THE LARGE GROUP OF  SHELTERED LIVING AND THE LIFE NETWORK GROUP

Dealing with fusion, fragmentation and division within the large group – in the setting of four assisted living communities as – a therapeutic community within the community – possibilities of therapeutic work

Andreas von Wallenberg Pachaly, Free non-profit counselling centre for psychotherapy

 

introductory remarks

 

The German emigrant and group analyst Foulkes, who had the ability not to let himself become the plaything of history, but made history himself, wrote in 1948 that it was the therapist’s task to work in the patient’s living space.

Stewart Whiteley (1996), over two decades director of Henderson Hospital, founded by Maxwell Jones, recently put it this way: “The patient’s entire life activities contribute to an understanding of his psycho-pathology, and I add “his constructive possibilities. They must be perceived and placed in the protective care of a single therapeutic team and not split between different authorities managing the patient.

This habitat of the patient , understood as a life network group , will give us the key to his understanding . It gives us the opportunity to create interpersonal conditions that promote psychic development and form an accepting, holding and growth-promoting network of relationships, a matrix. We should be aware that this matrix is also part of the habitat of the therapeutic worker.

In the course of the recent development of the practice of assisted living as a “Therapeutic Community within the Community”, we found that working with the large group and the Life Network Group has opened up new therapeutic possibilities. I would like to put our experiences up for discussion regarding large group processes and life-network processes as a mirror of the inner object and sub-object relationships, and especially in the context of today’s topic of psychosocial therapy as a mirror of the early ego-organizations of the psychotic human being and its precursor, the group ego, this non-self, whose existence precedes the formation of an ego-structure of ego and super-ego. I would like to discuss how this becomes visible and how this understanding, applied to our clinical practice of “Therapeutic Community within the Community”, opens up further therapeutic possibilities for the treatment of psychotic and borderline patients.

The setting

I would like to introduce my presentation with a short summary of the settings of assisted living as a therapeutic community in the community.

There are four patient groups of eight patients of each sex. Each patient group lives in a house or apartment. The diagnoses of the patients range from severe borderline disorders and extreme anxiety to psychotic or schizophrenic patients. The majority of patients had previously received in-patient treatment, about one-fifth of patients had received out-patient treatment only. About 75% take psychotropic drugs at the time of intake. The duration of their stay is 3 years, an extension of up to two years is possible if it appears therapeutically valuable.

Graph 1

The therapeutic community as such rests on four pillars:

1.) Each patient must participate in two different groups. One takes place in the apartment and concerns organizational things of living together, the other one takes place outside, in the office of the counseling center, which offers the institutional, protective umbrella to the “therapeutic community in the community”. This group dynamic group session takes care of the emotional needs of the residents. The interpersonal matrix is perceived and there is a continuous attempt to make unconscious dynamics conscious. A constant visualisation of the position taken by each patient in the living group is carried out. Motivating work is done, conflicts of all kinds, mainly concerning the here and now, between patient and institution or the outside world are discussed, rule breaks are perceived and solved if necessary.

2.) Each patient is obliged to follow a daily structure, either in the form of work, training, day clinic, supervised work, etc… At the beginning it is of course a hard task for the social workers to support the patients in finding a daily structure. Experience has shown that this process can take longer than one year and is supported by the so-called application group, which meets three times a week at 8:30 a.m..

3.) Each patient undertakes to undergo individual or group psychotherapy with a therapist according to his or her needs. The condition is that this therapist is willing to work continuously and openly with the staff of the assisted living facility, as is a matter of course in an inpatient setting.

4.) Every two weeks all residential groups, the social workers and the therapeutic staff of the Board participate in a large group, which forms the outer boundary of the therapeutic community within the community.

The residential groups are supervised by social pedagogues and social workers who have group dynamic experience and participate in permanent supervision and who lead the above-mentioned groups. Its main task is to coordinate and integrate the numerous learning and living fields of the patient (the Life Network Group, as defined later) and the separated or fragmented experiences. Another important task is to make transparent how each patient re-stages their fundamental conflicts and support the group in creating an atmosphere of curiosity, compassion and inquiry. By motivating patients to take part in individual or group therapy, the basis for enabling the patient to integrate into society is broadened; whether this means that he is educated, working or sheltered, can enter into couple relationships or later live in a free community.

