The psychoanalytic petticoats of a Rogerian group process.
This article aims to apply psychoanalytic theory to reflect critically on a Rogerian group intervention in a NGO setting, namely the training of prospective LifeLine (1) counsellors. I have employed an experience-near perspective to shed light on what may make these person-centred, group-based learning interventions consistent with psychoanalytic theory. I am mindful of the tension between the two theoretical approaches, but choose to foreground their similarities in order to show that a Rogerian approach is not altogether inconsistent with a psychoanalytic understanding.
In reflecting on my experience, I have drawn on fundamental concepts which span a number of psychoanalytic schools of thought: the unconscious, the frame, confidentiality, avoidance of dual roles and the use of countertransference. From contemporary Kleinian thought I have borrowed Bion's concept of containment, from the British 'Independent's' or middle group, Winnicott's holding and from Self Psychology, Kohut's empathy.
In describing my experience as a facilitator, I explicitly acknowledge that like all researchers, I am 'part and parcel of the setting, culture and context .... (I am) trying to understand and represent' (Altheide & Johnson, 2011, p. 582). Reflexivity, as disciplined self-reflection, thus forms an important means of interrogating this entanglement. I have thought about my LifeLine involvement through the years, and how holding these parallel theoretical paradigms internally pertains to my development as a psychodynamic psychotherapist. On the lighter side, this paper has also allowed me a Winnicottian playful engagement with theory and experience alongside the joy of writing.
Telephone counselling services
Telephone counselling services have expanded worldwide since the 1960s and form an essential part of community healthcare (Bobevski, Holgate & McLennan, 1997; Reese, Conoley & Brossart, 2002). There is a substantial body of research on telephone counselling which focuses on diverse aspects such as its overall efficacy (Lester, 2012; Meehan & Broom, 2007; Mishara, Chagnon, Daigle, Balan, Raymond, Marcoux & Berman, 2007; Reese, et al, 2002), the unique qualities of telephone interventions (Lester, 1974), the effectiveness of counsellor skills (Bobevski et al., 1997; Bryant & Harvey, 2000), the relationship between coping skills and burnout (Day, 1999; Rogers & Medlock, 2012) and the nature of calls made to crisis lines (Morgan & King, 1977). A smaller body of research explores counsellor experience such as motivational factors in volunteer counselling (Brimmer, 1994), the lived experience of being a telephone counsellor (Abrahams, 2006), and the challenges and limitations faced by telephone counsellors (Brockopp, 2012). Considered a cost-effective, relatively accessible supplement to traditional counselling by Reimer-Reiss (2000), telephone counselling nevertheless has its limitations. There is a lack of continuity, counsellors are limited to auditory cues, have no advance information on callers, little or no opportunity for follow-up and almost never know what effect they may have had (Bobevski et al., 1997).
Telephone counselling as an extension of mental healthcare services
In South Africa, psychological services in particular and the mental healthcare system in general remain chronically under-resourced (Lund, Kleintjes, Kakuma & Flisher, 2009). Given the resource-intensive and lengthy training periods required for mental healthcare professionals, South Africa is unlikely ever to have enough psychiatrists, psychologists, social workers and related mental health professionals to adequately address the needs of the population.
Against this backdrop of inadequate services, it is obvious that the complimentary contributions of the NGO and faith-based sectors to mental health and emotional wellness are crucial. One way we can hope to extend services is through well-trained non-professional counsellors. This is the arena in which LifeLine has operated locally for almost fifty years now, with counsellors fulfilling the vital function of a first contact point who can guide and support clients and then make appropriate referrals to professionals where needed. Considering that it takes more than a decade of tertiary education to train a psychiatrist, a minimum of seven years for a psychologist and four for a social worker, LifeLine produces a functional counsellor within approximately one year.
In the South African context, however, not even LifeLine is accessible to the poorest of the poor, as the cost of the call would be prohibitive. Despite this, telephone counselling remains an important adjunct to--and link with--more formal mental healthcare services. Human suffering ranges from ordinary distress to florid pathology. While the latter is arguably the domain of the professionals, the former is where organisations such as LifeLine are adept. This is borne out by Watson, McDonald and Pearce (2006), in their research into LifeLine Australia's free 24-hour telephone counselling and referral service available to all Australians, who found that rather than accessing suicide intervention per se 'callers are generally seeking social support from the service' (p. 471). Similar research in South Africa, with its social fragmentation, poverty and legacy of Apartheid, shows the need for social support especially amongst those burdened by mental disorders (Bantjes, Nel, Louw, Frenkel, Benjamin & Lewis, 2016). Indeed, a clear association has been shown between poverty and the risk of mental disorders (Lund, Breen, Flisher, Kakuma, Corrigall, Joska, Swartz & Patel, 2010). In one such study, Meehan and Broom (2007) evaluated the perceived helpfulness of South Africa's first national toll free suicide crisis line, established in 2003. They found that the majority of participants perceived the crisis line as helpful.
