losing, finding and failure: a group analytic perspective on the treatment of depression

LOSING, FINDING AND FAILURE: A GROUP ANALYTICPERSPECTIVE ON THE TREATMENT OF DEPRESSION

Charles Montgomery

We must surrender our hopes and expectationsas well as our fears and walk directly into disappointment.

(Chogyam Trungpa)

ABSTRACT Group analytic psychotherapy is one of the principle forms ofpsychotherapy offered within the NHS. One of the main reasons for referral forpsychotherapy is for the treatment of depression. There is growing evidence thatfor certain depressed patients group analytic treatment is effective and capableof producing lasting beneficial change although the mechanisms by which thisoccurs are not fully understood. In this paper I examine factors which I proposeare of particular benefit to the depressed patient. I suggest that within the highlysupportive set of relationships that the group comprises, themes of loss andfailure can paradoxically lead to integration and increased coherence leadinggroup members to a new perspective on the intersubjective nature of their lives.

The Context

Group psychotherapy is one of the most widely practised treatment methodsin psychiatry with depression being the commonest reason for referral fortreatment (Pines & Shlapobersky 2000). Within the NHS group analyticpsychotherapy is the principle form of dynamic group therapy offered topatients and yet the literature on the treatment of depression by groupanalysis is sparse. Recent meta-analyses of the usefulness of group therapyfor depression is unequivocal – it is an effective treatment (Robinson et al.1990; Tyllitski 1990; Budman et al. 1998). McDermut et al. (2001) providethe latest meta-analytic review, summarized in Evidence Based MentalHealth (August, 2001): 43 out of the 48 studies examined showed statisticallysignificant reductions in depressive symptoms, nine studies showed thatthere was no difference in effectiveness between group and individualtherapy and eight studies showed cognitive behavioural therapy to be moreeffective than psychodynamic group therapy. In the latest cumulative index

British Journal of Psychotherapy 19(3), 2003© The author 297

CHARLES MONTGOMERY is a Consultant Psychiatrist working in Exeter, Devon. He isa trainee group analyst with Group Analysis South West. Address for correspond-ence: Department of Mental Health, Wonford House Hospital, Dryden Road, ExeterEX2 5AF. [email: [email protected]]

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of the journal Group Analysis covering the 24 years from 1967 to 1991 thereare only eight references to depression; six of these papers came from aspecial section issue devoted to the subject albeit with a strongly cogni-tive/behavioural slant.

One possible reason for this seeming blind spot amongst researcherscould be that treatment with group analysis is actually treatment using thedepressive process itself as the mode of therapy i.e. the process is one ofshedding, letting go and disillusionment contained within a highly support-ive set of relationships. Group analysis is as effective for depressed patientsas non-depressed patients – all will through treatment become ‘depressed’.What can be transformational about this process is the re-emergence fromthe group matrix of individuals with a different orientation to others.

In this paper I highlight those aspects of group analysis which are particu-larly useful in the treatment of depression comparing them with psycho-analytic theory. I examine the role played by the successful containment offailure in the treatment of depressed patients and its use as a transitionalprocess, the outcome of which is a paradoxical increase in group and indi-vidual coherence.

Introduction

I start with the hypothesis that one of the central experiences during a groupanalysis hinges around the polarity of losing and finding. One loses one’sway. One loses humour. One loses face. Understanding gets lost; feelings getlost. Even the problem which was the reason for treatment gets lost. Thereis a large literature on loss and depression but the process of finding, whatit is that is found and how this helps has been neglected. The first steptowards a finding is to become aware of the loss. Just as one is drawn to theplace of loss of a real object (a bunch of keys) in order for it to be found, itis possible to conceive of an ‘emotional finding’ as only being possible at thesite of loss. In this sense grief requires a place and at the place of what hasbeen lost there is the possibility of a finding.

