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What Is the Nature of the Therapeutic Encounter in an Adolescent Psychotherapy Group?

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What Is the Nature of the Therapeutic Encounter in an Adolescent Psychotherapy Group? WHAT IS THE NATURE OF THE THERAPEUTIC ENCOUNTER IN AN ADOLESCENT PSYCHOTHERAPY GROUP? MONIQUE MAXWELL Professional Doctorate 2016 WHAT IS THE NATURE OF THE THERAPEUTIC ENCOUNTER IN AN ADOLESCENT PSYCHOTHERAPY GROUP? MONIQUE MARIE-CATHÈRINE MAXWELL A thesis submitted in partial fulfilment of the requirements of the University of East London for the degree of Professional Doctorate in Child and Adolescent Psychotherapy July 2016 ii ABSTRACT This study takes as its subject the clinical work with 7 older adolescents who attended for once-weekly psychoanalytic group psychotherapy, and focuses retrospectively on the first 15 months of this intervention, in which the researcher was a co-therapist. The clinical process notes formed the data set. The starting point for this thesis is our conception of an inherent, developmental relationship to groups, and to the intersubjective relating that exists in human beings. It then moves on to the psychoanalytic thinking about groups and the emotional disturbance that emerged during World War II found in the work of WR Bion and SH Foulkes. It further examines literature on adolescence as a developmental process, adolescent breakdown, and the particular psychosocial risks and challenges of later adolescence. The intrinsic complexity in the data precipitated initial conceptualisations – for example, borrowing Foulkes’ notion of figure-ground - to help apprehend the material. Then, using a form of Grounded Theory, the data set was examined methodically. This evidenced how members brought complex, changing constellations of feeling, and mental and bodily states to the group. Analysis revealed relational and developmental predicaments which would interweave inter-relationally at both conscious and unconscious levels. Using both narrative and tabular forms of presentation, it is demonstrated how this shared, multi-dimensional matrix of iii relationship and communication created the bedrock of the group therapeutic encounter. Emotional and psychological growth developed in the context of members’ capacities to bear emotional knowledge, and hold emotional states over time as individual preoccupations became less pressing within a heuristic relational encounter within the group. This conferred to the group the qualities of Bollas’ ‘transformational object’, while the matrix itself linked with Stern’s primary intersubjective matrix. It is suggested that group psychotherapy has much to offer young people whose relational and psychosocial struggles can be explored in the safety and stability of the clinical group setting. iv I confirm that no part of this thesis, except where clearly quoted and referenced, has been copied from material belonging to any other person, eg, from a book, the internet, handout, or other student. I am aware that it is a breach of UEL regulations to copy the work of another without clear acknowledgement, and that attempting to do so renders me liable to disciplinary proceedings. MONIQUE MAXWELL …………………………………………… UEL no: 0639689 Word count:…….. ... July 2016 v Contents Abstract iii Introduction xii Thinking about the group, adolescence, and the research xii 1. Literature Review: Adolescence and Psychoanalytic Group Therapy 1 Introduction 1 The significance of groups 1 Why group therapy with adolescents? 4 Adolescence: development, subjectivity and mental health 4 Developmental aspects 4 Adolescence 9 Subjectivity in adolescence 13 Late adolescence and young adulthood 18 Adolescent breakdown and suicidality 23 Adolescent mental health &public health 26 Adolescents and group therapy 28 Psychoanalysis and groups 29 Northfield and after 30 W.R. Bion 34 S.H. Foulkes 37 Foulkes and Group Analytic concepts 38 Irvin Yalom 39 Morris Nitsun 40 Didier Anzieu 41 Caroline Garland 41 Other contributions 41 Other forms of group therapy 42 vi Research and clinical studies of psychoanalytic group psychotherapy 43 Psychoanalytic group psychotherapy with adolescents 47 Conclusion 49 2. Methodology, Ethics and the Group 52 Introduction 52 The setting 52 What is psychoanalytical group psychotherapy? 