Thus telephone counselling provides an avenue for delivering a readily accessible form of immediate counselling help, information and referrals to those who may be either unable or unwilling to reach out to a mental healthcare professional (Wark, 1982).
LifeLine--A brief overview
LifeLine is a non-profit organisation in the mental healthcare sector which has been providing emotional wellness services, such as telephone and in-person counselling, trauma debriefing, crisis support--notably suicide intervention, referrals, awareness raising and training for over fifty years.
Founded by Dr Alan Walker, Superintendent of the Central Methodist Mission in Sydney in 1963, LifeLine has grown into an international affiliation of member organisations with a regional presence in Africa, Asia, North America and the Pacific. Comprising 264 centres and a volunteer corps of some 50000 lay counsellors (2), LifeLine operates in some nineteen countries (LifeLine Australia, 2010; LifeLine Pretoria, 2016). Services are delivered free-of-charge by carefully selected and trained volunteers, whose primary task is to provide non-judgmental counselling in a caring and accepting manner (Lifeline Australia, 2010). In 1968, Bishop Peter Storey brought LifeLine to South Africa and opened a centre in Cape Town (LifeLine Western Cape, 2016a). LifeLine has a total of nineteen affiliated community centres in all provinces except Limpopo and the Northern Cape. It runs a diverse range of projects and manages numerous national and local crisis lines throughout the region (LifeLine South Africa, 2015). The network focuses on promoting the emotional well-being of individuals and communities, through providing counselling, training and capacity building at the grassroots level. Nationally, priorities include the prevention of HIV/AIDS, gender-based violence and child abuse. LifeLine Western Cape currently has centres in central Cape Town, Khayelitsha, Mitchells Plain, Parow and Wynberg.
LifeLine's theoretical orientation
Interestingly, LifeLine's theoretical underpinnings are rarely referred to in its online presence. Only two websites explicitly identify the counselling approach as 'person-centred' (LifeLine Australia, 2010; LifeLine Western Cape, 2016b). The LifeLine Australia (2010) website also uses language which is immediately identifiable as Rogerian. Despite having seldom heard the name Carl Rogers mentioned during my years of involvement with LifeLine in Cape Town, all training interventions deliberately incorporate Rogerian principles in an experiential manner.
Humanistic therapies evolved in the USA during the 1950s, partly in reaction to the formal and hierarchical way in which the then dominant psychodynamic and behaviourist schools of psychology were being practiced. One of these humanistic approaches, the person-centred approach evolved out of the pioneering work of Carl Rogers (1902-1987) (BAPCA, 2015). Although his approach to psychotherapy and counselling was considered radical at the time (1940s-1960s), today his basic tenets have been widely adopted by psychologists, irrespective of their theoretical orientation. Research shows that it is the quality of the therapeutic/counselling relationship that is transformative (Orange, 2011). The person-centred approach, which privileges Rogers' (1957; 1962) core tenets of empathic understanding, congruence or genuineness and unconditional positive regard, speaks after all, directly to the relational context.
I have been unable to find background information on when, how and why LifeLine adopted a Rogerian counselling model, but this has been the case at the Cape Town centre for more than thirty years. Alan Walker's (1967) account of LifeLine's first four years of operation provides some detail as regards the curriculum of the early training of volunteer counsellors. This comprised a series of compulsory lectures described as covering 'biblical and doctrinal subjects, counselling problems and Life Line procedures' (p. 24). However no mention is made of any specific theoretical framework and the 'counselling problems' seemed to have provided an introduction to a range of social difficulties likely to be encountered. Lecture titles included 'Marital disharmony', 'The problems of youth', 'The psychologically disturbed' and 'Handling social distress', 'The physiological aspects of alcoholism' etc. (Walker, 1967, p. 49). The counselling approach, at least in those early days, seems to have rested on common-sense principles around maintaining anonymity, confidentiality, the safety of volunteers, thorough record-keeping and follow-up. It is likely that the counselling training has evolved over time and that as Rogerian counselling principles became mainstream they were increasingly incorporated into LifeLine training interventions.
LifeLine Western Cape's training interventions employ an experiential learning methodology. Small groups, each with its own facilitator, interactively work through a series of themed exercises using experiential facets such as personal narratives, focused reflections and group discussions. The facilitators meet as a group before and after each training session.
Narrative account of facilitating LifeLine training
I describe my own experience as a participant-facilitator, specifically during a check-in before a training session, below. This narrative illustrates a number of aspects: the experiential nature of the group process, the crisis line principles of anonymity and confidentiality, Rogerian genuineness and psychoanalytic concepts including holding and containment.