Of course there are a lot of assisted living communities in Germany, but in our opinion what makes the paradigm change is the following:

1. we use the group as a community that represents a life-working-learning institution and use the group and the large group as a thera-peutic culture.

2. we promote a culture of continuous demand within the group, and

3. we try to apply group dynamic and psychodynamic knowledge and approach to understand both the group situation and that of the individual patient.

4) We try to bring together the different split and fragmented experiences that the patient has in different areas such as life, work, psychotherapy. (The work with the large group and the Life Network Group, as I will present it today, is of great importance in this respect.

5. in order to be able to do all this, we try to set clear limits regarding time, place, roles within which a process of integration becomes possible at all.

We pursue the goal of fundamental structural personality change in so-called psychiatric patients suffering from schizophrenia, psychosis or severe borderline conditions.

7 And we adhere to an integrative group concept that intentionally combines less seriously and severely ill patients of different diagnostic categories.

It has its theoretical roots in the work of Jones, Winnicott, Ammon, etc..

The institutional framework which has created the conceptual and personal framework for this work is the Freie Gemeinnützige Beratungsstelle für Psychotherapie e.V. (Free Gemeinnützige Beratungsstelle für Psychotherapie e.V.).

definition

The actual large group, which meets fortnightly, consists of 25 – 35 people, including patients, staff and leaders, all of whom are therapeutically trained. Single contact is possible at any time.

Graph 2

From this I would like to distinguish the Life Network Group, which I understand and conceptualize as the entire social network of relationships in which the individual patient lives. Important for the further procedure is the realization that within the Life-Network-Group the same phenomena as in large groups occur, partly even more intensively.

Graph 3

The Life Network Group includes the patient’s residential group, the employees of our institution, the psychiatrists in their private practices, the independently working individual or group therapists, the work colleagues or their protected workplace, family, friends and in times of an acute crisis in the hospital, the therapeutic staff of the hospital and the employees of the regional association and the local social welfare office, who partly make the financing of the assisted living possible.

Mass and I

We are used to using the family model with father, mother and siblings in the small group. Fuchs created the concept of the matrix of conscious and unconscious communication in the group to describe the specific characteristics of a small group. Bion distinguishes between a working group and a basic assumptions group. The basic assumption group is in a state of resistance, where it does not work on its task, but deals with etc. fantasies in order not to have to work. Fantasies of dependence and omnipotence, of being persecuted and escaping or of a messianic expectation of salvation. The analytical group has the task to explore its own unconscious. It oscillates between regression and its reflection.

Freud provided us with a concept of mass as a mother-child relationship, characterised by dependence and idealisation, based on le Bon, who had written about the masses in the French Revolution. A mass without task and structure would be a basic assumption group characterized by extreme dependence on its leader and by prevailing paranoid fears. Clear structures and work tasks can alleviate these fears.

By the way, most of the contributions to the understanding of masses came from Philo-sophs, writers, sociologists, historians such as Ortega y Gasset, Riesmann, Bloch, Canetti, psychoanalysts are Mitscherlich, Richter, Kernberg.

The large group can be seen as a link between small group and mass, between mass psychology and group analysis. In 1996, Shaked summed up very well the effects of the large group on its members as compiled in the literature: Obviously a direct communication among the group members is very difficult with 35 to 100 participants. The inability of the individual to establish a personal relationship with all other group members is experienced as threatening in the initial situation. The participants feel restricted in their social competence. Your ability to think and formulate is reduced. The initial silence is accompanied by a feeling of paralysis. Verbal expressions are sparse and often refer to diffuse fears of identity loss and feelings of emptiness, isolation and lack of freedom. The perception of time and space is impaired. Fear of extermination emerges. The concentric seating arrangement with other participants in the neck promotes the development of paranoid fears and the defence mechanisms of projection and projective identification prevail. This has often been discussed in literature, recently by Kernberg in his lecture: Bureaucracy and Ideology as Social Defense against Paranoid Aggression (1995).

The fear of closeness and intimacy leads to the fact that the inner row of seats remains mostly initially unoccupied, symbolically expressing the inner emptiness and the absence of security (absence of the breast, comparable to Bion). Strongly compensatory fantasies of omnipotence develop, wishes for merging alternate with fear of being swallowed up by an archaic mother. Desires arise for total care and security, and for freedom from lack and responsibility.

