The Large Group and the Large System Group

Coping with fusion, fragmentation and splitting

within the large group settings of

the therapeutic community within the community –

Andreas von Wallenberg Pachaly, Duesseldorf

Free Counselling Centre for Psychotherapy, a N.P.O., N.G.O

Abstract

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 patient’s dynamic and to further the integration of his fragmentated or split

off personality parts.

Introduction

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 therapist’s task is to work in the

patient’s life space. Stewart Whiteley (1996) rephrased this in the following statement “ the

patient’s 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 patient’s 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 worker’s 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 patient’s 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.

The Setting

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

summarised.

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

value.

1. The therapeutic community itself rests on four pillars:

2. Every patient has to participate in two different groups. One takes place in the flat anddeals with the

3. organisational affairs of living together. The other group takes place at the head office of the Counselling

4. centre, which is the institutional umbrella of the therapeutic community within the community. This

5. latter group cares for the emotional needs of the inhabitants. There is a focus on the interpersonal matrix

6. and a continuing effort is made to make the unconscious dynamics conscious. A constant monitoring of

7. the interpersonal dynamics within the patient group is carried out and motivational work is done. conflicts

8. occurring in the here and now, and at all levels between patient and institution, or individual and the

9. outside world, are discussed, rule violations are acknowledged and eventually resolved.

10. Every patient has to live according to a structured daily schedule, either structured by work, schooling,

11. a day clinic, sheltered work, etc.. In the beginning, of course it is the task of the social workers to support

12. the patients in structuring their daytime activities.

13. Every patient is required to undergo individual or group psychotherapy with a psychotherapist according

14. to his needs.

15. Every two weeks, patients from all the flats, the social workers and the therapeutically trained board members

16. meet and participate in the large group proper, which forms the outer border of the therapeutic community

17. within the community.

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 patient’s 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:

1. We make use of the group as a community which provides a living/working/learning institution within the context of a thriving therapeutic culture.

2. We foster a culture of continuing enquiry within the group.

3. We try to apply group analytic and psycho dynamic knowledge and this informs our approach to the understanding of the group situation as well as to the understandingof the individual patient.

4. We try to integrate the various split off and fragmented experiences which the patient has in the different fields of his life space (work, play and therapy). (The work with the large group and the large system group, as discussed in this article is of prominent importance in this endeavour).

5. In order to be able to achieve this, we strive to enforce a set of clear boundaries concerning time, place and roles within which a process of integration becomes possible.

6. We pursue the goal of genuine structural personality change with psychiatric patients, some of whom suffer from schizophrenic and psychotic reactions or severe borderline states.

7. We also adhere to an integrative group concept, which intentionally combines severe and less severely ill patients of different diagnostic categories.

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.,

N.G.O..

Definition

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 patient’s life space. This includes the patient’s communal

group (his flat ), our institution’s 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 Kernberg’s discussion on

the disruptive power of large group processes in „Projective identification,

countertransference, and hospital treatment“ (1993). The hypotheses I wish to propose are:

1. That the large group dynamics and, even more so, the, large system group dynamics are prone to be experienced as threatening and persecutory, thus evoking projection, projective identification, splitting, in the case of borderline personalities, and fragmentation and fusion in the case of schizophrenically structured personalities.

2. We can observe parall processes occurring within the large group dynamics and within the psychotic, pre-oedipal nucleus of the individual personality (Bleger, 1972).

3. If, as influential members of the large group and large system group, we succeed in fostering a switch of the prevailing group dynamic towards one of a mutually holding relational matrix which fosters tolerance, respect, appreciation, communication, and containment, then, as a result, split off, fragmented feelings and aspects of personality become perceivable and discernable. They can then become contained, verbalized, worked through and integrated. This working through happens frequently within leading members of the large group. A sense of security and a feeling of becoming master of one’s own fate, of feeling able to survive and leave behind the catastrophe experienced by the self, grows within the patient.

4. It is part of my hypothesis that this feeling will grow in the staff member as well as in the patient, who will become more able to tolerate feelings of impotence and helplessness in face of the „landscapes of death“ (Benedetti, 1992) of the patient’s self. As a consequence they will be less compelled to resort to „managed“ care of the patient but, as a facilitator of emotional growth, accompany him on his journey.