I sit in the room again ... a space that old LifeLiners refer to as 'downstairs'. Downstairs is where facilitators meet for a check-in before a training session, as well as to debrief after such a session. The training sessions happen upstairs in the hall. Downstairs has a very particular feel. We sit in a circle. Everyone participates. People share in some depth about their current life challenges ('I'm distracted, my mother-in-law is in hospital ...', 'I'm feeling quite anxious about this evening ...') and are congruent in their expression of their emotional reality. At odds with social conventions which ask for the bland and predictable 'Fine thanks, and you?' And yet we know next to nothing of one another's biographical data: what each of us does for a living, age, marital status, level of education, etc. This is in keeping with the principles of the crisis line: anonymity and confidentiality. Who we are in the outside world is irrelevant. Who we know ourselves to be, and our capacity to self-reflect and relate to others authentically is what counts. I look around the room. We are fifteen including the presenter, she who facilitates the overall process from the front of the hall but whom, downstairs, is also a participant-facilitator as we are in our small groups. Layers. Checks and balances. It's the end of a working day. I feel myself starting to unclench from the bustle, the traffic, my usual preoccupations ... to become still inside, to remember to breathe. That slipping into an almost altered state of consciousness, a re-establishing of the connection with yourself, a clearing of mental clutter, a turning inward ... a mindfulness. A necessary space to move into for the evening that lies ahead. As my co-facilitators each take a turn to share where they find themselves in the moment, a sense of collective connection is fostered, a container is constructed. After everyone has checked-in, we talk about our expectations and concerns regarding the evening's upcoming session. People share their experiences of what has worked in their groups thus far and where they've struggled. We wonder about whether or not it's important to be liked by your group members, when to push and when to allow, when to challenge, how to deal with conflict, how best to manage limited time. In a nutshell: how to create the conditions which will foster personal growth. Pure Carl Rogers. As the discussion flows, my more relaxed state is rudely punctuated by spikes of anxiety. Just talking about the session on conflict is enough to evoke anxiety. It's the one I hate, the session I find most personally challenging. This process doesn't cover conflict (or relationships, or loss, etc.) in an intellectual way. That would be easy. Instead you are plunged into a situation which generates a visceral experience of, say, conflict. For me that entails pumping adrenaline, rocketing anxiety, racing heart, sweaty palms. Awful. Every time. It doesn't get easier with practice.
The group process
The group process, which I have chosen to deconstruct through a psychoanalytic lens, is employed in both the Personal Growth Course (PGC) and the Basic Counselling Skills and Communication Course (CSC) as offered by LifeLine Western Cape at its Cape Town centre. Both these courses entail a weekly three-hour session over a nine week period and are presented three times a year. They involve a facilitated, small closed-group process, which employs an experiential learning methodology. Small groups vary in size from four to seven members including the facilitator. Although members may drop out over the course of the nine weeks, no new members are admitted to a group during its lifespan. While therapeutic benefits may accrue to individual participants along the way, these are not group psychotherapy interventions, but experiential training groups or process groups. Since group therapy's introduction in the 1940s, multiple models have been developed with the overarching aim of enhancing emotional wellness. The process group, on the other hand, seeks to provide 'experiential classroom training' in a group format (Yalom & Lesczc, 2005, p. xii). The Personal Growth Course, then, aims primarily to facilitate personal growth/self-awareness and secondarily to provide the scaffolding for those who wish to proceed to become LifeLine counsellors. The goal of the Counselling Skills Course is to ensure that trainees acquire counselling and communication skills so that they are equipped to provide counselling services for LifeLine or in other contexts such as the faith-based, non-profit and healthcare sectors.
Intuitively, we know that we learn best through experience. Most of us would probably agree with Sophocles' words from 400 B.C., 'One must learn by doing the thing, for though you think you know it--you have no certainty, until you try' (Gentry, 1990, p. 9).
Experiential learning, as understood in the learning theory literature, harnesses experience as the source of learning and development. In stark contrast with theoretical or didactic learning, in which the learner is relatively passive, experiential learning employs an interactive approach which emphasises 'learning through reflection on doing' (Kolb, 1984, p. 17).
Both LifeLine courses faithfully follow the Kolbian learning cycle (1984) of doing or having an experience, then reflecting on that experience, followed by drawing abstract 'lessons' from the experience and finally experimentally trying out what has been learned. For example, an exercise in which group members have paired off and spoken to each other about say, a significant loss, will usually be followed by group time around questions such as 'What was it like to talk about that?' and 'What have I learned about myself?'. The following session will then commence with a reflection on what, if anything, was different during the preceding week. Although participants are not explicitly encouraged to 'try out what they've learned', often these group check-ins will include spontaneous reports about how someone did something new as a direct result of enhanced self-awareness.