Large groups and masses are particularly easily accessible to narcissistic size fantasies. These fantasies of omnipotence offer security through the self-increase of the group, protection against threats and insults from inside and outside, against divisions and death, and create the illusion of timelessness and immortality. We can observe this in large analytical groups as well as in masses.

All in all, we find conditions in this large group that are more reminiscent of archaic societies. The relations are like in a clan, Freud’s ancient hordes with the tyrannical ancestor who forbids his sons to take possession of his wives and is killed by his sons. Overwhelmed by fear and remorse, they consume the father they have killed and introject his prohibitions as the two great social taboos of murder and incest.

The large group leader, on whom the large group is extremely dependent, is experienced as a representative of social norms and his deposition promises freedom from oppression and sexual freedom. At the same time, the group members identify with him and his authority and love him in an ambivalent way. The large group solves this ambivalence conflict in its own way. The leader is admired, but is attacked and mocked with every false step. Or a scapegoat is searched for, which is lowered and exposed in place of the leader.

Since the leader of the large group does not satisfy the needs for protection and care, pseudo-alternative leaders can be used to seduce the group away from an arduous but realistic solution to their difficulties and towards a regression to a primitive form of urge satisfaction. We also know such developments well enough from the political sphere, which always make use of scapegoats.

The large analytical group is a working group that is only structured by the basic analytical rule. In it we have the possibilities to reflect these phenomena and states of consciousness and try to integrate them instead of acting.

The hypothesis to be investigated

The following hypothesis is an attempt to promote and challenge the discussion of our understanding of large group processes and to discover the conditions under which these processes are constructive and healing. It is also a response to Kernberg’s discussion about the splitting power of large group processes in: “Projective identification, countertransference and inpatient treatment.” (1993) The hypotheses I would like to test are:

Graph 4

1. a) Large group dynamics and even more dynamics of life-network groups tend to be experienced as a threatening, persecuting background that evokes projections, projective identifications and division in the case of borderline personalities and fragmentation and fusion in schizophrenic-structured personalities.

2. b) We can observe parallel processes within the large group dynamics and within the psychotic, pre-ödipal core of the individual personality (Blégé, 1991).

3. c) When we succeed as influential, therapeutically working members of a life network group, transforming its dynamics into a holding background that promotes tolerance, respect, communication, holding and receiving, split and fragmented feelings and personal aspects will become visible, they can be perceived, pronounceable and thus workable and ultimately integrable. A feeling of security to become mei-ster of one’s own destiny, to become able to survive and to leave behind the catastrophe experienced by the self grows with the patient.

4. d) This feeling of security and the feeling of having created the world itself, of having created the breast itself, as Winnicott described it, grows in the therapeutic team as well as in the patient. Both I and I are increasingly able to tolerate feelings of impotence and helplessness in the face of the “landscapes of death” (Benedetti , 1993) of the patient’s self.

Diagnostic potential of the Life Network Group and the large therapeutic community group within the community

Peter v.d. Linden (1994) sees in the large group the possibility of internalized interpersonal and group conflicts coming to bear, petrified traumatic scenes of the there and then. De Mare describes the large group as an unconscious, which learns to express itself, to enter into a dialogue. Our job is to listen to him.

The unstructured Lebensnetzwerkgruppe invites to revive existential fears of the there and then, to be devoured by fears of destruction and fears. Unstructured in the sense that the interpersonal and the communication between groups is not ritualized or regulated, although everyone knows somehow of the existence of the Other, since he has heard of it through third. These fears are evoked in patients, but also in the therapeutic staff of the Lebens-Netzwerk group.

In both large group situations, the defense mechanism of fusion, fragmentation and splitting is outstanding. I have observed how borderline and psychotic defense mechanisms regularly occur when patients with a borderline personality structure and psychotic patients are part of the Life Network group.

Graph 5

Psychotic patients oscillate between fusion and autism and react with fragmentation to a world they experience as overrunning. Defense mechanisms of fusion, autistic retreat and fragmentation try to protect an ego, which is existentially threatened by demands for closeness, distance and inner needs.

Borderline patients unconsciously take refuge in clefts as a way to cope with their own inability to deal with ambiguities, doubts and open questions in relationships, to tolerate them and to deal with them. They find comfort and refuge in their experience of the world as a place of constant struggle between good and evil.

From a developmental psychological, psychogenetic and group-genetic point of view, feelings experienced in the large group go back to a time in life when the differentiation between I and you, the world and the self had not yet been developed.

