On the origin of clinical intervention

My agreeable response to Dr. Shay’s invitation1 took a sudden and unpleas-urable turn in reading the clinical situation. Aversion towards the whole group: a bunch of disgruntled individuals paired with “Pat,” a struggling, ineffective therapist.

All of us therapists share the fantasy that the group will do our work—or at least some of it—and it is not unreasonable to expect that group members be useful. I suspected that these (imaginary) patients were thrown together because their (imaginary) individual therapists did not know what else to do. And now, along with the (imaginary) group leader, I was thrown in with them.

Dr. Shay’s exaggerated clinical example intended to make it easier. It offered us six characters in search of a leader. Too much for a novice group therapist, and too little for me to work with, and I did not want to. The catchphrase, “Why can’t they just get along,” rattled my thinking, and I realized that the platitude virtually echoed Dr. Newland’s parting message to the group: take turns, be helpful. With only partial success, I put the group out of mind for several weeks.

And then, this disturbing dream:

My wife and I are raising our four children.2 My wife suggests we think about giving away the youngest, perhaps eight months old, to a young Southern family. I am surprised, but only mildly, and with some relief, arrange a drop off to their home. Their two children, who I discover are about seven and nine years old, are very excited and so happy to have a little girl plaything.

About a day later I am back in New York and at a meeting of some sort. I recount the details of my recent trip to a friend or colleague. He too registers only mild surprise by the thought and now reality of giving away our baby, which surprises me, and I mull it over uncomfortably.

Now I am perturbed: What were we thinking? How could we do that? After an anxious pause that in dream time felt like an hour, I resolve to retrieve the baby. 1 wonder how difficult this might be legally for us, and emotionally for the disappointed family. I wake up with these questions, along with a disturbing urgency.

The dream stayed with me throughout the day, and longer. Although it was not difficult to make immediate sense, I could not put the dream away. Taking ownership of the dream made me feel ashamed for being out of touch and hurtful, in a moral stupor that I distributed to my maternally oriented wife—who better than a mate to be the target of projection?—and later to an unidentified friend.

1 reminded myself to stop indulging in painful depressive ruminations, an old, apparently enjoyable tendency. I had to get on with retrieving this project and forgive myself for wishing to abandon it. Over time, thoughts began to generate; disjointed as they were, they gradually supplied sufficient confidence and mental order to concentrate and commit.

Why my self-disclosure?

My aversive responses, conscious, unconscious, and dissociated, impact my conceptualizations, and for that reason among others, they are clinically relevant. A basic premise of the relational approach is that psychoanalytic data are mutually generated by the therapeutic participants, co-determined by conscious and unconscious organizing activities, in reciprocally interacting subjective worlds (Stolorow, 1997).

All players—including imaginary ones of this clinical example—influence how we therapists think (and do not think), comport ourselves, relate to our groups, and therefore how they relate to us. It follows that the group therapist’s psychology, and the members’ experience of the therapist’s psychology, should be a focal center of the therapist’s clinical interest.

I have declared, somewhat facetiously and for emphasis, that it is “all about ‘Me’” (see Chapter 3). Not myself, especially, of course. “Me”— the therapist’s working self—functions variably and inconsistently; it is professional and yet personal, mature and immature, healthy and neurotic (Racker, 1968). And always: regulated by the emotional state of the relational matrix.

In my opinion, no therapist is a “seer,” “mystic” (Bion, 1970), “analyzing instrument” (Lipin, 1992), or “telephone receiver” (Freud, 1912). The therapist’s unconscious conflicts, character structure, and misunderstandings lead to inevitable iatrogenic resistances; however, they also provide vehicles for learning and transmitting intersubjective information (Boesky, 2000). Contemplating one’s evolving mental relationship to the group, and its influence on the group, brings layers of meaning to the clinical situation, however conceptualized.

The dream connects me to the assignment

I had not merely put off but had attempted to wall myself off from the troublesome group. I could not think about the group in a meaningful way, or even not think about it, until 1 dreamed it back into conscious experience (Ogden, 2003).

