The author gives a report on the therapeutic use of the large group within the setting of sheltered living as a "Therapeutic Community within the Community". The setting is outlined and a definition of the large group and the large system group as the entire network of significant others within the living field of the patient is given. The diagnostic and therapeutic application of both settings are illustrated. The large group and even more the large system group is understood as a powerfull therapeutic means to gain an understanding of the psychotic and borderline patients dynamic and to further the integration of his fragmentated or split off personality parts.
Foulkes, who had the capacity not to allow himself be made the punching ball of history, but
who himself made history in 1948, wrote that the therapists task is to work in the
patients life space. Stewart Whiteley (1996) rephrased this in the following statement " the
patients whole activities contribute to an understanding of his psycho-pathology," and I
would add, "his constructive potentialities". This needs to be recognised and incorporated
within the team philosophy and brought under the aegis or protective covering of one
therapeutic team. In practice there is a great risk that the opposite will happen and the life
space will be split up and managed by different authorities.
The patients entire life space, understood as a large system group, presents us with the key
for understanding him. It offers a chance to create the optimum interpersonal conditions
necessary to build a containing, holding, growth-enhancing matrix for the facilitation of his
psychic development. At the same time we should be aware of the fact that it is also part of
the therapeutic workers life space.
In the course of more recent developments of the practice of "the therapeutic community
within the community" we found that working with the large group and the large system
group has opened up new therapeutic opportunities. I want to present for discussion our
findings that large group processes and large system group processes may mirror and " put on
stage" the patients inner objects and part object relations. This understanding, when applied
to our clinical practice of "the Community within the Community", has opened up further
therapeutic possibilities for the treatment of psychotic and border- line patients.
Previously the clinical practice of "The Community within the Community" was presented in
this Journal ,Wallenberg Pachaly, Sylvia 1997). Therefore the setting is only briefly
There are four groups of eight patients of both sexes. Each group lives in a flat or in a
house. The diagnosis of the patients range from severe borderline-conditions and extreme
anxiety to schizophrenically or psychotically reacting patients. The majority of patients
have had previous in-patient treatment, but about one fourth have had out-patient treatment
only. About 75% are on psycho-chemicals at the time of admission. The duration of their stay
is 3 years, but a prolongation of one or two years is possible, if thought to be of therapeutic
The sheltered flats are managed by a team of social workers. They are trained in group
dynamics, are under continuous supervision and conduct the groups mentioned above.
Their prominent task is to co-ordinate and integrate the patients various fields of living
and learning (the large system group as defined below) and prevent splitting and
fragmentation from occurring. Another important task is to make transparent the
underlying conflict, how it is re-enacted and "put on stage" and to support the group in
creating an atmosphere of curiosity and enquiry. By motivating all patients to undergo
group or individual the basis is broadened such that the patient becomes able to integrate
into society; be this by means of continuing education, paid work, or sheltered work. Of
course, there are quite a few sheltered flats in Germany, but what makes the change of
paradigm in our view is:
The institution which has created the conceptual, financial, and organisational framework to
enable us to conduct this work is the Free Counselling Centre for Psychotherapy, a N.P.O.,
The large group proper consisting of 25 to 35 persons, includes the patients of all four flats,
staff, and board of directors. All staff are therapeutically trained and "face to face"
communication is possible at all times ( see Fig.1). I distinguish between the large group and
the large system group in that the latter may be conceptualised as the entire social network
which represents the individual patients life space. This includes the patients communal
group (his flat ), our institutions therapeutic staff group, the psychiatrist with medical
responsibility for prescribing and monitoring medication, the individual or group therapists, the
people at work or at his sheltered work place, family and friends and, during times of acute
crisis and subsequent hospitalisation, the hospital staff and the representatives of the social
welfare agency which provides the financial support for the social work input. ( see Fig.2 ).
Since the large system group is characterised by the fact that "face to face" communication is
no longer possible, it easily arouses persecutory anxieties and reinforces the defence
mechanisms of projection, projective identification, splitting and fragmentation.