The development of one’s own identity is in an initial stage and feelings of omnipotence alternate with feelings of complete helplessness and impotence. Projective identification in this phase is an important part of the mother’s communication with her child and fears of persecution alternate with feelings of oceanic bliss, complete bearing and ecstatic fusion.

The ego and its forerunner the co-self

At the beginning of our psychic existence we are not ourselves, we have no ego. But who and what are we? Bion said that we are a group, a psychotic is a group, and from an evolutionary point of view, we are a group at the beginning. In the beginning we have a non-self, a self that is indistinguishable between me and you, between subject and object. At this level we cannot make use of object relationship theory.

The newborn and already the embryo in the last months of its intra-uterine existence has a special structure, a group self, called Co-Self by the Israeli group researcher Abraham.

Graph 6

It describes the part of the ego that is able to perceive moods and tensions in its group environment and react to them without initially being able to shape them decisively. We can observe this co-self in group situations where mothers bring their babies into the group therapy session and experience how the baby reacts sensitively to the surrounding group.

The large group seems to be very threatening for our later psychic structure of ego and super ego. The co-self, on the other hand, seems to be very dependent in its emotional state and perceptive faculty on the experiences it has had of what we felt and felt in the beginning. And so, in large groups, according to our earliest experiences, we sometimes feel a good feeling and others a bad feeling, depending on the development of the co-self.

The co-self also has a body image, its own structure, which is not a regression. In the act of love we can experience this structure in which there is no separation between you and me. This functional structure remains throughout our lives. It is the part of ourselves that enables us to be in groups for good and for bad.

The group in turn, and especially the large group, is a very powerful instrument to touch the deepest layers of the human psyche. This is where the opportunity for change opens up. The co-self does not live conflicts but moods, which can change very fast.

The psychotic ego or better self-organization is now the result of a disruption of this early development time of co-self and ego development. It is at this point where a disturbance already occurs and where we can carry (contain) an arrested development, if it can then be seen in scene in the life network group, and interpret the resulting conflict or interact interpretatively.

De Maré, a student of Bion and Rickman, a collaborator at the Tavistock Clinic and the London Psychoanalytic Institute, describes the large group as being experienced on the one hand as a persecuting environment that imposes itself on the individual who does not feel free to spontaneously express his ill-considered thoughts and on the other hand as an environment that conveys the feeling of not belonging to it, which produces a feeling of freedom, accompanied by extreme panic in the face of perceived abandonment. Let us remember that this is similar to the psychotic response of a patient moving between fusion on the one hand and division and fragmentation on the other.

If we follow de Maré, who proposed to understand the schizophrenic organization as a large group process stopped at an early, chaotic and devastating point, we can understand the Life Network Group Therapy as an access to the therapy of the psychotic and schizophrenic organization. If we succeed in getting this frozen process of fragmentation and fusion, which takes place in the large group, moving, we will create a tremendous piece of integrative and motivating work for and with the patient.

We can use the idea of parallel processes to visualize the interdependence of the structuring of the life network group and the psycho-tic world of the patient. Of course, the other way around, a psychotically reactive life network group is keen to induce the patient to react psychotically. So we can observe an interdependence.

If we, as influential members of the Lebens-Netzwerk group, are successful in dealing with the destructive communicative divisions of the network in such a way that we can see them as an expression of the predominant defensive organization of the patient, as an expression of a deeper internalized conflict of the pre-linguistic stage and as an expression of developmental deficits and ego disorders, then this understanding gives us important and impressively strong insights for a deeper understanding of the patient’s existential dilemma, the traumatic scenery he carries within him, which he has not yet been able to leave behind to become free to live his own life.

The following clinical example of a severe borderline personality with a long history of self-injury due to a life-threatening blood loss in hospital shows how the Life Network group can give support to the patient.

“The patient was very shy and retired during her time in the flat-sharing community. She had a long history of self-inflicted injuries and her attempt to study had failed because she could not bear the many people on campus. She was the daughter of a former priest who then married her mother. He suffered and was ashamed of having been so shamefully expelled from the priesthood.

On the visitor’s day of a time-limited therapeutic community she expected her parents to visit her. But although they had promised to come, they did not come, nor did they say why. The patient felt very depressed and experienced a severe devaluation of her person, especially because she was proud of her achievements in the community.