Figure 1

The Large Group Proper

30 Patients of four Flats

of the

Therapeutic Community within the Community

Three members The staff of

of the board three social

of directors workers and

trainees

Figure 2

The Large System Group

(35 – 70 persons)

The Patient

within the

Therapeutic Community within the Community

Patient’s Psychiatrist, Patient’s Family

who gives medication members

Patient’s Individual and/or Patient’s friends

Group Psychotherapist Patient’s 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

Diagnostic potential of the large system group

and the large group proper

of the therapeutic community within the community

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 patient’s position of fusion on the one hand and fragmentation and autism on the

other. If we follow De Mare’s 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 patient’s 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

patient’s 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 didn’t 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

depressed.

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 group’s 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 patient’s 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.

The healing Potential of the Large System Group and the Large Group Proper

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

fragmented.

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

needs.

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 son’s 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 patient’s 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:

1. An awareness of relatedness and interdependence is generated and can be perceived and accepted.

2. The fear of being oneself, envy that other members can be themselves and fear of envy becomes perceivable. At best, it can be tolerated and the aggression that underlies it is not experienced as annihilating. Maslow referred to this phenomenon as the Jonas complex.

3. A constructive form of splitting can occur which enables many patients to survive the pressures of the therapeutic setting.

4. Persecutory anxieties of a very primitive, generalised kind can be projected into the

5. space that develops within the large group proper, which is then experienced as threatening. When this occurs, the small group can function as a refuge or a place of safety.

6. Paradoxically the large group offers liberation from the intensity of the neurotic family dynamic within the more intimate small group matrix, where conflicts may be continuously re-enacted over and over again without resolution.

7. The staff must not be experienced as overwhelming any longer than is necessary and disagreement between staff members can serve as a stimulus for individuation. In our experience, there even growth a considerable diagnostic capacity of the patient members of the large group concerning fellow patients. But the patients become also skilled in diagnosing the staff’s problems. E.g. wether staff members become easily fused with the patient, wether they cope with the anxiety aroused in themselves in relating to the patients by making themselves ridiculous, wether they are capable of enforcing a clear setting, concerning time, roles and transgressions of rules.

8. The patients and the staff members of the large group proper and the large system group grow, as they experience themselves as capable of actively participating, influencing the group process with meaningful topics and contributions.

9. The essence of the large group proper, enduring over time and space, independently of its particular composition at any given time, serves as a transitional object for the individual patient (Smith, 1989). The therapeutic community as a transitional object allows the patient to regulate distance and intimacy, fusion, closeness or autistic withdrawal according to his needs in order to become able to create „his“ community. His community serves to protect him from the annihilating feelings of abandonment ( for instance between therapeutic sessions ) as well as from feelings of being devoured and being swallowed up by actively distancing himself through projective identification (e.g. the whole community consists of a bunch of nuts who don’t understand me ). The community as a third object is frequently an important step towards developing the capacity to be alone and to be oneself, when being with others.

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,

1995,1, 1995,2).

Leading the Large Group

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

arising anxiety.

1. Nourishment versus deprivation ( Foulkes versus Bion ).That means he can either tell stories related

2. to the group’s life, share some of his interests, e.g. report from his attendance to a professional conference

3. related to the therapeutic community’s work. In other words, sort of “ breast-feed “ the group, sharing his

4. experience and his personality with the group or on the other hand maintain strict neutrality in the analytical

5. sense, thus depriving the group from outside nourishment.

6. Structure versus unstructure. By this I mean the leader can leave the group completely to itself or structure

7. it by regulating the communication. This can be done by posing questions, raising certain topics relevant to

8. the group’s agenda or by creating well structured sub-groups, which can serve as a refuge from the large group.

9. What influence these interventions will have will of course depend on the development stage of the group.

10. These interventions could as easily increase the threatening aspects of the group and increase the resort

11. to projection and projective identification. They may with equal ease interfere with the expression of

12. deep feelings and independent relating within the group. This needs careful instant analysis, whereby

13. the counter transference of experienced anxiety is one important and reliable criteria.

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.

Final Conclusions

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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