An important task of therapy is to find the place of loss and to wait there.This in itself requires a considerable and painful effort but then how does afinding happen, what makes this possible and out of what is it made? Isuggest that ‘finding’ can only come about out of a failure to find. What iswanted or expected is not found. The lengthy and profound sense of indi-vidual and group failure that is a dominant, although often unacknowledgedpart of therapy, if successfully contained, gives way, through the ongoingnecessity of communication, to an inner sense of coherence and a newunderstanding of the intersubjective nature of self. This links with one ofFoulkes’s central notions, that the individualistic neurotic position is‘genetically the result of an incompatibility between the individual and hisoriginal group’ (Foulkes 1964). In the broadest sense then in group analytic

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terms coherency, or synthesis, or integration between the individual and thegroup, is what can be discovered and experienced through therapy.

Finding

Although the concept of ‘insight’ is aligned historically with one-personpsychology it is useful at this stage to see how it fits into the idea of finding.In the O.E.D. (1989) it is defined thus, ‘internal sight, mental vision orperception, discernment. A glimpse or view beneath the surface’. In WebstersDictionary, ‘penetrating into or apprehending the inner nature of things’.Freud linked insight to the discovery of unconscious reality. In ‘Remem-bering, repeating and working through’ (Freud 1914) he postulated insightas being the decisive cognitive act and that working through occurs subse-quent to it. Kris (1956) argued for the concept of insight to be attached notonly to the contents but also to the patient’s accessibility to his thoughts. Inthis way insight is seen as a process of integrating psychic activity whereopposing mental levels are brought together requiring the mastery of a stateof tension. What is ‘found’ then are thoughts, the previously unthoughtknown (Bollas 1987), which allow for new and integrating connections.

Group analysis takes as its starting point that mankind’s nature is socialthrough and through with the group existing before the individual.

The group, the community, is the ultimate primary unit of consideration, and theso-called inner processes in the individual are internalizations of the forcesoperating in the group to which he belongs. (Foulkes 1971)

In other words inner processes are internalized group dynamics and so the‘finding’ from this persective is about place or context. By this I mean theindividual has to come to the realization that he is not an individual at allbut ‘part of the whole’ and this requires a painful letting go. This first findingor insight then of itself requires a further loss.

I would like to propose that from a group analytic perspective the ‘finding’is less to do with the restitution of the ‘good object’ or the finding of thenascent ‘true’ self, and more to do with the experiencing of a new perspec-tive on all that which surrounds and is connected to the self. It is a discoveryof the context of self which broadly can be described as the social but which,I think, goes further than this. The social comprises the intricate network ofinterpersonal relationships that surround the baby before and after its birth,the ‘Intimate Social’, to give it a name, and the larger ‘Cultural Social’context that places the Intimate Social within an historical process.

But more than this, beyond the social and the historical, the place fromwhich the self has emerged has an evolutionary context; the self belongs tothat group of living things that comes into existence, feels the warmth of thesun, the weight of the wind, fades and dies. Foulkes refers to this as the‘primordial matrix’ and at the deepest level it is what is activated during agroup analysis. In this paper I want to expand on the notion that, through

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the repeated processes of losing and finding, a tension develops betweenfailure and its successful containment, and that within this paradox oppor-tunities are created for increased coherence, not just within the self, butwithin this larger intersubjective space.

From Communication, Through Cohesion, Towards Coherence

Yalom’s (1970) well-known 11 therapeutic factors characterize the range ofhealing potential in group psychotherapy. Of these the most significant forthe treatment of the depressed patient are the instillation of hope, univer-sality, interpersonal learning and group cohesiveness. In a recent paperTschuschke and Dies (1994) studied five therapeutic factors: group cohesive-ness, self disclosure, feedback, interpersonal learning and family re-enactment. Group cohesion shows a linear positive relationship withoutcome in all published reports of group therapy efficacy; it has beensuggested that it acts as precondition for therapeutic change. They suggestthat affective integration into the group promotes self disclosure which inturn leads to more frequent interpersonal feedback. The earlier thisinterpersonal feedback ‘loop’ is established the more likely it is that therewill be a positive outcome for that individual. This suggests that inter-personal feedback needs to be fully integrated before it can be experiencedas helpful. Their study highlights the point that different change-inducingmechanisms become important at different phases during the group’sevolution.