Two weeks later, her individual therapist had promised to join our supervision group to exchange information about the patient. Of course – who did not come was her therapist, whom I only knew from telephoning. The patient had been very interested in such an exchange and was naturally very depressed and experienced it as a repetition of the situation with the parents. I myself cursed the individual therapist in a way and felt very devalued in my work after one of the social workers told me that the therapist had devalued the therapeutic community during a telephone conversation and called it a holiday camp. I couldn’t help but see this as a staging. After three weeks I finally decided to call the therapist and we had a very open and fruitful conversation where we could share our feelings and observations about the patient and each other and she then participated in our supervision group. This in turn led to a clear relief for the patient, who now seemed to be more relaxed and confident in this world.

The large group consists of different subgroups and opens a space to recognize how the different subgroups behave within the large group and to determine their stage of development.

For example, a residential group of 8 patients adopts a very closed posture loaded with persecuting fears. All statements were experienced as cheating the group.

Another residential group strives for narcissistic satisfaction by presenting seemingly urgent conflicts over and over again in order to gain the attention of the large group and represent the ever hungry group. We could also see the fragmented, the symbiotic group, the compulsively obsessed group, etc.

In the large group our counter-transference feelings are of great importance to diagnose the position of a patient in the group and to intervene immediately if necessary. For example, when I feel a sense of security and contact with the residents of the flat-sharing communities, I could feel black holes, non-existent participants in the sense of the figure-background phenomenon and verbalize this. Experience has shown that these are often the most suicidal people.

The healing potential of the Lebens-Netzwerk group and the actual large group

Kernberg (1995) describes the Paranoiagenesis in institutions as an expression of destructive processes in network groups. But against institutions that represent large network groups, one must not only protect oneself, they can also give security to patients who feel very insecure.

If we successfully create a positive life network group background, a positive, security-giving, growth-promoting effect can be observed.

Graph 7

The art of leading the Lebens-Netzwerk group seems to consist in cultivating a benevolently accepting and reassuring (here I am, here I may be) communication that favors a culture of understanding communicative difficulties as an expression of patients’ difficulties and the limitations of individual collaborators. In the best case scenario, this will result in the Life Network group developing an observational ability that will enable it to

1. to become interoperable and

2. to observe oneself and one’s feelings and to exchange information about them

3. and to survive the feared destruction or destruction.

The exchange of information with the individual or group therapist and the responsible psychiatrist in the case of hospitalisation in times of extreme crises is of extraordinary importance and is an expression of participation and interest and is often experienced by the patient as maintaining interest, as being held. Not only does it save the patient from being torn between different therapists, but it increases the feeling of trust, the confidence that his conflicts, his inner monstrous world can be endured and kept in check and the therapeutic group will not be destroyed, as a parallel process to this his inner world is kept in check, boundaries are set and destructive forces are restrained.

A border membrane grows as a demarcation against the outside world, which was experienced as overwhelming and fragmented, and against the inner world of the person who was experienced as threatening.

Feelings that seem too aggressive, dangerous and uncontrollable within the small group can be revealed through the security provided by the large group and even more so by the Life Network group, and experienced as survivable and not catastrophic.

This not only applies to the patients, but also to the therapeutic staff, who are strengthened, held and supported. The ability of team members to differentiate themselves from the inner psychotic world is greatly enhanced by the experience that conflicts and emotions are not overflowing, devouring and devastating. This leads to a general ability to positively influence the dynamics of the life-network group in such a way that it supports the patient in his life-affirming parts.

Michael

The growing trustful, communicative breeding ground of the Lebens-Netz-werk group has a holding function that enables the patient to find a protective refuge, even in the case of severe interpersonal difficulties. It serves not only as a protective container of fragmented personality traits, but also as an umbilical cord that provides security, where the patient is in control because he is not dependent on only one person, one employee, and can regulate proximity and distance according to his needs.

I’m thinking, for example, of a 23-year-old patient with a manic-psychotic reaction. His parents were divorced at an early age and the father had a senior position in the city government. He was put in an embarrassing situation when he had to pay his son’s bills and at the same time was confronted with his manic son coming into his office. He had expected us to heal his son immediately and was deeply frustrated when he began to react manically. He went on to take a completely unrealistic view that his son could finish his studies, become a social worker – his son bought a piano for 80,000 DM and ran naked across the station. The mother had always worshiped her son in a seemingly very selfish way, in a way he had to replace his father. At the same time she was convinced that her son was suffering from an incurable genetic defect, would die at the age of 20 and that she only had to make his life as pleasant as possible, culminating in her letting him sleep in her bed from time to time – the patient successfully seduced our intern into a sexual relationship during a psychosis. After one year of assisted living, the patient was more and more torn apart between the different authorities he was confronted with – similar to at home.