In addition to this sequence, the learning experience also takes place according to the Rogerian principles of empathy, congruence and unconditional positive regard (Rogers, 1979). Given that there are many and varying definitions of empathy in the psychoanalytic literature, here I shall define this elusive concept simply as striving to communicate a deep understanding of another's subjectivity. I take a closer look at empathy within the group process from a Kohutian perspective later. Congruence refers to the capacity for genuineness, while unconditional positive regard speaks to total acceptance or valuing the other for who s/he is. These are the core conditions which Carl Rogers (1957; 1962) posited as the necessary requirements for fostering growth in a therapeutic relationship. In similar vein, facilitators of LifeLine's courses are expected to embody these attitudes within the group process and, through modelling, to encourage group members to do likewise, such that personal growth is facilitated.
All facilitators are LifeLiners. While this may be stating the obvious, LifeLine is very strict about the fact that anyone (staff member or volunteer) that is involved with the training, selection or supervision of counsellors, must themselves have undergone the same learning processes. In addition, facilitators are also participants: both in the facilitators' sessions, as illustrated in the narrative account above, and in their small groups. They are active members of their small group, take part in all exercises, answer all questions and have equal 'airtime' when it comes to sharing their personal experience. In other words, nothing is asked of a group member that is not also asked of facilitators.
As much as these group-based learning interventions hold significant potential to contribute to the ranks of South Africa's lay counsellors, there are also barriers to accessibility. Not everyone who may wish to take part in these courses is able to. Firstly, eligibility requires quite a sophisticated level of both spoken and written English. Bear in mind that that which is spoken about is often the subjective realm of internal experience, difficult enough to articulate even in one's mother tongue, let alone in a second or even third language. The courses are only offered in English at this stage, thus language remains a potential barrier to prospective counsellors whose first language is not English.
In terms of geographical accessibility, these courses are only offered in Cape Town by LifeLine Western Cape (other LifeLine centres offer equivalents in metropolitan areas elsewhere). Prospective counsellors from rural areas face significant challenges in accessing opportunities of this nature. Furthermore, the courses are not free of charge. LifeLine, as a typical cash-strapped NGO responsible for covering its own operating costs, relies heavily on income from these courses. Although it also attempts to subsidise prospective candidates where possible, its ability to do so is limited. While in theory the LifeLine courses are open to all who may be interested, in practice there are very real linguistic, geographical and financial barriers in terms of accessibility.
Basic psychoanalytic principles
In my efforts to reflect on the narrative presented above and my experience of facilitating this Rogerian group process, I have employed a number of psychoanalytic concepts to illustrate what I have termed the 'psychoanalytic petticoats' of LifeLine's training. Each of these concepts, namely the frame, containment, the unconscious, countertransference, empathy and holding and their theoretical origins, are briefly described below.
The psychoanalytic frame can be defined as that set of conditions (for example spatial, temporal and attitudinal) which allows the [group] to function and the therapeutic process to unfold (Quinodoz, 1992). In applying Bleger's (1967) constituent elements of the frame to this context, spatial facets would refer to a quiet room with only the facilitator and group present; temporal aspects to regular sessions of a fixed length and frequency; and attitudinal considerations to the group maintaining strict confidentiality and avoiding dual roles, as well as a facilitator who avoids 'doing' and retaliation.
The very idea of maintaining a frame in a hall containing upwards of seventy people may seem implausible at first glance. However, I hope to show that the frame, albeit in radically modified form, is indeed kept in place. Given the extent to which the multiple-groups-in-one-space format precludes many spatial aspects especially, minimum-requirement attitudinal considerations related to maintaining strict confidentiality and avoiding dual roles (Bleger, 1967) are foregrounded.
One of the basic rules of LifeLine's training courses, selection and ongoing supervision, is the avoidance of dual roles. Careful thought is given to who works and interacts with whom. For example, facilitators are careful not to include anyone whom they know--whether as a friend, colleague, acquaintance or family member--in their group. The ideal is that a group is initially made up of strangers. Similarly, you would not include someone in your Counselling Skills Course group, whom you have previously facilitated during the Personal Growth Course.
This rigor inevitably places a burden on LifeLine in terms of requiring a large pool of facilitators to draw from, and requires a constant mindfulness on the part of anyone involved in the training, selection and supervision processes.
The dual role concept often presents difficulties for those just entering the Personal Growth Course. In the first few weeks, participants can become quite taken with the novelty of the kind of relating that is fostered during the process. People begin to feel safe and comfortable with each other in a way that often feels different to what happens in the rest of their lives. People naturally respond to this experience with an impulse to establish social contact, perhaps via social media or by spending time together outside of the course. Explaining that the safety and confidentiality of the group is premised on the principle of no dual roles and how easily this fragile but crucial state can be compromised, falls to the facilitator. Here we have the process group equivalent of the basic analytic principle of no contact outside of 'the room'.