What the dream revealed described a course of mental action and potential clinical behavior: resentment, isolation, and refusal, and then guilt, curiosity, and concern. The dream had purpose to reconnect me to Dr. Shay’s assignment of addressing the evolution of my thinking.

[I resolved] to retrieve the baby. I wonder how difficult this might be legally for us, and emotionally for the disappointed family. 1 wake up with these questions, along with a sense of disturbing urgency.

I took five elements out of the dream that I decided would direct this chapter (other elements were possible too): a disowned baby, retrieval, legal difficulty, emotional difficulty, and a sense of disturbing urgency. Without illusions of clinical precision, or need to evidence mechanisms of projective and intro-jective identification (which 1 take for granted), I assumed that these elements had or could have relevance to the predicament of Dr. Newland and the struggling group.

A disowned baby

In each of us there is a baby, easily distressed when wrenched away from our comfort zones of attachments. Whatever the benign actualities of the referral processes, in psychic reality, the members of this imaginary group felt abandoned by their individual therapists, thrust into to a strange situation, and hated—exiled from all that was or could be good. Distrustful, aggrieved, and envious, these self-centered people were alienated from themselves, from others, and from the idea and reality of group.

  • 1 had to face an aggregation of contact-shunning individuals (Hopper, 2001), each encased within a self-protective shell of refusal (Billow, 2007). The very thought of the group disturbed my equilibrium and I turned away.
  • 1 had attempted to banish the group. Dr. Pat self-vanished, hid behind the proverbial blank screen of classical individual and group technique. Allegiance to vestigial ideas of neutrality and anonymity produced an emotionally detached therapist, devoid of personality.

Dissociated, suppressed, and enacted baby thoughts and feelings—terror, anger, and hatred, as well as longing, hurt, curiosity, and joy—need to be gathered up in the here-and-now group situation and connected to ongoing process. In the lifeless group under discussion, the vitalizing baby had revealed itself only by being disowned by us all.


In all individuals, “two different categories of mental activity” coexist, and it is the “painful bringing together of the primitive and the sophisticated that is the essence of the developmental conflict” (Bion, 1961, pp. 159, 172).

All individuals and all groups rely on primitive—meaning developmentally early—preverbal schemas of psychic organization to think, communicate, and group, and to defend against these processes. To function with “sophistication,” that is, with clinical intuition, empathy, and accuracy, the therapist must embrace the “developmental conflict” and eradicate as much as one can, not anxieties, resistances, wishes, and fears, but their repression (Racket, 1968). The developmental conflict—to remain a baby or to also be mature—cannot be banished or hidden from. We rely on others to help us think about what we cannot bear alone.

Freud (1921) concluded that we are “horde animals,” for no matter the protestation, individuals seek groups, and groups seek leaders. We are inherently groupish. The pull to group is irresistible, and pulling away leaves one that much more socially preoccupied, although unsatisfactorily. Shunning the group, I succeeded in joining it, only after my “baby” reemerged.

Legal difficulty

The therapist has access to legitimate and illegitimate modes of leadership. The illegitimate may hide under a stiff rubric of “correct” technique (Jacobs, 2001), while the legitimate extends to the unconventional, to humor, linguistic play, affective openness, challenge, and confrontation.

To preserve a well-working group, or attend to the difficulties of this ineffective one, the leader wears “two faces,” being constructive and decon-structive (Billow, 2005). To establish trust and secure relationships, the therapist defines boundaries of participation, addresses the needs of each person, and closely monitors and often directs group process. However, he or she must also challenge characterological boundaries, falsities, and social collusions that obstruct or preclude emotional learning. Without such leadership, a group—whether in formation or ongoing—is more likely to be marked by conventionality, stalemate, and submission to and rebellion against authority.

Ideally, what the therapist says, and how it is said, should represent personal risk and open the way for mutual discovery. In a relatively new group with an unfamiliar therapist, the members may not immediately understand the intended meanings of some of the leader’s interventions, but the discourse goals must be perceived as ethical: caring and helpful. Incongruities and discontinuities should be interesting, relevant, and sufficiently safe to be enjoyable and stimulate curiosity.