Step by step, we were able to successfully set limits: For the mother, for the sexually involved student, who became a kind of co-therapist by omitting an intimate relationship, but at the same time serving as an early warning system for manic reactions, for the father, who established a trusting relationship with one of the social workers. We began to make contact with the biologically oriented psychiatrist of the clinic, to which he had to return in times of crisis, who increasingly openly accepted our cooperation, since the patient often ran away from there and broke all agreements. The common worrying in its manic acting brought together – similar to at home – many different factions: Co-patients, psychiatrists, social workers, parents, his individual psychotherapist, etc. Recently, we have succeeded in motivating the patient and the parents to work in sheltered work, where a close and open exchange with the master is possible. In this dynamic of the large net group, the patient could use the various members of this system by serving as sub-objects on which he projected parts and feelings without really establishing a relationship with them. Gradually all its fragmented parts were scattered among the members of the large netgroup and all aspects could be alive within this container. In the course of 2.5 years it became possible to close the borders of this large net group and to carry the extreme feelings of the patient.

The rupture of constructive communication is the most valuable diagnostic element for psychotic dynamics at work. The restoration of an open flow of communication reintegrates the patient’s energy and his ego boundaries within the set boundaries. If we can deal with the threatening inner world of the patient in this way, he will experience an increase in security, which also applies to the employees. In my imagination, this resembles the baby’s archaic trust in the safe keeping mother, who is “captivated by the mere existence and presence of the baby” ´´, which on the other hand is the feeling of a healthy, stable and

complete self birth.

The patient will assign a role to the therapeutic staff and his fellow patients of the large network group, which corresponds to the unconsciously reproduced inner-psychic world. My observation is that the patient within the Life Network group dares to reproduce the most hidden, destructive and destructive object relationships and sub-object relationships. This enables the Life Network group to become a very effective therapeutic community when working with the analysis of the respective individual and group countertransferences.

One patient, who had been hospitalized several times before, had a psychotic reaction during her life in assisted living and a simultaneous group therapy. She had grown up with a very negative, pushy, fat mother who always tried to destroy every positive desire, plan, need, impulse from her. She experienced everyone in the environment of the assisted living as persecutors, hostile, aggressive and fled to the biologic oriented hospital ward, where she had already been because of previous psychotic episodes. She was on neuroleptics, but insisted on a very low dose. Because she strictly refused a higher one, she created the psychiatrist’s anger over her psychotherapy, which in his opinion was too much more excitement, frustration and feelings for her than she could stand.

In the flat-sharing community she felt poisoned and persecuted, in the hospital after three days of psychological reintegration she fought hard for the concept of assisted living as a therapeutic community within the community and defended her group analyst. After two weeks she managed to be released by demonstrating that she could continue where she had left off. Today, four years later, she lives with her boyfriend in her own apartment, works regularly with a stable income and continues her psychotherapy, which she still pays for herself.

I have come to the conclusion that the large group has an integrating and retaining force which is decisively greater than that of a small group.

Graph 8

Through the big group:

– a consciousness of being in relationship is generated, mutual dependency

The rights and duties of the employees can be perceived and sustained.

– The fear of one – to be oneself, envy that others are oneself

and the fear of envy can be experienced. In the best case scenario.

and the aggression that goes with it,

are no longer experienced as devastating. Maslow calls these dyna-

than Jonas complex.

– a constructive cleavage may occur that allows many patients to

to survive a therapeutic setting.

– fear of persecution of a very fundamental and generalized nature

can be projected into the room, which is located within the large group

which is then experienced as threatening and the small group can now

will again become a safe haven for the large group.

– the liberation from the neurotic family dynamics within the

Small group dynamics is made possible, in which conflicts are repeated again and again.

but no solution could be found.

– the employees no longer need to be experienced as overpowering and

Disagreements between the employees serve as stimulation for

Individuation. In our experience, there’s even a significant increase

diagnostic ability of the patients of the large group regarding the

Employees.

– The patients and employees of the large group and Lebens-Netzwerk-

Group grow by experiencing themselves as capable of actively participating

and the group process with meaningful topics and contributions on

influence.