This has been frequently discussed in the recent literature, in particular by Kernberg in his
paper on "Bureaucracy and Ideology as Social Defences against Paranoid Aggression" (1995).
It is my understanding that the large group and even more the group large system group is a
means of getting in touch with the psychotic nucleus of groups as well as of individuals.
The following hypothesis is an attempt to challenge the conventional knowledge relating to
large group processes and to facilitate a dialogue which will explore the conditions under
which they become constructive and healing. It is also a response to Kernbergs discussion on
the disruptive power of large group processes in "Projective identification,
countertransference, and hospital treatment" (1993). The hypotheses I wish to propose are:
Three members The staff of
of the board three social
of directors workers and
Patients Psychiatrist, Patients Family
who gives medication members
Patients Individual and/or Patients friends
Group Psychotherapist Patients spouse or Partner
The hospital staff in fellow worker and boss
times of hospitalization at work
during acute crisis or sheltered workplace
Lawyer, social worker or 30 Patients of four flats
relative who has custody of
over the patient The Therapeutic Community
within the Community
Three members The staff of
of the board three social
of directors workers and trainees
Representatives of the social welfare agency
Peter van der Linden (1994) discussed the large group as a stage upon which
internalized interpersonal and group conflicts and petrified traumatic scenes of the "there and
then" came to life, De Mare (1991) described the large group "as being an unconscious,
learning to speak". Our task then must be to listen to it.
The unstructured large system group encourages the revival of existential anxieties of the
"there and then", feelings of annihilation and of being swallowed up. It is unstructured in the
sense that interpersonal and inter-group communication is neither formalised nor
regulated, though everybody, somehow, knows of the existence of the other, often via a third
party. Anxieties aroused in patients, are also experienced by the therapeutic staff members of
the large system group.
Prominent in both the large group setting and the large system group setting are the
defence mechanisms of fusion, fragmentation, and splitting. I have observed that these
psychotic and borderline phenomena occur regularly if psychotic and borderline patients are
part of the large system group. This seems to be because of the fact that psychotic and
schizophrenic patient sway between fusion and autism and reactions are fragmented in the face
of a world experienced as overwhelming. Borderline patients unconsciously resort to splitting
as a way of coping with their inability to sustain, tolerate and contain ambiguities, and handle
doubts and open questions concerning relationships. They appear to find comfort in their
experience of the world as a permanent struggle between the good and the bad. From a
developmental, psycho-genetic and group genetic point of view, it is my understanding that
feelings experienced in the large group, date back to an early developmental period in the life
of the infant, where the differentiation between I and you, self and other, the inner self and
the external world is at best blurred but certainly not yet fully established. The establishment
of a mature sense of identity is in a state of status nascendi, and feelings of omnipotence
alternate with feelings of complete helplessness and impotence. Projective identification is a
major means of maternal communication with the infant and persecutory anxieties alternate
with feelings of oceanic well being, complete containment and ecstatic fusion.
De Mare (1974) described how the large group is experienced by its members alternatively as
a persecutory environment which is oppressive to the individual member, who does not feel
free to express his half-thoughts spontaneously, and on the other hand, the feeling of not
belonging at all, which creates a feeling of freedom simultaneously accompanied by feelings of
extreme panic in face of the experienced abandonment. This resembles the psychotically
reacting patients position of fusion on the one hand and fragmentation and autism on the
other. If we follow De Mares thinking, which seeks to explain schizophrenic personality
organisation in terms of a large group process arrested at an earlier stage of chaos and
annihilation, we may regard large system group therapy as an avenue towards the therapy of
the psychotic and schizophrenic individual. Because if we succeed in unlocking the arrested
processes of fragmentation and fusion occurring in the large group we may achieve a
considerable psychic workload of integrative and motivational work on behalf of the patient.