The idea of cohesion overlaps to a large degree with the concept ofcommunication, a central aspect of group analytic theory. Foulkes came toequate verbal communication with the therapeutic process itself:

Communication is a process which moves from remote and primitive levels ofthe psyche to ever richer and more articulate modes of conscious expression . . .it is closely bound up with the therapeutic process. (Foulkes & Anthony 1957,p. 246)

Without communication there is no chance of cohesion but cohesion of itselfis not necessarily therapeutic. Cohesion is about binding together parts tomaintain a unity; coherence, on the other hand, is a more complex organiz-ing principle in which there is an inherent capacity to attain integrationthough internal processes; it implies a maintenance of balance and harmonyas an active process involving higher levels of functioning than that ofcohesion. It is far harder to measure than cohesion but is a central outcomeof group analytic treatment (Pines 1986). Depressed patients in particularhave difficulty in articulating their problems as acknowledging the associ-ated feelings of destructiveness and hostility is usually strongly resisted.Initially much help is needed to enable the patient translate his symptominto a social medium, language, in order that it can become available to thegroup.



Paradox in the Group Approach

This un-blocking of the communicational field is the prerequisite for a goodoutcome but it doesn’t guarantee it. The group will tire of attending to thespecifics of a group member’s problem and after a time it will fade into thebackground. This can be a puzzling time for the depressed patient who hasjoined the group to talk about his difficulties; he will instead be drawn intothe ‘passionate discussion of and involvement with the shifting roles,relationships and behavioural communications that make up the system ofthe group itself’ (Garland 1982). According to Garland the involvement ofthe patient in an alternative system to the one in which his symptom wasgenerated and maintained, his concerning himself with the ‘non-problem’, isa powerful inducer of change. I would add crucially that the loss of ‘theproblem’ as the focus of therapeutic endeavour confirms for the depressedpatient a sense of failure that is paradoxically an important ingredient in hisrecovery.

It is necessary, for my purposes, to differentiate between the terms‘contradiction’ and ‘paradox’. Where a contradiction may be a ‘a state ofopposition in things compared: variance; inconsistency’ (O.E.D. 1989), aparadox is not quite the same. In a paradox there is the appearance ofcontradiction, but a paradox differs as it is a contradiction which is subsumedunder a unifying principle. A paradoxical statement, then, is one which is‘seemingly self-contradictory or absurd, though possibly well founded oressentially true’ (my emphasis) (O.E.D. 1989). For example, I love and hatemy child. Hatred and love may seem to be contradictory, but they actuallybelong together in me. Both feelings live simultaneously in one person, theone holding the contrary two. Returning to Klein’s metapsychology (Klein1946), the contradiction may be illustrated by the concept of the ‘paranoid-schizoid position’ with its splitting and projection, the paradox can becompared to the depressive position in which there is an ongoing attempt toreconcile oneself with ambivalence. (‘The co-existence in one person ofcontradictory emotions or attitudes towards a person or thing’ (O.E.D.1989).) What the patient then experiences as his problem gets lost is a lossof attention and interest which brings him up against this paradox: he hasjoined a group within which the relationships provide a high level of nurturewhilst also failing to provide nurture. As Beisser (1972) describes in ‘Theparadoxical theory of change’, growth is most likely to occur when neithertherapist nor patient is trying to make it happen: ‘. . . change occurs whenone becomes what he is, not when he tries to become what he is not’. Andso the patient who brings his ‘problems’ to the group to be solved may findthat they proliferate until such time as he is forced with the group’s help toview them as paradoxes to be experienced rather than as problems to besolved.



As long as a paradox is treated as a problem it can never be dissolved. On thecontrary, the ‘problem’ can do nothing but grow and proliferate in ever increas-ing confusion. (Bohm 1972)