The principle of confidentiality is well established in the healthcare sector in general. It also forms the bedrock of the psychoanalytic project. One of LifeLine's promises is that it provides an anonymous, confidential counselling service--whether by telephone or in person. The principle is applied not only during actual counselling sessions, but right from the start of the Personal Growth Course and throughout the training process.
During the facilitators' check-in and debriefing sessions, group members' names are never used and every attempt is made to avoid using language which could point to a particular individual. For example, at LifeLine as with the mental healthcare sector globally, men are underrepresented. So if you only have one male group member, even using the pronoun 'he' may be enough to allow other facilitators to infer who you are speaking about and thus compromise that member's right to confidentiality. Given how fundamentally gendered language is, some amusing and convoluted grammatical constructions have resulted from attempts to avoid gendered pronouns.
Maintaining confidentiality within the group can be tricky terrain for group members initially. In the first session of the Personal Growth Course, members are asked to identify what they might need from the group in order for it to work for them. Invariably the word 'confidentiality' comes up. Yet upon interrogation, it also regularly emerges that this is a concept which is grasped superficially, at best. Once it becomes clear that as a group member you will not be able to rush home and share 'juicy bits' of detail from someone else's life with your spouse/friend/parent/child, members start to realise the hard work, discipline and vigilance that confidentiality requires. Of course if group members are unable to manage this discipline at the foundation level of the Personal Growth Course, how are they to do so one day as a counsellor?
Confidentiality and the avoidance of dual roles are thus two crucial ways in which the frame is maintained. Further elements include sessions of the same duration taking place at the same time and place each week and the closed nature of group membership. To the extent that circumstances allow the retention of at least some aspects of the frame, an experience radically different from participants' workaday existence is facilitated. Within this space, then, a way of experiencing can emerge which fosters growth and self-awareness. Finally, Quinodoz (1992), commenting on the fundamental relationship between the frame and containment, holds that 'the setting will then be the entity through which the analyst's container function is expressed' (p. 628).
Facilitators often speak of how 'containing' the check-in before and debriefing after each training session is. While this word is being used in its 'ordinary' (i.e. non-theoretical) sense, such usage derives from facilitators' lived experience of the process. Here Bion's (1962) theory of containment proves useful in understanding this process in the LifeLine context. Bion's (1962) concept of the 'containing' mother has been widely used in the analytic literature as a model for the therapist's role (Banks, 2002; Mendelsohn, 2007) and the supervisor's role (Eagle, Haynes & Long, 2007; Kottler & Swartz, 2004). The theory also offers insight into how containment can enable thinking, learning and ongoing development (Revington, 2008).
Bion's (1962) theory speaks to fundamental processes of digestion and transformation facilitated by particular ways of thinking--what he calls 'reverie'--within the mother-infant dyad. What is digested and transformed are primitive affective states, notably of anxiety, confusion and terror. According to Bion (1962), the infant's early experiences consist of an overwhelming 'confusion of impulses and sensations' (p. 116), which require conversion in order to be rendered meaningful. This process of producing meaning or understanding ('alpha-elements') from raw experience, Bion (1962) terms 'alpha function'. Alpha function is 'the unknown process involved in taking raw sense data and generating out of it mental contents which have meaning, and can be used for thinking' (Hinshelwood, 1989, p. 218). Here the mother's capacity to absorb and contain the infant's terror and confusion helps the infant to tolerate anxiety and make sense of unprocessed experience. Should this process fail to take place, the infant is left with nonsensical, raw experiences ('beta-elements') which can neither be thought about nor represented.
So as to provide this containing function for the infant, the mother must herself maintain an internal state of 'calm receptiveness' (Hinshelwood, 1989, p. 420). She must simultaneously contain the infant's distress while not becoming overwhelmed by her own anxiety (Waddell, 1998). Bion (1962) refers to her capacity to do so as 'reverie'. Similarly, an important part of a facilitator's function is to moderate and contain affect: both our own and those of our group members. We as facilitators can only contain our group members to the extent that we are ourselves contained. Thus the purpose of the check-in and debrief before and after a training session, is to contain the containers. This is not a happy byproduct, but rather a deliberate, explicit principle of all LifeLine training and supervisory interventions. These check-ins and debriefs, which I have described from my own experience, serve to foster a state of reverie. Facilitators are encouraged to lay down the day's frenetic activity, to turn inward and to reconnect with their internal 'calm receptiveness'. In addition, facilitators are also invited to verbalise their (conscious) anxieties and fears regarding the evening which lies ahead, whether related to the content, their group's dynamics, countertransference regarding specific members, or doubts about their own competency etc.
