pick them up but wants to play with the analyst instead. He refrains from playing and reminds her that Mummy's things lie on the floor and that the girl doesn't take care of them. Later, she puts Mummy's things on the play cupboard, where they remain until she asks the analyst to help her hang them on the hook again.
The group starts to comment on the presentation. Anne says, ‘I think of the way the analyst formulates his inventions. He seems to work in a … pedagogic vein, as opposed to more … psychoanalytic interventions. I refer to his recurrent comments about mother's things on the floor’. (I feel criticized. I think Anne has not understood the importance of maintaining the psychoanalytic frame with the girl.) Now, Ben makes a comment. He comments on some remarks the mother had made earlier. To him, they indicate mother's hate of men, as well as her confusion about gender roles. ‘It is as if she advocates a family life without a man, but also intimates how desperately she needs him to help her with the girl.’ Carrie picks up how one should label the analyst's interventions. Are they pedagogic? She thinks it is more a question of maintaining the analytic frame. ‘What if the analyst had ignored the clothes and played with the girl?’ (I start to reflect on the differences between doing pedagogy and maintaining a psychoanalytic frame.) Ben returns: ‘Does the analyst focus on the clothes because he wants to help mother with a paternal function?’ Dorothy wonders why the mother is present in the session. ‘Can't she leave the girl with him?’ (I feel misunderstood. I invited the mother to take part. The girl's panic was uncontrollable when I worked with her alone.)
Someone brings up the image of Mummy's things, which the girl left on the play cupboard. As she visualises this scene, Evelyn gets an image of a uterus with Fallopian tubes. She links this to the discussion about the father's role and wonders if the analyst unconsciously wishes to protect, by his paternal function, the girl's attacks on the maternal function. (I reflect that if I had heard the uterus image earlier in the discussion, I would have found it far-fetched. Now, I can listen to it as to a dream. It seems an evocative primary-process condensation of what the girl struggles with.)
We bring this vignette to illustrate how the rules of procedure support the analyst to abstain from a dialogue with the group. It is possible that Anne's and Dorothy's remarks contained a kernel of a basic assumption: the analyst is either authoritarian or helpless. That is why he resorts to pedagogy. It is also possible that their remarks contained a valuable and justified critique of his technique. Since no dialogue was encouraged, the analyst could ponder with an interested non-defensive attitude on their points. He realized that they said something important about the mother's transference on him and on the girl's father.
Similarly, the analyst initially came to regard Anne and Dorothy as proponents of the female sex. This was another basic assumption, a variety of Pairing, baP, when a couple in the group unites in some critical tenet. The presenting analyst felt this tendency to be under way in Anne's and Dorothy's comments. Since he had acknowledged that Ben was the first one to speak positively of him, his basic assumption assumed the form of ‘good men vs. malicious women in a hopeless war between the sexes’. The moderator might have considered this situation as an expression of, and a defence against, rivalry and primitive anxiety. However, the moderator would not formulate such an intuition openly. Thanks to the method's procedure, the group found its way back to work-group functioning. The analyst was left in peace to discover his assumption, and he could understand it as his way of counterbalancing the mother's negative transference on him—and as his mirroring the girl's need for good male figures. Had he gone into a debate, the result would probably have been like in all wars: no winners but only losers. A debate cannot contain these assumptions, therefore they must be prevented from being acted out. Similarly, the absence of debate made it possible for each group member to reflect on his/her budding basic assumptions.
Another issue we want to bring up is Evelyn's uterus image. Primary-process visions sometimes emerge in the group members' minds. Within a competitive atmosphere, a participant might feel urged to present premature speculations anchored more in his/her mind than in the clinical material. Here, on the other hand, Evelyn's comment, while of course anchored in her internal world, lay close to and expressed an important unconscious aspect of the clinical material. The evidence lies in the analyst's feeling of novelty and surprise plus his recognition of its link to the girl's internal situation. She has an intensely ambivalent mother relation, which is represented by the image of a uterus to be attacked or protected. Evelyn's image exemplifies an aesthetic object that is allowed to be created due to the procedure. It emerges in one participant's unconscious and reflects an important aspect of the analysand's unconscious.
Discussion
In order to understand the functioning of the ‘weaving thoughts’ method and the link between the psychoanalytic process and the process in the peer group, we have to approach it from the perspective of both the group and the individual member.
The analyst who writes down a session is not aware of all the hidden aspects of the session and the presentation, although they may colour them. An analytical session is infinitely complex and impossible to present accurately. Every moment in the session is connected to all that has been going on since the analysis started. Some aspects may have been left outside the emotional containing link between analyst and analysand. The analyst inevitably makes choices. Some aspects are preferred as more understandable since they fit in with others. Different aspects are felt to be avoided, evocative, attractive etc., depending on the analyst's thinking, training, experience and personality. When the analyst has an ‘emotional experience of a sense of discovery of coherence’, what Bion called a selected fact (1962b, p. 73), this will bring order and a feeling of security and will form the matrix for interpretation.