This paradoxical situation, I suggest, is developmentally facilitating asthrough the tension that develops between failure and its successful contain-ment the self is forced into a reappraisal of its relationship with the world.This is a crucial phase in the treatment of the depressive within the groupas this loss will not be experienced singly, rather it may appear as part of aseries of losses that merely confirms for the patient his own worthlessness.There is a danger when feelings of failure abound that for the depressedpatient there will be a re-projection of the bad object onto the group whichcould result in the patient dropping out disillusioned. The conductor needsto be alert to this possibility and may need to call up forgotten positiveexperiences which can then co-exist within this atmosphere of failure. As anexample, I’ll describe a two-year-old group consisting of seven patients fourof whom had long histories of depression. Contemplating the decision of onegroup member to leave had plunged the group back into feelings of failureand impotence. ‘It’s as though we’re back where we started,’ stated onegloomily. ‘I hate it when it’s like this,’ stated another. This prompted onedepressed member, Steve, to recall his feelings of loss when his eldest sonleft home. Following a discussion of children leaving home another member,Jane, asked Steve if he’d ever told his son and remaining daughter what hethought of them. This led Steve to recall fondly the times when he hadmanaged to tell them that they’re ‘great’. There followed a long and fullsilence in which I, as conductor, thought the seemingly all pervasive atmos-phere of failure was being lightened. I recalled from a previous session manymonths ago an episode in which Steve’s children had demonstrated theirconfidence in their father despite his prolonged depression and inability towork. I reminded him of this and asked whether they ever expressed theirfeelings towards him. At this he was able to tell the group, with tears in hiseyes, of a recent occasion when this had occurred and how surprised he hadbeen by their affection and interest. This led to a positive exchange betweenthe group member who had decided to leave and Steve. Alongside ‘thefailure’ there came to exist feelings of gratitude and acceptance whichseemed to me to deepen the capacity for containment within the group andwhich in turn for Steve allowed for a softening of his persecuting self image.

Failure as a Transitional Process

Patients who present as depressed, according to the object relations view,are stuck with an identification with a lost object. They are unable to separ-ate what has been lost from themselves; when they see what has been lostthey see a reflection of themselves, they are lost in the mirror of Narcissus.A depressive relationship with an object is attained by experiencing it as



separate from the self; this experience is enhanced by experiencing it ashaving relationships to objects of its own in which one does not participate.This oedipal situation is recreated many times over in groups where it actsas a force separating out individuals and acting against the very strongtendency to merge. Early on the manifest failure of the group conductor toprovide enough nurture for each individual and the unfairness at having toshare the conductor’s attention along with the unavailability of both con-ductor and group between sessions induce strong feelings of wrath, failureand badness amongst group members. These themes need to be toleratedand worked with as, through the conductor’s interpretations, co-existingalongside these ‘bad’ feelings ‘good’, positive feelings can be found thatprovide nurture. In a facilitating group that is working towards maturity,wrath, failure and badness are given their rightful place. The oppositionbetween ‘good’ and ‘bad’ is dismantled and through tolerance of ambiva-lence a spectrum of experience is revealed. The working through of ambiva-lent feelings occupies a crucial part of therapy especially for the depressive.For the person whose experience of loss and injury has been overwhelmingevery effort is made to evade anxiety and mental pain with a withdrawal inwhat John Steiner (1993) has termed ‘psychic retreats’. Here a pathologicalorganization has evolved which is designed to protect the person fromawareness of their hatred and wish to avenge the earlier injury. If the groupcan make sufficient contact with this psychic reality to acknowledge both hishatred, which leads to his wish to destroy the object, and his love, whichmakes him feel remorse and guilt, then development will be possible. Forthe depressed person the burden of guilt is excessive; the group is an effec-tive setting where guilt can be faced and reduced to more manageable pro-portions. Sally Dean (1997) in her qualifying theory paper makes theimportant point that it is excessive guilt that magnifies the conflict of ambiva-lence to unmanageable proportions – the guilt of hating where you also love.According to Bion (1963) it is the tolerance of ambivalence that is essentialin facilitating an increased ability to think which is the beginning of a gainingof new perspectives.

In Winnicottian terms applied to groups there is a move through thefollowing developmental stages: (1) presence to be omnipotently mergedwith; (2) disillusionment and transitional processes; (3) group to relate to,and (4) group to use.