We may use the idea of parallel processes to visualise the interconnectedness of the large
system group process and the psychotic world of the patient. A psychotically reacting large
system group is prone to induce a patients psychotic reaction. We can observe a two-way
interdependency. We may, as "influential members" of the large system group, succeed in
monopolising the leadership of this group in order to cope with the destructive
communicative disruptions from within it. These disruptions mirror the predominant defensive
organisation of the patient, and may be viewed as an expression of his or her deep seated
conflicts arising from an earlier pre-verbal stage of development or as an expression of
developmental deficits, defects or ego distortions. This understanding provides us with
valuable and impressively forceful insights which enables a deeper understanding of the
patients existential dilemmas and of the traumatic scenery he carries within himself which he
has not succeeded in leaving behind in order to fully live his own life.
The following clinical example of a severe borderline-personality organisation with a long
history of self-mutilation who was hospitalised for a life endangering loss of blood, illustrates
how the large system group can succeed in containing the patient.
The patient had been very shy and withdrawn during her stay at the flat. She had a long history of self-mutilation, and her attempt to go to university had failed, because she could not tolerate the publicity of the campus. She was the daughter of a former priest who had married her mother. He had suffered and felt ashamed because of having been expelled from his priesthood in disgrace.
On the visitors day of a time-limited therapeutic community, Wallenberg, ( 1992 ) she had
expected her parents to visit her. But although they had promised to come, they didnt turn up,
nor did she receive an explanation. The patient was proud of her achievements in the community and wanted her parents affirmation but felt devalued at their absence and very
Two weeks later, her individual therapist had promised to join our supervision group
to exchange information on the patient. Previous to this, we had only spoken on the telephone. He did not turn up. The patient had been very eager that such an exchange would take place and was, of course deeply depressed experiencing it as a repetition of her parental situation. I myself, felt de-valued and angry with the therapist and more so because I recalled a social worker reporting to me that the same therapist had disparagingly labelled my therapeutic community a" holiday camp ". I could not fail to register the significance of the event and realised that some scene was brought " on stage ". After three weeks I finally decided to call the therapist in question. We had a very frank and fruitful talk, where we shared our feelings and observations concerning the patient and each other. This in turn resulted in a significant relaxation of the patient, who now seemed to be more at ease with herself and the world, more self confident."
The large group proper consists of various sub groups and provides the space necessary to
observe how the sub-groups behave within it, to diagnose their developmental stage, and
assess the prevailing defensive and creative coping strategies. This becomes easily discernible
from the background of the large group proper.
For instance the life of a group of eight patients of one flat takes is full of very secretive, and
loaded with persecutory anxieties. All utterances are experienced as a betrayal of the group.
The group of another residence seeks narcissistic gratification by presenting over and over
again new, seemingly pressing conflicts to gain the large groups attention. This represents the
hungry group. We may also see the fragmented group, the symbiotic group, the obsessive
compulsive group, etc. In the large group proper our feelings of counter transference may
help us to diagnose a patients position in the group and at times to intervene immediately:
e.g., when I felt a secure feeling, being in touch with the residents, I could sense, in terms of
figure/ground and verbalise and bring to the open black holes, non-existent members, who in
my experience are often the most suicidal ones.
Kernberg (1995) described paranoia genesis in institutions as an expression of
destructive processes in large system groups. But institutions representing large system
groups have not only to be defended against, they can also provide security for patients
who feel very insecure. If we succeed in creating a positive large system group back-
ground, a positive, security giving, growth furthering effect can be observed. Central to the
development of such a background is the issue of leadership.