53 Co-therapists 53 The group 54 The frame 55 House rules 56 Research project 57 Data collection 57 Ethics 58 Process notes and the data set 59 Apprehending the data and data analysis 60 How I set about analysing the data 64 Tangent – Ontology, epistemology and child and adolescent psychotherapy 65 What I did in the end: presenting the findings 67 Theoretical issues 69 Becoming a subject 72 Conclusion 73 3. Apprehending the data: Findings 74 Introduction 74 Introducing the group 74 What the membership brings: complexity and intense states 80 vii Themes 82 States of Feeling 86 Projecting feelings &catastrophe: Serena 90 Holding the depression; biting back Peter 93 Holding the madness: Averil 96 Aggressive anorectic brinkmanship: Frank 98 States of Mind 100 Questioning relationship based on meaning: Serena 102 Persecuted by his own aggression: Peter 103 Sitting out in psychic retreat: Frank 105 Mindlessness and contact-barrier: Averil 106 States of Body 109 Betrayed by the embodied self: Serena 111 Collapse: Peter 112 Theatres of the body: Averil 113 Education 113 Group-specific phenomena 114 The working group 115 Different types of communication 117 Spaces between 119 Breaks and endings 121 Non-attendance 122 Not-working (Basic Assumption) group 123 The co-therapists 126 How we worked: holding the frame 127 Solo co-therapy 128 Holding and containing 129 Protecting the boundary 130 Keeping the group on-task 132 viii Maturational change 136 The group’s capacity to bear emotional knowledge 136 Socialisation and engagement 138 Conclusion 140 Tables 142 4. Conclusion 150 The group’s development 150 Bonding 151 Observations of change 152 Arriving at some definite findings 153 Why group psychotherapy for adolescents? 154 What I learned and what has stayed with me 155 Group psychotherapy and child and adolescent psychotherapy 156 Further research in adolescent group psychotherapy 157 References 158 Appendix 1 NHS Ethics Approval letter 205 University Research Ethics Committee letter 208 Appendix 2 210 Table 1: Representation of link between group and co-therapists’ interactions 211 Table 2: preliminary workings: Emergent themes and categories 261 Table 3: Findings: individual group members and aspects of maturational change 288 Table 4: Themes of group sessions in months 0-7 and 8-15 295 ix x Acknowledgements There have been times of unadulterated pleasure writing this, and I wonder what on earth I shall be doing with my weekends from now on! But none of it would have been possible without my supervisory team, who’ve stuck it out for the last 5 years: abundant thanks and gratitude are therefore due to Professor Stephen Briggs, Director of Studies, and to Professor Michael Rustin both of the University of East London for expert, painstaking guidance, particularly in the dovetailing of clinical, theoretical and academic thinking, for being generous with their time; for zen patience, kindness, rapid response to SOSs, and generally good counsel, and for the many catalysing supervisions. Thanks and much gratitude are also due to Dr William Crouch, Consultant Clinical Psychologist and Adult Psychoanalytic Psychotherapist, Tavistock & Portman NHS Foundation Trust - and to Jonathan Bradley Consultant Child and Adolescent Psychotherapist whose idea it was that I join Will Fond gratitude is due to Sara Bannerman-Haig, fellow traveller, for those Saturday night chats and reality checks, even when she was sailing (out in the North Sea, I always imagined) and to Paul Smyth, child psychotherapy colleague in CAMHS, for reminding me about Grotstein - and for much grounding leg-pulling Thanks are also due to Birkbeck College for use of the library, for which I am speechlessly grateful To Dr Hannah Linford, Clinical Psychologist, for administering the information sheets and collecting the consent forms from the group And to Tavistock Clinic library, especially for letting me have a copy of Garland’s 1982 type-written monograph xi Introduction The starting point for this doctoral enterprise was - for reasons perhaps best unknown to myself - being asked part way through my clinical training whether I would co-run a psychotherapy group for adolescents. I had no problem in declining the offer; clearly my attempts at self-concealment had failed! On the other hand, here - true to the Jungian idea of psychic equilibrium - was an opportunity for balance. So (courageously – I did feel I was being asked to walk the plank) - I relented. This proved to be a tremendous – if at times nerve-wracking – learning experience but one that has, without exaggerating, had a profound effect on my professional and personal development, with an attendant quantum shift in perhaps more fully comprehending – or apprehending - what intersubjectivity is. Thinking About the Group, Adolescence and the Research As we were being asked to think about proposals for doctoral research, I felt mine was in my lap: as a second adolescent group was being planned, I already had an intimation that whatever it was that happened there was powerful and merited exploration. But I also felt I needed to check and discuss with others this doctoral idea, and sought out senior clinicians in the Tavistock Clinic’s Adolescent and Adult Departments1: was this idea feasible, or possible even? Would it constitute a viable piece of research? I was interested in what it was that went on; what was therapeutic? Was it therapeutic? And if so, what was the nature of this therapeutic 1 These
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