Relational Group Psychotherapy: From Basic Assumptions To Passion (Book Review)

Author:  Billow, Richard
Publisher: London: Jessica Kingsley, 2003
Reviewed By: Patricia O. Hunter, Summer 2004, pp. 63-65

Relational Group Psychotherapy: From Basic Assumptions to Passion is difficult for me to be objective about. Like with Billow’s (1999; 2001; 2003) other writings about Bion’s work, I was moved and transformed as I read and reflected upon the ten chapters that comprise this amazingly hopeful book. Admittedly I was biased, as I really liked those previous articles. Nonetheless, this book was a true delight.

James Grotstein, who was himself analyzed by Bion, introduces the book by saying “I am not a group therapist, but after reading Dr. Billow’s theoretical and clinical explications, I began to wish that I had been.” Grotstein agrees with Billow’s assertion that Bion was one of the prophets in the contemporary relational reformation that has been taking place over the last two decades. He also suggests that Bion, like Lacan, liked to write in “poetics,” that he is hard-reading for most, and that Billow through this book has made Bion much more accessible. Billow has thoughtfully applied some of Bion’s ideas to his study of the group psychotherapy process and according to Grotstein, though Bion thoroughly immersed himself in the theory of groups and group relationships, his main thinking centered on the individual “whom he considered to constitute a group in itself.” According to Billow, Bion (1970) saw the mind structured on a dissociative-integrative continuum that defines itself according to the emotional atmosphere of the particular moment. Interactive, separate sub-organizations of personality move in and out of consciousness. Billow refers to the work of many contemporary relational writers, such as Davies (1999), Aron (1996), Bromberg (1996), and Mitchell (1993; 2000) when suggesting that “new meaning emerges from the discovery of isolated, split-off, or undeveloped aspects of the self linked to recurring, developmentally early, emotional experience.” (p. 129)

Grotstein, like Bion and Billow, believes that “the group experience brings out dimensions of a patients character that all too frequently escape detection in individual treatment” (p.15). He makes the assertion that analytic training institutes should do a better job of encouraging their candidates to pursue both individual and group therapy. Billow speaks of the “dread and fear of doing group therapy’ on the part of many analysts, which, like the analytic process “acts like a poultice to summon bad demons from inside to the surface to be experienced.” In group therapy situations, as in individual analysis, the patient is unconsciously enjoined to regress, and from this regression to project infantile anxieties into the analyst. Billow says that group therapy frightens therapists because “a group of individuals who are undergoing a therapeutic regression” is subject to what Bion (1961) calls “valency,” whereby groups “amplify emotional reactions, resulting in a combustible process of emotional contagion (p. 54). The therapist in such a situation feels and is vulnerable to having his or her own unresolved characterological issues stimulated:

“The narcissistic therapist fears that an active group will undermine... uniqueness.... The schizoid therapist fears invasion...The depressive therapist needs to remain (the universal supplier.... The compulsive therapist fears… (he/she) must control. The hysterical therapist fears being overwhelmed (p. 49)”

During the time that I first began to read Billow’s (1999) writings on Bion, I was in the process of grieving my mother’s death, while at the same time beginning to facilitate a group with female ex-offenders at the Fortune Society in New York City. These women were attending a day treatment program as an alternative to their returning to prison. As I contemplated my first group meeting, I was having fantasies of feeling ganged up on and overpowered by the hostility of the group members, given their difficult experiences in life up until that point. Although I had previously and spontaneously connected Bion’s writings with the grieving process about my mother, I didn’t think to apply Bionian principles to my work with the group. I remember struggling then with my fears of the group becoming out of control, of my becoming overwhelmed with posttraumatic memories from my own past, and of becoming depressed from memories or insights recovered during the group.

Billow quotes Bion (1965) as saying that in breaking down existing meaning for self and others, and confronting what is unknown and confusing to the group, the therapist’s own anxieties, fears of persecution and potential for depression are exacerbated. Despite using certain ideas from Billow’s writing during individual sessions with my patients, I realize now that I did indeed “dread and fear” the inevitable therapeutic regression of the group. I was, in tiptoeing enabler fashion (Beattie, 1991), subverting, avoiding, and attempting to distract myself and the group from unpredictable bouts of and anger and rage being expressed, particularly in relation to me. Davies & Frawley (1993), who Billow cites in his book when he discusses Bion’s ideas about personality and multiple self-states, put my dilemma into words with these lines:

“Uncomfortable with their own aggression… clinicians may defuse patients’ aggressive transference reactions.... This preserves the therapist as a good object.... Keeping the relationship with patients primarily loving and “nice” may represent survivor/therapist attempts to compensate patients and themselves for the wonderful childhood neither ever had (p. 64).”

Billow’s Relational Group Psychotherapy: From Basic Assumptions to Passion, however, has helped me to focus attention towards emerging group dynamics that coexist with, vividly illuminate, and add an element of insight and of meaning to my fears. My clinical background up to that point had included intensive group work with sexually abused children, and before that I had intensive group experience as a cognitive-behavior therapist (Ellis & Hunter 1991). I had, until reading Billow’s work, been approaching the group work with a sensitivity to and curiosity about the traumatized backgrounds of the women, as well as a desire to help them develop coping skills for dealing with their difficult emotional and behavioral histories. Although familiar with the relational literature in psychoanalysis, it hadn’t occurred to me to bring it all together in group: my interest in Bion, my interest in group trauma work and my knowledge of relational psychoanalysis. But essentially this is what I have been able to do, and what Billow has done theoretically and clinically, with Relational Group Psychotherapy. He has brought Bion’s early work on the group experience (Bion, 1961), Bion’s complex theoretical writing on the basic assumptions (i.e., three types of primitive object relations, fantasies and affects which individuals project and act out in social settings), and Bion’s writing on the countertranference experience, together.