Apart from the circle of facilitators referred to above, containment also takes place within each small group. In this parallel context, the facilitator can be understood as providing a containing function similar to that of a mother, and through this containment, the group member (infant) comes to internalise aspects of their group-fostered experience. How does this happen? Recall that the infant begins to develop 'his own capacity for reflection on his own state of mind' (Hinshelwood, 1989, p. 420), as the mother provides alpha functions and a sense of reverie. Thus thoughts and a framework for organizing these thoughts come into being and 'thinking' can take place (Bion, 1962). Time and time again, participants and facilitators consciously move through the Kolbian cycle of experiencing and then reflecting on their experience, while containment is provided.
While Waddell (1998) holds that the ability to learn from experience allows growth and development to occur, there are a number of difficulties which may serve to disturb the learning process. For example, the group is subject to the pathologies and personalities of all its members including the facilitator's (Driver, 2002). High levels of anxiety and unconscious conflicts impact the group and thus each group will have unique dynamics (Bion, 1961). Additionally, anxiety, envy and rivalry commonly play out in groups and hold the potential to disrupt thinking (Mollon, 1997). Facilitators therefore need to be able to contain group dynamics while also focusing on the interaction between themselves and each group member. This container function is an active one which allows the facilitator to modify and give back to the group in a digestible form, that which is being communicated. The facilitator's responsiveness allows group members an experience of being contained, affirmed, soothed and mirrored. Benjamin (1998) describes this process as 'that response from the other which makes meaningful the feelings, intentions and actions of the self (p. 12). Thus fears and confusion are rendered more palatable, raw experience is mulled over and assimilated and a particular kind of thinking is fostered. 'Thinking' for Bion is the 'emotional experience of trying to know oneself or someone else' (O'Shaughnessy, 1981, p. 178). Wilfred Bion's words capture the essence of what the Personal Growth Course feels like subjectively.
While the unconscious is not a feature of Rogerian theory and is not referred to in any way during the LifeLine group-based processes, those of a psychodynamic persuasion believe it to be always and universally present. Bion (1961) amongst others has noted the impact of anxiety and unconscious conflicts on group dynamics and that envy, rivalry and transferences typically manifest in group settings. I have selected two instances of how the unconscious can be seen to be at play during the group-based processes: idealisation and its partner devaluation and, projective techniques.
As the weeks of the course go by, jockeying for position vis a vis the facilitator's favour or attention, can often be observed. Similarly, a strong recurring theme in facilitator debrief sessions, is the obvious idealisation of facilitators by group members and sometimes, vice versa. Individual group members may make reference to facilitators in the wise, all-knowing terms characteristic of Kohutian idealisation. Idealizing experiences--which Self Psychology views as necessary ingredients for the healthy development of the self--require powerful others 'to whom the child can look up and with whom he can merge as an image of calmness, infallibility and omnipotence' (Kohut & Wolf, 1978, p. 414). While it can be gratifying to experience yourself in this one-up position as a facilitator, it is equally likely that you will find yourself on the receiving end of idealisation's counterpart, devaluation. Devaluation of individual group members also occurs and it is not uncommon to hear a facilitator express frustration or disillusionment at the one 'black sheep' in the group who does not fit in or is disruptive or uncooperative. Both idealisation and devaluation, whether of a therapist by a patient, or of a facilitator by a group member or vice versa, range from more mature and healthy to the more archaic or defensive modes (Freud, 1992).
The Personal Growth Course in particular, employs a number of exercises which are readily identifiable as projective in nature. The psychoanalytic premise is that unconscious elements of the personality are projected onto stimuli such as drawings, images, incomplete sentences or inkblots such as the well-known Rorschach test, and thus revealed (Frank, 1939). To illustrate, participants on the Personal Growth Course could be asked to make a pencil crayon drawing of a river. This is then explored in the group on the assumption that each person's drawing represents the self in some way. Part of this exercise asks of participants to consider in what ways their drawing is similar or dissimilar to themselves. Another session employs a meditative, imaginary journey which includes a conversation with a 'wise one'. While participants are asked to think about this exercise in the context of their belief systems or spirituality, psychodynamically this can be understood as a means of fostering access to contents of the psyche which might otherwise be difficult to reach. Group members often express surprise at what emerges for them during this exercise, which may illustrate the unexpected quality of that which Christopher Bollas (1995) refers to as 'news from the unconscious'. So while the unconscious is not referenced in Rogerian theory, my reading is that it is incorporated into the experiential methodology of the group-based interventions.
Countertransference has been understood in a number of different ways in the psychoanalytic literature, although interestingly Freud left the term undefined (Heimann, 1960; Winnicott, 1949, 1960a; Wishnie, 2007). I am using it here in the broad sense of all a therapist's feelings and inner reactions towards a patient and about the therapeutic encounter with that patient. There is, however, broad consensus that countertransference is an important source of data about the patient and can be used self-reflexively in the therapeutic endeavour (Wishnie, 2007).