It is, however, also possible that the selected fact will ‘neutralize the sense of insecurity’ and that the analyst will not be aware ‘that discovery has exposed further vistas of unsolved problems - “thoughts” in search of a thinker’ (Bion, 1967a, p. 166). The analyst may already have received these thoughts without noticing: ‘At edge-of-awareness I seemed to have told in visual image what I could not yet tell myself in words’ (Gardner 1983, p. 54) ‘… because I wish to dull my vigilance’ (p. 70). As with all unconscious, non-contained aspects of a personality, the search for containment goes on. These aspects are what Bion called ‘thoughts without a thinker’ (Bion, 1962b, p. 83, 1967a, pp. 165-6, 1992, pp. 309, 326).
Psychoanalysis can be understood as a kind of group work: ‘the psychoanalytical situation is not “individual psychology” but “pair”’ (Bion, 1961, p. 131).
The analyst presenting in a group submits work that actually was done in a minigroup of two: the analyst and the analysand. Therefore, we will discover the same assumptions in the analytic situation as in a larger group. There can be the mistrust and fight and flight of baF; the dependency, idealisation and denigration of baD; and the erotised and jealous transference of baP.
The peer group listening to the presentation is a sensitive instrument that responds to the impact of any basic assumption mentality in the clinical material. The critical question for the group, however, is whether it will maintain the aims of a work group learning from experience, or whether it will act out its anxiety and turn into a basic assumption group. ‘The basic assumption of the group conflicts very sharply with the idea of a group met together to do a creative job’ (Bion, 1961, p. 64). It is however not the group that is responding to the material; it is rather the individual members that respond to the material and to the comments by other members. The individual responses and mutual interchanges then gather into a group mentality.
From the vertex of the individual in the group, everyone approaches the impact of the presented clinical material with the same theoretical and technical tools as when one is working as an analyst. The group members are analysts with training and experience in listening in a ‘psychoanalytic state of mind’ (Green, 2000, p. 63) with an evenly suspended attention (Freud, 1912, 1923, p. 239) without memory and desire (Bion, 1967b), in reverie and transformation in dreamwork (Bion, 1962a, 1962b, 1992). The impact of the presentation sets the minds of the receptive listeners to work. Here, the role of the group becomes evident. Its members offer themselves as thinkers for the hitherto un-thought thoughts.
However, the participants are not receptive to identical aspects when they listen with their unconscious and conscious minds. Therefore, the participants' comments may be contradictory. Just as in the psychoanalytic situation, no effort is made to solve contradictions. Any comment may contribute to further perspectives and understanding, and therefore no effort is made to organize or focus the comments. The only order is the list of speakers. All loose ends hang in the air. As this goes on, it often happens that an interesting weave of thoughts appears. At the end of the session, any effort to gather the impressions and knit up the loose ends is avoided. The discussion is left unfinished and without conclusions. When it has worked well, this may give the analyst a sense of ‘newly washed eyes’ in the following work, a new perspective on the analysis.
Concluding remarks
Any group runs the risk of turning its members' conscious expectations of workgroup functioning into basic assumptions, which reflect the unconscious of the members. We have argued that in psychoanalytic case presentations in a group, the dynamics of the group have to be taken seriously and that the setting and procedure must protect and facilitate for the presenter and for the group members to work together. Consequently, we have devised a ‘weaving thoughts’ method of dealing with them. It takes group dynamics into consideration by a design that allows thoughts to wander about and that averts people from debating with each other. The aim is to safeguard a work-group climate, instead of compromising the integrity of its members by letting basic assumptions come into power. The prerequisite is that it is agreed upon from the beginning that this is a special procedure with defined rules.
The rules aim not only at protecting the participants from the destructive potentials of basic assumptions functioning but, by their kinship to the rules of the psychoanalytic frame, they also aim at bringing about a psychoanalytic attitude in each group participant. This will help bringing out the participants' psychoanalytic instruments to provide comments on the presented material. By listening to each other, the presenter, the moderator and the group members will discover new perspectives on the presented work and on one's own work. We even envisage that, for the presenting analyst, the impact of the members' comments might be greater than the sum total of their comments. This is probably because the analyst not only receives interesting comments on the work, but also appreciates the group sharing the containment of the analyst's and the analysand's often difficult positions. Thus, the ‘weaving thoughts’ method facilitates its participants to learn more from each other.
Dedication. After our writing the first version of this paper, Johan Norman fell ill. He struggled with his disease from which he passed away in April 2005. I dedicate our paper to his memory. Björn Salomonsson.
NOTES:
We fitted the method also for smaller groups of therapists lasting two hours (our note) Luca Caldironi
Or Psychotherapists as well (our note) LC
Not only in Psychoanalysis (our note) LC
We had smaller groups of therapists as well (our note) LC
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