The art of wielding leadership within the large system group seems to consist of fostering
a benevolent, accepting, reassuring communication system which proliferates a culture
whereby difficult communications are understood as an expression of the difficulties of
the patients and the limitations of individual staff members. The exchange of information
with the individual or group therapist and psychiatrists in charge ( in the event of
hospitalisation or in times of extreme crisis ) is of overriding importance. It is an
expression of concern, and is mostly experienced by the patient receiving such attention as
being held. It saves the patient not only from being torn apart between different
therapists, but as the feeling of confidence grows, an awareness that his conflicts, his
inner monstrous world can be tolerated and contained develops and the fantasy that he will
destroy the therapeutic group evaporates. As a parallel process, his internal world is being
contained, limits are set and the destructive forces checked. A border membrane grows as
a delineation against on one hand, the outside world which is experienced as
overwhelming and threatening and the inside world of the person, experienced as
Feelings that seem too aggressive, too dangerously uncontainable within the small
group can, through the security provided by the large group proper and the large system
group be brought out into the open and be experienced as survivable, and not as previously
feared catastrophic.This applies not only to the patient. The therapeutic members of the
large system group too, can become reassured, contained and held.
The capacity of the staff member to demarcate against the internal psychic world increases
considerably and they may experience a growing sense that conflicts and feelings are
not necessarily going to overwhelm, devour and annihilate. This leads to a general capacity
to influence and shift the large system group towards a positive dynamic thereby furthering
the patients integration of his life acknowledging parts.
The growing, trusting, communicative matrix of the large system group serves as a
container and provides a holding function which enables the patient to find refuge even
whilst experiencing severe interpersonal difficulties. It serves not only as a container of
fragmentated parts, but also as a life line which is under control of the patient. In this
sense, it provides a particular sense of security because the patient is not dependent on one
person or one member of staff. He can regulate distance and closeness according to his
The following example is of a 23 year old patient who had a history of manic psychotic
reactions demonstrates the containing function of the large system group.
His parents were divorced at an early age and the father occupied a leading position in the
city government. He was put in an awkward position when he had to pay his sons bills
and at the same time was confronted with his manic son coming in to see him in
his office. He had expected us to contain his son immediately and when he started reacting
manically was deeply frustrated. He continued to hold completely unrealistic expectations,
He wanted his son to finish his studies to become a social worker. His son bought pianos for
35,000 British pounds and ran naked over the train station. The mother had always adored
her son in a seemingly very selfish way and in a sense the son had to replace the father. At
the same time she was convinced that her son suffered from an incurable biological, genetic
defect, would die in his late twenties, and she could only make life for him as pleasant as
possible. This resulted from time to time in the patient sleeping in her bed.During a period
of florid psychosis, the patient succeeded in luring our trainee student into a sexual
relationship. After a year of sheltered living within the community, the patient became
increasingly torn apart between the differing views of the different authorities with whom
he was confronted ( rather like at home ) .
Gradually we succeeded in setting limits for the mother. The sexually involved student
became sort of a co-therapist in the sense that she refrained from an intimate relationship,
but simultaneously served as an early warning system for manic reactions. The father
established a trustful relationship with one of the social workers. We began to communicate
with the biologically orientated psychiatrist from the ward, where the patient had to go
in times of crisis, ( he often ran away from the ward and broke many promises ). The
common caring in relation to his manic "acting out", brought many different factions together. This included fellow patients, psychiatrists, social workers, parents, his individual psychotherapist etc. We finally succeeded in motivating the patient and his parents to let him work in a sheltered workplace where a close intimate relationship and open communication with the person in authority was possible.
In this large system group dynamic, the patient made use of the different therapeutic large
system group members by using them as partial objects, projecting parts and feelings on to
them, without necessarily really taking up any meaningful relationships with them.
Gradually all his fragmentated parts became scattered over the members of the large system
group and all these aspects could be experienced and permitted to come "alive" within this
containing matrix. In the course of one and a half years it became possible to close the
boundaries of this large system group and to contain the extreme feelings of the patient.
The presence of disruption within constructive communication is a most valuable diagnostic
element for identifying psychotic dynamics at work. The restitution of an open
communication flow reintegrates the patients energy and ego boundaries within the set
limits. If we as staff can cope with the threatening internal world of the patient both the
patient and staff will experience an increase of security. In my imagination this resembles the
archaic confidence a baby might feel towards a securely holding mother who is enchanted by
the mere existence and presence of the baby which, in turn, gives birth to the feeling of a
healthy, stable and complete self.