Another very important healing factor that I have observed is the

Generation of social energy. This leads to a generally higher psychological tone of the different subgroups and the individual patient. Helping the patient and the living group to leave depressive paralysis behind is a prerequisite for change to occur at all.

By social energy, I do not mean the narcissistic gratification of the patient’s praise for this trait or great deed, but the recognition of the patient in his own right, the way he is in the depth of his heart, and to convey this understanding to him. This results in the energy necessary to take on the risk of change.

Leading the large group

When we started the large group four years ago, I was overwhelmed by many unpleasant feelings, so that at that time I could only hold on to the chair, deeply convinced that it was right to sit here to work through my own ambivalence in the further process, as Prof. Benedetti (1995) described this for the psychotherapy of schizophrenia.

In the beginning, patients and employees delegated the responsibility for the large group processes to the leader, they felt emptied and hated the large group setting. They vehemently rejected me because I was stealing the time from them to carry out small groups in which much more closeness could be established. In the beginning the large group was carried out next to and not instead of the weekly group dynamic small groups, as an expression of the ambivalence of their value.

I felt overwhelmed by the extent of the existential fears of some employees until I realized that being a member of a large group or a life network group was a considerable narcissistic challenge. The illusion that above all an intimate dyadic relationship, which can also be maintained in a group therapy, is the main reason for the development of the patient, can no longer be maintained. Occasionally, the team members are flooded with feelings of being a plaything of the forces of the large group. The therapeutic worker is inevitably confronted with the fact that development is the result of a network of relationships. The patient is not at the mercy of a therapist, but the therapist is at the mercy of the network. This is reminiscent of the Galilean paradigm shift regarding the center of the solar system.

The leader of a large group and the leader of a life network group even more, should be aware above all that the identity of the therapeutic members is also in danger.

Employees – especially in the initial and unstructured phases – tend to regress into paranoid or autistic positions. I remember an extreme example when an otherwise well qualified team member sat in the large group reading a newspaper, although the group had been going on for a long time.

It is a great help to realize that this is not a lack of training or expression of bad manners, but a regressive defense mechanism typical of large group processes.

This makes it all the more important for leaders to treat individual members with respect and dignity. Interestingly, the network group often appears as a group-dynamically leaderless group, as is generally assumed.

Kernberg (1993), in his aforementioned article on projective identification, gave a good example of a psychiatric hospital as a conductorless network group.

The therapeutic team of a Life Network group that wants to take leadership should be aware that defense mechanisms are at work to neutralize the fears aroused by the large group. He should be aware that he and the therapeutic team are also part of the system and therefore exposed to the same influences. It is my experience that the members of a large group, or a life network group, who do not feel themselves to be existentially dependent on this membership, can develop the strength to exert influence on the group event, which can make the significant difference whether a following or a holding, growth-promoting atmosphere prevails in the large group.

In my experience, the leader of the large group and the large network group can consciously intervene to regulate two dimensions in order to regulate the extent of emerging fears:

1) Feeding versus deprivation: (Foulkes versus Bion). This means that he can neither tell stories that relate to group life, share some of his interests, such as his participation in a conference on working with therapeutic communities, in other words, quiet the group by sharing his experiences and personality with the group, or on the other hand, maintain strict neutrality in an analytical sense, depriving the group of food.

2) Structured versus unstructured. By this I mean that the leader can leave the group completely to himself or give structures by regulating communication, by asking questions, by raising specific issues, or by forming well-structured sub-groups that can serve as a refuge from the large group.

Of course, it depends on the stage of development of the group what influence its intervention will have. Whether they will reinforce the threatening aspects of group setting and the mechanisms of projection and projective identification or hinder the expression of deep feelings and the process that participants engage in autonomous relationships with each other. This requires a careful continuous analysis, whereby the countertransference of the currently experienced fear is an important and reliable criterion.

The composition of the large group is another important point. In principle, the attitude must be shared towards the possibility of psychotherapeutic therapy of psychosis and schizophrenia, as well as the will to gain knowledge about the basics of psychodynamic defense mechanisms in working with borderline disorders.

The key to successfully dealing with and leading large groups and life network groups, in my understanding, is our feelings of counter-transmission. Fear of persecution and extermination are predominant. Communication is often experienced as treason. I remember well that when I started to build the supporting, holding culture of the LifeNetwork group, I was treated like a traitor who, trying to communicate with the other members of the LifeNetwork group, was treated like a traitor who violated privacy. Processes of splitting in the Life-Network group could immediately become visible, processes of projective identification were easily triggered and could be observed in almost pure form.