Emotional difficulty

Retrieval entails painful loss (to the split off Southern self) and gain (an integrated “United States”). What an individual discovers and the group reveals may feel “not nice,” judged as immature and irrational (which is, indeed, what it often is), socially inappropriate and personally embarrassing.

Therapy is an act of symbolic aggression, interfering, challenging, and undermining beliefs, values, and relationships, and even a sense of self. Therefore, individuals remain in conflict over developing emotional truth, since it causes anxiety and pain. All group members (including the therapist) struggle with a limited ability and willingness to pursue the infinite potentials of the meaning-making process. We tend to wall off that which is unpleasant, unknown, or confusing.

Dr. Shay presented us with a difficult group situation— troubled patients “expelled” or “exported” from their individual therapies, “aliens” in a “new land” of group therapy with an unskilled therapist. However, no matter the group and the sophistication of the leader, the self of the therapist also remains troubled3 and must be attended to before, during, and after interventions are made to others.

A sense of disturbing urgency

Experience does not roll out smoothly. Each paper (and each group) needs time and mental freedom to unfold. However, papers do not write themselves nor do groups flourish without active, ongoing leadership. A group in early stages of formation has urgent purpose. While a group comes together and depends on combinations of emotional linkages, member-therapist bonds usually are primary. Member-member and member-entire group bonds follow.

Early on, but in all stages of group life, the group therapist needs to pursue that which is painfully immediate and most meaningful. At the same time, he or she must shield others from that which is immediate, but too painful to become meaningful. In situations of high stress and aggressive charge, such as this group, the therapist must function as a lightning rod, diverting unbearable affects and antagonisms away from the group and towards him- or herself, providing the ground for safety—easing angry and alienated members back into their own functional minds.

The variety and flexibility of the therapist’s activity, internal and interpersonal, exposes the qualities of the therapist’s care and establishes the therapist’s authenticity. Through his or her behavior, the leader or therapist defines the working group culture: how group relationships and experiences are to be regarded and the depth to which narratives and exchanges may be considered.

1 present an alternative reality to illustrate urgent responsiveness.

Relationally revising the group interaction4

THERAPIST: Hello. Anyone want to begin today?

ANGELA: Why can’t you just let us start the way we want to start? We’ll begin if we want to begin.


DIANNE: I’m happy to begin.

THERAPIST: Whoa.... no reaction to Angela? She’s begun, and not so happily.

DIANE [IGNORING THERAPIST]: This weekend, I didn’t want to work on my dissertation so 1 went to a party and had too much to drink.

THERAPIST [EVENTUALLY BREAKING): Don’t we have dissertation work to do right here? You [Diane] don’t want to do it!

DIANNE [IGNORING THE metaphoric PLAY]-. I was talking about iny dissertation and going off with this guy and I wound up in a lot of trouble.

THERAPIST [SHADING THE MEANING OF “TROUBLE"): That’s why I want you to slow down and stay focused on your work here, so you won’t be so troubled.

DIANNE: Well 1 am feeling “troubled” by you, just like being controlled by the dissertation committee, who I hate! But I think you are trying to help me to take control.

ANGELA: Well, I don’t like it. It’s like before when you asked us to begin.

Therapist responds with wordless agreement, as if to say I understand what you don’t like and how you feel.

DIANNE: Don’t you see Pat is trying to help you too. You’re always criticizing Pat.

ANGELA: You’re always defending Pat.

ANOTHER: How does that help to get Angela angry at Dr. Pat? Or Dianne? I’m confused.

BETTY: There is a lot of arguing in here and I’m not sure what the purpose is.

THERAPIST: Are you angry at me too, Betty?

BETTY: No, I just don’t think I’m getting anything out of this group.

THERAPIST: That sounds like anger. You are saying, “I don’t agree with how you play and I am going to take my marbles and go home.” Even though it is pretty lonely at home. The purpose here is to learn about how you feel and how others feel about you.