The patient will always attribute a role to the therapeutic staff members and his fellow
patients of the large system group. This often corresponds to the unconsciously reproduced
intra-psychic world. According to my observations of the large system group, the patient
dares to reproduce even the most hidden, destructive and annihilating object relations and
part - object - relations. This process, if "worked through" properly utilising an analysis of
the respective individual and group counter transference will allow large system group
processes to enhance therapeutic value of the therapeutic community.
One female patient, who had had several previous hospitalisations became psychotic
during her period at one of the sheltered flats and whilst undertaking group psychotherapy.
She had grown up with a very negative, fat mother, who always attempted to destroy any
of her positive impulses, needs, wishes or plans. She experienced everybody in the milieu
of the sheltered flat as being hostile, aggressive and persecutory. She "escaped" to the
biologically oriented hospital ward, where she had already stayed during former psychotic
episodes. She received neuroleptic medication but insisted on very low doses and refused
to have it increased. The ward psychiatrist was of the opinion that her psychotherapy was
causing too much excitement and frustration than she could comfortably contain and was angry at her refusal to accept a correspondingly higher dose of medication. Whilst in the sheltered flat she had experienced the feelings of being poisoned and persecuted. After three days of experiencing the ward, she fought for a return to the sheltered flat and defended her group analyst. After two weeks she managed to be discharged, demonstrating that she could continue where she had broken off. Today, four years later, she lives with her friend in a home of her own, works regularly, has a stable income and still continues her psychotherapy, for which she pays herself .
On the whole, I have come to the conclusion that the large group proper has an integrating
and containing power that can considerably surpass that of the small group. My reasons for
thinking this are that the large group proper has the following features:
Another very important healing factor, I have observed, is the generation of social energy. It
leads to a generally higher level of arousal within the individual patient and within the various
subgroups. To enable the individual patient and the group as a whole to move from the
depressive position of emotional paralysis is an important pre-requisite for change to occur.
By social energy I do not mean the narcissistic gratification of simply praising the patient
for his traits or deeds, but the the positive acceptance of the patient in his own right, the way
he is in the depth of his heart and communicating this understanding to him. This results
frequently in the energy necessary to take upon oneself the risk of change Wallenberg (1979,
When starting the large group proper, I was overwhelmed by rather unpleasant feelings that at
that time I only could survive by holding to the armrest of my chair sticking to my deep
conviction that it was right to sit here and further more, I needed to work through the
ambivalence which I felt within myself, Bendetti ( 1992 ). In the beginning, patients and staff
delegated responsibility for the group process to the leader, they felt depleted and hated the
large group setting. They challenged me vehemently for taking away from them precious time
to conduct small groups, which they felt could give the patients much more intimacy. In the
beginning, the large group proper was conducted alongside and not instead of the small group.
This is an expression of the ambivalence held regarding its value. I also felt astonished at the
extent of the level of existential anxieties experienced by some staff members, until I realized
that being a staff member in the large group proper and even more in a large system group
poses a considerable narcissistic challenge. The illusion that the primary intimate dyadic
relationship which is the foundation stone for therapeutic work in small group therapy cannot
be upheld any more. At times staff members are flooded by the feeling of being a punching ball
of the forces of the large system group. The therapeutic worker is uncompromisingly
confronted with the fact, that improvement is the result of a network of relations, a matrix, so to speak. The patient is not at the mercy of one therapist, but the therapist is rather at the
mercy of a network. One could think of a "Galilaen switch". Thus the leader of a large group
proper, and of the large system group must first and foremost, be aware that the identity of
the therapeutic staff members is also at risk.
The members, especially in the beginning phase and in unstructured phases are prone to
regress to a paranoid or autistic position. I remember a striking example, when an otherwise
well qualified team-member set down in the large group proper and kept reading his
newspaper, though the meeting was well underway. It is of great help to be aware of the fact
that this is not a sign of a lack of therapeutic training or a " bad " attitude, but a regressive
defence mechanism, a typical feature of large group processes. The more it is important to
encounter, as leader, the individual members with respect and dignity.