One of the principles that is emphasised throughout LifeLine training interventions--whether as a group member or a facilitator--is that of paying careful attention to one's emotional responses. Counselling telephone calls, for example, can strongly trigger one's own emotions, as can interactions with group members. When this happens, one is encouraged to view such experiences as indicators of the need for further self-exploration. Abrahams (2006) points out that 'emotions guide counsellors in that they serve to reveal both caller and counsellor concerns and guide counsellors in their interaction with callers' (p. 50). Here we have in different clothes the psychoanalytic principle of using one's countertransference reflexively in service of the therapeutic encounter.
Similarly, as a facilitator, one of the key tasks is to be aware of their own subjective experience, to continually reflect on its meanings and to share these with their group members as appropriate. The facilitators are also participants and built into all exercises is an invitation to think about and share their experience of a particular exercise. This methodology fosters self-awareness, by creating an oscillation between experiencing and reflecting in a disciplined manner over a period of time.
One of the concepts central to both Rogerian theory and self psychology is that of empathy. The closely-related concept of empathic immersion is useful. Empathic immersion is the process whereby the clinician feels her or himself into the psychological reality of another and attempts to understand experiences from the other's perspective (Kohut, 1959). The key word here is 'attempts': in a South African context fraught with difference--be that racial, class, language or other differences--full empathic immersion remains aspirational. As Swartz (2012) points out, the capacity for empathic attunement is necessarily limited in racialized contexts where 'difference confers a fluid, shifting, but ever-present otherness on every encounter' (p. 196). While I am a white, middle-class, female facilitator my group members are black, coloured and white; male and female; working and middle class. Many of their stories fall outside my realm of experience. Despite these very real limitations, participants have commented over the years that they appreciate my sustained efforts at understanding. These efforts are made possible, in the first place, by the frame, which enables me to concentrate, think psychodynamically and function as the 'attentive other' (Szecsody, 1997, p. 240). Facilitators often receive feedback in the written assessment which each group member completes weekly, specifically around our ability to listen or 'really listen' as it is often phrased.
One of the very first exercises in the Personal Growth Course requires group members to pair off and take turns to introduce themselves to each other for a couple of minutes. The group then reconvenes and each member has a turn to introduce their partner to the rest of the group. Members do not know that they will be asked to do so before the time. Often participants recall very little of what their partner said and as a result do a rather shoddy job of introducing them to the group. This is the point of the exercise: to demonstrate how poorly most people listen. So the experience of being with a facilitator who is listening--really listening--offers something different. People notice this and it illustrates the power of attention of this nature. Having someone being curious about one and one's world, who is working hard to understand, is a profound experience for most people. Group members often provide feedback reflecting that they feel personally responded to and engaged with. Of course listening and empathy are not the same thing; listening is a building block for empathy and without the former the latter would simply not be possible.
Much has been written about the distinction between holding and containment, constructs which are similar in some respects but different in others (Ogden, 2004). Very briefly, Bion's container-contained concept focuses on the processing of thoughts derived from lived emotional experience, while Winnicott's idea of holding is about the mother's capacity to safeguard the infant's continuity of being. Over time the infant gradually comes to internalize the mother's holding of his or her being, a crucial part of the maturational process (Ogden, 2004). In my experience, one of the central psychological processes playing out during the group-based intervention is that of holding. Winnicott (1960b) used the mother's literal, physical holding of her infant as the metaphor for this key process, which forms part of his overall theory of the development of the psyche and its relationship to the external world. He identifies holding as the crucial environmental condition in the provision of good-enough maternal care, which facilitates the development of the infant. It includes physical holding initially, later the more complex and abstract aspects of emotional holding, as well as environmental provision more broadly. It requires attunement, empathy, reliability and patience on the part of the mother (Winnicott, 1960b).
Holding is about providing the right kind of environment; one in which growth and development can occur. As a facilitator, I have often had a sense of being a midwife: a feeling of being both actively involved in and witnessing some subtle birthing process. What is being birthed? As the weeks go by, people come to new understandings, discoveries are made and fresh ways of thinking about themselves--and themselves in relation to others--emerge. As the facilitator, it falls to me to hold the individual in mind in a particular way, to be the constant in their flux, to be the reference point should they feel lost or confused, to make links so that they too can see the thread. It is less about words than it is about silence. In psychoanalytic terms, it is more about the non-interpretive dimensions, the silent but necessary backdrop, although this does not exclude interpretations altogether (Slochower, 1996). Slochower (1991) describes the holding environment as being embodied by the 'reliably available, empathic presence' of the other (p. 709). Of course the timescale here is completely different to the full developmental processes Winnicott originally had in mind. But even over a few short weeks, one can observe the subtle emergence of new perspectives and experiences; the delicate tendrils of growth. Group members, in their written feedback at the end of the course, will often use language such as 'I see myself differently' or 'I've grown'. Sentiments of this nature would seem to suggest that something both additional and different has been gained in terms of the group member's sense of being in the world. While this represents the best possible outcome for a participant, it is by no means guaranteed. Doing this kind of work inevitably also exposes one to experiences of not being the good-enough facilitator.