BETTY: Well, I’m annoyed at you.

therapist (big smile): I like that a lot better!

NED (TO DR. PAT): I like how you are standing up to criticism. I was able to get back to working on my novel because I stopped worrying about the criticism the readers had made of my writing.

ANGELA: I wish I could let criticism roll off my back.

WILL: You said it!

DIANE: What do you mean. Will?

WILL: 1’11 pass, but thanks.

OTTO: Criticism is very hard for me too.

NED: Not for me. People who criticize are often just jealous so I’m not going to let it get to me.

THERAPIST: Mmm. Is Ned talking about us? Are we a jealous group?

Silence; the group seems mystified.

Several members move to other subjects, which Dr. Pat soon connects to “Ned’s idea of jealousy.”

Members pick up the ideational thread. Like Ned, they focus on being the target of jealousy, freely dispersing criticism and blame to outside forces.

therapist (with ironic exaggeration): So much comfort with anger and frustration! A good way to express your own jealousy!

The session is ending—no opportunity to further contextualize jealousy within the group. The members had gone deeper in their exploration of psychic reality and that had satisfied the therapist. A nuclear idea had emerged, a unifying theme with personal resonance (Billow, 2016). Even for the leader who realized that jealousy of “better” groups and experienced group leaders had contributed to the therapist’s disaffection. Dr. Pat felt gratitude towards Ned and the whole group for this disinhibiting insight, which would be useful in future sessions.


No one said that running groups is easy, or that it should be. To organize a group and make it transformative, the leader must be both “woman” enough to establish preverbal bonding and “man” enough to enter in and fascinate with language (Billow, 2013a; Harper & Rowan, 1999; Lacan, 1977/1953).

An essential aspect of the professional/personal “Me” involves, then, existing in one’s own mind as a complex, procreative partner to each person (and to the group-family) and exposing this self in words and behavior. If the leader feels or is “de-skilled” by the group, he or she is effectively neutered or castrated and cannot successfully carry out the dual symbolic role.

1 used my own experience in responding to Dr. Shay’s assignment to illustrate key relational principles. The first is the emphasis on intersubjectivity, that is, on relationships, internal and external, and their dynamic, life-supporting qualities. The second is a rejection of the classical model of the healthy analyst and neurotic patient or group. Those we treat and we ourselves have transferences and other perplexing, often unconsciously motivated emotional and cognitive responses. Therapeutic relationships are reconceived in terms of co-constructed or mutually inspired interactions that are worthy of understanding rather than evaluated in terms of pathology.

Third, psychoanalytic purification (Freud, 1912), resulting in ideal equanimity, detachment, and clinical objectivity, is an impossibility. Moreover, such a posture constrains us from accessing and creatively utilizing our own subjective experience in connecting to others. Rather than aiming at a false “professional” stance, we need to possess and convey a warm, human presence.

Finally, as therapists, we are subject to compelling social forces, remain embedded in them, and enter group representing deeply rooted identifications, perspectives, and reality beliefs based on ethnic, national, and political affiliations, economic status, gender, sexual orientation, race, age, and so forth.

1 suspect that all theories, formulations, and case presentations, such as my imaginative revision, are in some ways retrofitted or aligned to the personality of the formularizer. Therapists of all persuasions bring foundational concepts to clinical work, which provides structure and direction—shifting mindsets that lead to certain paths and potentialities but may foreclose others. Ideally, we allow ourselves passage to other places by other thinkers, particularly by our group members. If the therapist is emotionally open and creative, new mental pathways may be tested.


  • 1 Dr. Shay’s (2017) invitation to illustrate Billow’s approach to group therapy is further described in the editor’s note to Section I.
  • 2 In actuality, we have three adult children. I gave birth to a fourth child because apparently, even in a dream, I could not bear to part with one of our own. Likely, too, the child was the assignment itself.
  • 3 The analyst’s “internal and external dependencies, anxieties, and pathological defenses...[respond] to every event of the analytic situation” (Racker, 1968, p. 132).
  • 4 The original group vignette can be found in Shay (2017).

Chapter 2

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