Interestingly enough the large system group as a leaderless group occurs more often than one
might tend to assume. Kernberg (1993), in a paper on projective identification gives an
excellent example of a psychiatric hospital as a leaderless large system group.
The therapeutic staff members of a large system group who want to take over leadership
functions have to be conscious that there are defensive manoeuvres at work, that seek to
neutralise the anxieties evoked by the large system group. Staff members too, are part of the
system and thus submitted to the same group dynamic forces. It is likely that members who do
not feel themselves existentially dependent upon their membership of the large group and are
supported by independent groups, may develop the strength to exert some influence that
can make a significant difference as to whether or not a persecutory atmosphere prevails or
whether a holding, growth enhancing atmosphere is predominant.
In my experience the leader of the large group proper and the large system group can
consciously structure and regulate along two dimensions, in order to tune the amount of
The composition of the large system group is another important point. There has to be a
basic belief system. A shared belief or conviction as to the value of psychotherapy for
individuals with psychosis and schizophrenia coupled with a willingness to acquire
knowledge and skill in the management of the basic psycho dynamic defence mechanisms at
work with borderline individuals.
The key to successfully adopting and maintaining a leadership role within the large group is
dependent upon our ability to handle persecutory and annihilatory anxieties which tend to
dominate the counter transferential field.
Communication is often experienced as treachery. I remember very well, that when I set
out to create the containing culture of a large system group, I was treated like a
perpetuator, violating intimacy, when trying to establish communication with other
members of the same group. Instantly, splitting within the large system group
occurred, processes of projective identification were easily triggered and could be
observed in almost pure form.
In a discussion of what lies at the heart of successful large system group leadership my
collaborators and I came to the preliminary conclusion that processes occur which are
similar to those occurring in the individual treatment of schizophrenically reacting patients.
The leader will need to be able to absorb all kinds of most unpleasant projections,
fragmented, disconnected and contradictory personality parts and conflicting feelings. If
he is able to contain and digest them, he will be able to encounter the other members of the
large system group in a new, detached, and more engaged way. Thus providing the
possibility of containing and working through, or at least placing within tolerable limits, the
seemingly unbearable conflict. We have also found that leadership in the large system
group is shifting and not always executed by the same staff member.
Last year we carried out a retrospective study ( Hafers, 1996 ) where we obtained similar
results as in a study conducted by the Henderson some years ago(Whiteley, S.1980). On
reflection what benefited the patient most, were his peer relationships with fellow patients.
Our therapeutic task is to facilitate the growth of this live-enabling, growth-furthering
interpersonal matrix which we call the large system group by creating the interpersonal space
where it becomes possible to feel and resolve psychic pain , traumatic feelings and unbearable
longings. The challenge of the nineties seems to me to be a question of how to take the
therapeutic community closer to the community. The investigation of a deeper understanding
of the individual and group resistance which prevent therapeutic principles from being
implemented. Is it only because of the reigning Zeitgeist of splitting and fragmentation that
this integrated and holistic approach in the last decade of this century still has not reached
the mainstream of psychiatry and psychotherapy.
In his paper on the "Unspeakable" Peter van der Linden (1994) reminded us that
psychiatrists and, I would add, psychotherapists and the entire therapeutic staff want to
maintain a distance between themselves and the emotional confusion, irritations and fears
that psychiatric patients inevitably evoke in us, as soon as we start to plumb the depths of
their individual history and predicament. The ICD-10 seems to be a globally agreed upon
defensive manoeuver in this respect. He put forward the idea that psychotherapy through
re-enactment in the large group should be seen in the wider evolutionary cultural context.
It was Da Vinci who said that "nature is full of countless causes which never enter
experience". The therapeutic work with the large system group as defined above, is the
endeavour which will broaden our therapeutic understanding and take our work beyond the
existing limits into unknown territory.
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