The countertransference writings seemed particularly relevant to the relational point of view. Billow states,

“Although painful to absorb, internally and also make sense of, Bion believed that the group therapist’s subjective reactions could be utilized to process information about the group and its members, and could serve as a basis for interpretation...Using primary process-the capacity to free-associate, imagine and dream-and secondary process, the analyst gathers and deciphers the patients and groups unformulated experience. The therapist makes the thought and emotion tolerable, gradually representing (re-presenting) them to the members in the form of words, silence, and nonverbal and paraverbal behavior (p.114-115).”

Billow illustrates this idea when he describes exchanges between himself and a supervisee who, in running her group, noticed that the group had “heated up” since she had been in supervision. She said that she liked the liveliness, but she also mentioned that she did not like the feeling that her emotions were getting out of control. Billow wondered playfully whether she ever felt her supervisor was out of control, and whether, at present, she even liked him.

After reading Billow’s book, I found myself becoming increasingly able to do with the group what I had been allowing myself, with the help of excellent relational supervision, to do in individual therapy for many years: use the countertransference as a way to understand the patient’s experience. Billow uses Racker’s (1968) suggestion that the analyst continues to be “variable-inconsistent, professional and personal, mature and immature, healthy and neurotic, all regulated by the emotional state of the relational matrix” to describe the group analysts behavior as well. This accepting, permissive, inviting attitude towards the therapist’s sensibility and vulnerability pervades the book, and allowed me to soften unrealistic demands I was making on myself for an idealized and seamless “performance.”

As I sat with the women in my group, whose lives had been pervaded by violence and transgression, and who desperately needed contact rather than a calculated performance by an anxiously inhibited “professional,” I realized that Billow’s encouragement for the therapist to “go with the flow” of the groups’ emotionality had freed me to be more myself, and in so doing, had freed the women to be more of themselves while with me:

“In being receptive to the infantile, primitive and neurotic aspects of one’s own personality, the therapist may more fully experience his or her own experience, and this is, I believe, the precondition that allows the therapist to help the group members do the same (Billow, 2003, p.34).”

After a time they began to talk much more openly about the behaviors and events that had led to their being sent to prison in the first place and their traumatic experiences both inside and outside of prison, while I began to emotionally “be with them’ in a way that moved me beyond words.

The first chapter “The Authority of the Group Therapist’s Psychology” emphasized that insight is a relational process that, while reducing suffering, produces anxiety and pain for all group members. Billow believes that what ultimately holds a group together is the therapist’s ever expanding understanding of the group and its members as well as the therapist’s success in reaching and deepening such understanding, however painful and unwelcome. For this achievement, according to Bion, represents “passion.” The following chapters, in a nutshell, address the therapist’s resistance to the group (Chapter 2), the basic conflict between thinking and anti-thinking (Chapter 3), the occurrence of entitled thinking and dream thinking (Chapter 4), and containing and thinking (Chapter 5). Each chapter builds on the previous chapter, more in a spiral than a straight line, involving cogent and candid concrete examples from Billow’s vast clinical experience.

There is a chapter on the adolescent group experience (Chapter 6) where Billow’s recounting of various group interactions made me smile (e.g., Billow: “I notice that this group can’t take two weeks in a row when people are being emotional” Adolescent: “Fuck you.” Billow: “Very clever. Now I know that you can take it and really think about what I’m saying. Duh.” [p.148]), where Billow says the task is to contain the adolescents’ ambivalent, often confrontational communications with playful use of the therapists own subjectivity. Billow believes a therapist contributes to group not only through words, but especially through a preverbal feeling of bonding. In Kleinian terms, according to Billow, “a secure sense of bondedness represents achieving “the depressive position.” (p. 153). Rebellion in group (Chapter 8) is discussed as a strategy of social action: to overthrow the group’s status quo or adamantly to oppose its revision. Billow expresses a tremendous respect for this process, stating, “Submissive groups and compliant individuals lack creativity, which is stimulated by independent thought and freedom of expression.” (p. 174). References to Foucault (1978), Marcuse (1955), Sartre (1956) and Lasch (1978) suffuse this chapter with a broader sociopolitical viewpoint while Symington’s (1983) sensibility about the freedom of the analyst to communicate caring while preserving a sense of inner freedom is also included to good cause.

Primal Affects, Loving, Hating, Knowing (Chapter 9) is the heart of Bion’s basic assumption theory and later thinking regarding premonition, beta elements and alpha functions. Billow illustrates these highly complex abstractions beautifully in concrete and clinical terms. His discussion of an “impasse in K’ during an eight week postdoctoral seminar he conducted opened my eyes to the enigmatic ways that knowing can be subverted even by a group devoted to that very purpose. The Passionate Therapist, The Passionate Group, is the title of the final chapter on Primal Receptivity. It is the grand finale for a grand book:

“[Passion involves] enduring the breakdown of meaning, tolerating the mourning process, submitting to and suffering through the disorganizing, even frightening sensations accompanying paranoid-schizoid and depressive phenomena. (p. 217) The process necessarily includes feelings of catastrophe, for old meaning must crumble before new meaning is built (p. 225).”

I thank Billow for creating such new meaning for me.

Reviewer Note

Patricia O. Hunter is in private practice in New York City. She graduated from the Manhattan Institute for Psychoanalysis and has been a member of the Trauma Treatment Center of Manhattan Institute; and was recently appointed as visiting faculty with the Suffolk Institute for Psychotherapy and Psychoanalysis on Long Island, NY.

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