The shift into the depressive position, or, as Winnicott termed it, the ‘stageof concern’, where a realistic separateness allows for the possibility of grief,is often signalled in groups by group members experiencing a profoundsense of failure – the whole group is a failure, the whole enterprise a wasteof time. I suggest that every group fails its members if it is to succeed inrestoring to them a sense of their own value in the great scheme of things.Failure is inherently built into the group in the sense that it cannot be anymore than it is. As Winnicott (1958) pointed out, the therapist’s job is to fail



as a substitute parent in order to give the patients an opportunity to investi-gate the meaning of the not-good-enough mother. Through this wrestlingwith failure unspoken omnipotence and unrealistic expectations have to giveway to a humbler reality. It is the equivalent to the group suffering thenarcissistic wounds of infanthood. When the group reaches this level it isworking profoundly on the process of failure which, I believe, is an essen-tial aspect of work with depressed patients. A different set of metaphors arebeing activated from the matrix not those of success, growth, integration butweakness, vulnerability and loss. To quote Hillman (1972):

When I am in despair, I do not want to be told of re-birth; when I am ageing anddecaying and the civilization around me collapsing from its over-growth that isover-kill, I cannot tolerate that word ‘growth’, and when I am falling to bits inmy complexities, I cannot abide the defensive simplicities of mandalas, nor thesentimentalities of individuation as unity and wholeness. These are formulaepresented through a fantasy of opposites – the disintegration shall be compen-sated by integration. By what cure through likeness where like takes care of like?I want the right background to the failure of life; I want to hear with precisionof those Gods who are served by and thrive upon and can hence provide arche-typal background to and even an Eros connection with the defeat, decay anddismemberment, because these dominants would reflect the experienced psychein the actuality of its only known goal which is also its way and its substance,death. (p. 6)

Failure and Containment

How can this be of value to the depressed patient? The therapeutic elementin the group relies upon a sort of natural impetus within people, the deepneed to belong, and in order to belong one has to find a way of workingtogether. Farhad Dalal (1998) makes the simple but important observationthat it is the process of arriving at the point of working together, of arrivalat a place of belonging, that is in itself the therapy. This arrival after muchstruggle at a place that feels like the beginning corresponds to the shift awayfrom the anxiety-laden, conflict-ridden, paranoid-schizoid position to themature group where depressive relations are established based on realistic,undistorted perceptions and current rather than archaic meanings. Bion(1963) referred to this as the ‘work group’. It is the mature work group whichprovides the containment for the failure and loss which has been experi-enced in childhood as unmanageable at best and usually as totally anddamagingly overwhelming. The recovery from such narcissistic blows to abalanced state of healthy narcissism is seldom fully accomplished. The valueof the re-experiencing of failure lies in its containment within the group; thiscauses or reinforces the capacity for self containment. It is the juxtapositionof the self containment of failure set alongside the network of nurturingrelationships within the group that can be healing. We all fail in the sensethat eventually everything has to be given up in death, but there is nolanguage to describe this as an ongoing reality. The failure of omnipotence



in childhood heralded the beginning of this long goodbye. In the search fora shared communication within the group that does not serve evasion ordenial even at the bleakest depths, words are found that gather a life aroundthem. This forces a different perspective of the world on the group member,one of acceptance and tolerance; what opens up is an awareness of the placesaround the self.

The Places Around the Self

Kohut’s (1977) self psychology and psychoanalytic thinkers such as Mitchell(1988), Ogden (1994) and Stolorow & Atwood (1979) have emphasized theintersubjective nature of human relations. Intersubjectivity locates theexperience of, for instance, the analysis as it exists in the patient’s psychesomewhere between the patient and the analyst. The intersubjective field isthought of as a system formed by the reciprocal interplay between two ormore subjective worlds. It is an exposition of the myth of the isolated mindand as such is a radical perspective that is more than just an interpersonaltheory; it is a view which leads psychoanalytic theorizing several stepstowards a group analytic view. The self-object, the other, is always an essen-tial part of the self’s development; in stressing the continuing need fordependency it overlaps to a degree with Bowlby’s attachment theory. It fallsshort in that, in so far as ontological priority is still given to individualpersons and then to the things that happen between them, they are stillthought of as existing a priori to the group from which they emerged.

