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TFP approach to psychoanalytic group psychotherapy

I shall outline, in what follows, strategies, tactics, and techniques of the TFP model of analytic group psychotherapy. The main strategy consists in facilitating the interpretation of Bion’s (1961) basic assumption groups, in the context of a strict focus, on the part of the therapist, on the nature of the primitive object relations and corresponding defensive operations activated in the course of any basic assumption group. In practice, the defensive operations activated in the dependency and in the fight-flight group present the total repertoire of primitive defensive operations based upon splitting mechanisms characteristic for borderline patients. As such, they are eminently relevant for the exploration of the psychopathology of patients with severe personality disorders, who find their dominant emotional reactions powerfully activated in the group situation.

Rather than interpreting the sequential activation of individually determined dominant transferences activated in the course of the group sessions, the therapist’s emphasis is on the sequence of group processes, the progressive and regressive fluctuations of the group tension that facilitates the activation of particular conflicts of individual patients–their “group valence”– at difference times. The individual pathology of any particular patient comes into central focus at a point where he/she occupies one of the polarities of the conflictual dynamics of the group. The fact that the therapist’s interpretations follow the dominant group dynamics, his/her pointing out how this dynamic is played out by different members of the group, practically facilitates interventions geared to individual patients at the time when their corresponding conflicts are affectively dominant. Thus, the TFP principle of interpreting affectively dominant conflicts holds for both the analysis of the group tension (Ezriel, 1950; Sutherland, 1952) and the analysis of the position of key members of the group in the enactment of and reaction to this group tension.

In practice, therefore, after the therapist has interpreted the dominant unconscious dynamics of the prevalent group tension, he may address himself/herself to how this group conflict touches all the individual members’ conflicts in terms of their position taken regarding that particular group conflict. In so far as individual patients’ transferences are directed to other members of the group, to the group as a whole, and to the group leader, moments where all these three vectors come together may provide a powerful source for emotional understanding for individual patients.

The therapist’s interventions in the group are guided by the same principles as the interventions in individual TFP sessions: first, by what is affectively dominant in the group, second, by the nature of dominant transferences operating within the group atmosphere, and third, by his/her countertransference. The therapist’s interventions consist in clarifications–namely, efforts to clarify the dominant issues affecting the group at a certain point; confrontation–namely pointing to the non-verbal behaviors that accompany and often overshadow the verbal communication among group members and of the entire group toward the leader, and interpretation per se–namely, of the unconscious conflict inherent in the activation of a determined group tension and the corresponding basic assumption group. The interpretation consists in focusing on the dominant group theme, by first pointing to the predominant conscious and preconscious experience of the group; then, the opposite, avoided theme and the motives for this avoidance, and finally, the nature of the experienced threat connected with what is avoided.

The therapist maintains an attitude of technical neutrality regarding the developments in the group, limited by his establishing clear rules about what is not tolerated: particularly, physical aggression against the therapist, against other members and property, or gross sexual harassment, such as seductiveness in the form of stripping, or self-destructive behavior, such as self-cutting or burning. The techniques utilized, in short, are interpretation, transference analysis, technical neutrality, and countertransference utilization. Countertransference utilization refers to the analysis in the therapist’s mind, of both concordant and complementary identifications he/she experiences regarding the group as a whole and individual members, followed by the utilization of the understanding of these developments as part of the interpretive formulations.

The technical approach, therefore, follows the same general principles and guidelines of the technical approach in TFP, while the overall strategy, of highlighting and resolving the dominant split off or dissociated primitive internalized object relations of these patients, are systematically explored in the order in which these object relations are achieving dominance as part of the group regression. Dominant object relations may be enacted by the group as a whole in relation to the group leader, by individual members toward the group, the leader, and toward other individual members. By means of the activation of projective identification, the role of self and object representations may be rapidly exchanged among the members of the group as well as between the group and the group leader.

So far the strategic and technical applications of TFP to this modified Ezriel-Sutherland model. From the viewpoint of tactical interventions, they include general arrangements that are specific for a group therapy approach, and particular ones corresponding to the specific application of a TFP model. Regarding general tactical interventions, they refer to the selection of members of the group, a complex decision making process, that, in general terms, corresponds to the same criteria for indications of Transference Focused Psychotherapy in individual patients mentioned before. Contraindications include patients with an intelligence level below an IQ of 85 or 90; severe, uncontrollable secondary gain of illness; significant antisocial behavior, that would risk the confidentiality of group processes to which the participants have to commit themselves, and objectively threaten other group members; and severity of acting out or comorbid conditions that could not be easily handled by an individual therapist taking care of those aspects of treatment outside the setting of the group psychotherapy.

The development of particular complications and severe regression of individuals in the group usually can be managed when the overall group setting is clear and consistent. Chronic monopolizers can be managed easily by pointing to the group’s tolerance or unconscious fostering of such behavior, and its meanings under the concrete group circumstances. The chronically silent patient may be much more behaviorally active in the context of shifting group themes than what is revealed by language alone, and varying meanings of the defensive use of silence can be explored in the context of its function as part of the group process. The manifestation of group resistances in the form of shared, extended silences, trivialization of the contents of the group discussion, demonstrative ignoring of the group leader and of his interventions, all become part and parcel of potential transference interpretations.

References

Bion WR (1961). Experiences in Groups. New York: Basic Books.

Ezriel H (1950). A psychoanalytic approach to the treatment of patients in groups. J Ment Science 96:774-779.

Sutherland JD (1952). Notes on psychoanalytic group therapy. I: Therapy and training. Psychiatry 15:111-117.

Otto Kernberg, New York