In a discussion about what is at the heart of successfully managing a large group system, we came to the conclusion that similar processes occur as those discussed in the individual treatment of schizophrenic-reactive people. The leader will absorb all sorts of extremely unpleasant projections, fragmented, disjointed, contradictory personality parts, and conflicting emotions. If he is able to preserve, endure and “digest” them, then he will be able to meet the other members of the Life Network Group in a new, distanced yet more committed way.

The leadership of the Lebensnetzwerkgruppe represents rather a taking over of leadership, in the sense of establishing and representing the ability to dialogue, in the sense of feeling and resisting feelings and in the sense of bearing and resisting injuries, feelings of annihilation, deadly emptiness.

I’m thinking here of the child psychoanalyst who joyfully accepted her little patient’s chair, the piece of shit that his gift to her represents. Only a deep understanding of the patient’s psychodynamics can perhaps create this quality of love and kindness.

Culture, Method and Fear

The cultural background of group anxiety in Germany is, of course, the traumatic, contradictory experience with groups, large groups and masses during the Nazi era.

The essence of a traumatic experience, however, is that the traumatic event in itself is usually very easily remembered, but that the feelings associated with it have caused an unbearable conflict, which has activated defensive mechanisms of repression, division, denial, self-containment, identification with the attacker, and so on. Thus the merging of the masses, the delegation of the superego to the leader, but also warm feelings of security in youth groups of the HJ, are in conflictual contradiction to the shame and the feelings of guilt, which were caused by the acts of violence against Jewish fellow citizens and other minorities, not least also mentally ill, as a result of a mass that had given up responsibility.

This conflict is updated and can still be studied worldwide at any time today when German citizens take part in mass events such as the Lido etc., where shame and guilt prevent them from diving into a regressive state of fusion with relish.

This topic also includes fears of a paradigm shift among therapists, social workers and affected institutions. I put this up for discussion in another lecture and do not want to go into it further today.

Joachim Galuska, director of the Fachklinik Heiligenfeld, in his lecture, Healing of Psychoses in Transpersonal Understanding, Joachim Galuska analysed the absolute limit of understanding, still established by Jaspers at the beginning of the century, as born out of the investigator’s fear of the disruption of one’s own consciousness.

The feeling of eeriness, fearful restlessness or bottomlessness that occasionally spreads in the therapist is inextricably linked to the consciousness processes of psychotic people. One of our tasks is to understand under which conditions these feelings can be endured, experienced and survived.

Final findings

This contribution is an attempt to give a stimulus about processes which take place in large groups and systems and which we can either therapeutically use or which, if we neglect to consider them, unfold a destructive dynamic in the sense of Vulcan’s discussion that under certain conditions in a group the need for enemies becomes overpowering and the same destructive, life forbidding or even stagnating processes take place as they partly take place in the soul life of the pa-tients.

Our therapeutic task is to facilitate the growth of this viable, growth-promoting interpersonal matrix, which we call the Life Network Group, to create an interpersonal space in which it is possible to feel and leave behind mental pain. The prevailing zeitgeist of the 90 years seems to me to be marked by division and fragmentation. Managed care, as we have been able to study in the USA in its as-soul form for several years now, is spreading rapidly. Managing managed Care, a new counter-movement around the psychoanalyst Leon Wurmser and Senator Ted Kennedy, tries to give more importance to the importance of sustainable relationships and continuity in psychotherapeutic-psychiatric work. The integrative and comprehensive approach of assisted living as a therapeutic community in the community also tries this.

In his essay on the unspeakable, Peter van der Linden reminds us that the psychiatrist, and I add the psychotherapist and the entire therapeutic staff, want to maintain a distance between themselves and the emotional confusion, irritation and fear that psychiatric patients inevitably awaken in us as we begin to explore the depths of their personal histories and causes. He puts forward the idea of discus-sion that psychotherapy should be seen through re-enactment in a large group in a large evolutionary cultural context:

When Leonardo da Vinci wrote: “Nature is full of innumerable causes that never enter the realm of our experience, then the therapeutic work with the Large Group and the Life Network Group, as defined above, is the effort to expand our therapeutic understanding and to work beyond the known borders on unknown territory.