In Farhad Dalal’s (1998) in-depth critique of Foulkes’s group analysis,Taking The Group Seriously, a radical alternative is offered in which theconsequences of viewing the group, the community, as the ultimate primaryunit of consideration is argued through.

What Dalal describes in essence is the breaking of a new paradigm whichrequires a new way of thinking analogous to the new thinking that isrequired when describing quantum physics. Groups, communities andsocieties are not primarily made up of individuals but of networks and field-forces held together and kept apart by the glue of the social unconscious.One consequence, according to Dalal, of taking the group seriously is to saythat the personal includes the impersonal personalized. By impersonal ismeant the structuring forces of ideology and history as they are embeddedin the social unconscious; as they are instituted in language and social struc-tures they are taken in as language is acquired; they are swallowed whole as‘an undigested piece of society’ (Harland 1987). In this way of thinking ‘self’becomes a transpersonal construct, a fluid constantly evolving almost un-definable entity that slips through language like water through fingers. Thequestion – where does the self reside if not within an individual? – comes tosound very like a Buddhist koan; there is no answer and if one is temptedsuch as, within the matrix of the social unconscious, this simply leads to other



‘koans’ – where is the social unconscious? etc. etc. We are bumping upagainst the limits of understanding, as Elias (1978) has said, becausethought, speech and knowledge are one and the same, and all of them failto reflect the true multiplicity of existence.

Returning to the therapy group, thinking about what gets lost and whatgets found takes on new meaning when the reality of a social or collectiveunconscious is allowed for. It must be that elements of the personalizedimpersonal become activated in transferences – thus we can have feelingsand reactions to things outside our experiences. The individual experiencesof childhood failure and loss constellated in the matrix are available to alland in so far as they can be communicated are part of the group’s socialmemory.

In the group through the repeating cycles of loss, which alternate withgains, themes emerge which peak, last awhile and then fade. During thebuild-up phase there may be intense discussion with the accompanyingfeeling that something worthwhile is being created and connections made;there is the sense of expansion and expectation. These alternate with periodsof contraction when, often following conflict, doubts and uncertainty areexpressed, a loss of meaning descends like a fog and group members retreatinto defensive silence. The ensuing loss of communication resonates withother losses; there is palpable deflation and failure. The group may reachinsights at any stage within these cycles which are sometimes accompaniedby a profound and moving atmosphere that resonates within and around thegroup. The experience is always remembered but very often the detail getslost. Insights cannot be held onto as a possession of the self but are sharedwithin the group’s process. This involves group members in an oft-repeatedpattern of relinquishing what has been found to be precious. This releasingand letting-go of what has been found for me and which is therefore mineinto the social stream of the group is healing as it orientates the personalitytowards a greater and more complex wholeness. For the depressive this canbe experienced as a relief – it is not just about me and my self in isolation.Paradox abounds: the more that is lost the more that is found, the emptierI feel the fuller I become. When less comes to feel like more, a degree ofcoherency is taking place within the self in which excess and surfeit aregiving way to realistic absence, which is not the same as emptiness, as in thisabsence after much hard work and waiting there can come to be felt, faintlyat first, the connecting pulse of presence.

Conclusion

In summary this paper has attempted to tease out some of those aspects ofgroup analysis that may be of particular benefit in the treatment of depressedpatients. I have used my own experiences of treatment to reconsider thethemes of loss and losing which I view as existing in a constant state of



tension with emotional ‘finding’ or insight. Out of the see-sawing of thesepolarities in which there is a lack of satisfactory resolution there developsthe theme of failure which has to be wrestled with for the group to survive.The emergence of failure and disillusionment corresponds with the groupshifting into a depressive set of relations where the ability to tolerate ambiva-lent feelings comes to occupy a central role in the group’s work. For thedepressed patient an understanding of the origins of long staved-off feelingsof guilt becomes possible through ambivalence having been made moremanageable. Through its successful containment, failure can operate as atransitional process which enables members to move from a position ofrelating to the group, to using the group. Out of this engagement with failurethere emerges paradoxically the potential for healing with group membersacquiring inner coherence and a new perspective on the intersubjectivenature of their lives.

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losing, finding and failure: a group analytic perspective on the treatment of depression

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