Finally, it follows that facilitators are only able to hold their groups to the extent that they themselves are held. Winnicott (1960b) puts it thus: 'It should be noted that mothers who have it in them to provide good enough care can be enabled to do better by being cared for themselves in a way that acknowledges the essential nature of their task' (p. 592). This, then, is the function served by the facilitator check-in and debriefs which bookend each evening's training session.
Theoretically and epistemologically, the Rogerian and psychoanalytic approaches differ on many dimensions such as how the personality and its development are understood, and what constitutes psychological well-being versus psychological disturbance or psychopathology. These theoretical approaches also have markedly different understandings of the psychotherapeutic process and what is required of the therapist. These differences in turn translate into how the therapeutic project is conceptualised in terms of aims, techniques and the manner in which the therapist relates to the patient/client. While person-centred approaches privilege the here-and-now, analytic thinking is strongly informed by how the past influences the present and the role of the unconscious. Depending on the particular psychoanalytic school of thought, what they may have in common is an open-ended i.e. non-directive approach and a privileging of empathy and the therapeutic relationship (especially in the relational and intersubjective schools of psychoanalytic thought). One of the ways in which I am able to reconcile these seemingly disparate approaches in my own work as a group facilitator, is to foreground the quality of my relationships with group members. Another is that while I draw on analytic concepts, such as those discussed above, to make sense of what is happening in a group in any given moment, this does not necessarily mean that I will share my understanding with my group and, if I choose to, will not do so using analytic language. It may well be easier to hold both theoretical paradigms in mind because of the 'nontherapeutic' nature of the group work i.e. the tensions would perhaps be more pronounced in a therapy group.
The analysis I have presented shows that even though the group process is explicitly person-centred, there is still a group process that unfolds and that it is useful to employ psychoanalytic concepts to make sense of this process. Through sponsoring reverie, this sense-making provides containment for me, thus allowing me to continue providing containing and holding functions to the group. The utility of thinking psychodynamically in this context is therefore perhaps less about offering interpretations to the group, than it is about providing containment for the facilitator.
As mental healthcare professionals, we work in an under-resourced mental healthcare context which is highly unlikely to ever provide enough trained professionals to serve the needs of all South Africans. Thus there is a real need for greater numbers of para-professional and/or non-professional counsellors on the ground, especially at the primary healthcare level. The NGO sector and faith-based organisations represent important adjuncts to state-based service provision. The reach of mental healthcare can be further extended by harnessing telephonic and internet-based delivery of services. Against this backdrop, organisations such as LifeLine continue to provide an invaluable contribution, both in terms of service delivery and cost-effective training. While LifeLine and other organisations rely heavily on lay volunteers, they also constitute one way in which the community of psychologists and other mental healthcare professionals can become involved and make a contribution.
The idea which I have explored in this paper is that the group-based interventions employed by LifeLine rest on implicit psychoanalytic scaffolding. I have argued that this scaffolding comprises fundamental psychodynamic concepts such as the unconscious, the frame, the use of countertransference, containment, holding and empathy. I am mindful that this contention could just as easily be inverted by a person-centered practitioner; it can also be argued that psychodynamic group processes are underpinned by sound Rogerian principles. I have no doubt that both are true. The direction of argument I have chosen is perhaps more influenced by the idiosyncratic trajectory of my own professional development, than by anything else.
Furthermore, I have suggested that the value of using psychoanalytic ideas to understand the group process may lie chiefly in the containment it provides for the facilitator. And, finally, that there is perhaps more congruence between these two apparently very different theoretical approaches, than initially meets the eye.
I have been involved with LifeLine Western Cape for some fourteen years now with a hiatus of two years during my clinical training. It has been a remarkable journey which started where all LifeLiners start: with the Personal Growth Course. Then followed the Counselling Skills Course, a selection process followed by a supervised probationary period over seven months and, finally, a quiet joining of the ranks of anonymous, unpaid lay counsellors. The time-has-stood-still building in Roeland Street, Cape Town, which serves as LifeLine Western Cape's headquarters, represents, for me, a space where individuals are seen and heard, where the subjective and invisible realm of emotions is privileged, and where healing happens. So very much at odds with the harsh, hurting and edgy society in which we find ourselves. Lest this sounds like idealisation, I am also able to acknowledge that the corridors and hall at LifeLine are as filled with politics, fractiousness and poor communication as anywhere else.
It is highly probable that as you are reading this, a volunteer counsellor is listening to some troubled soul on the LifeLine crisis line--mostly just allowing them to speak from their hearts, suspending judgement, offering comfort, occasionally averting a suicide. All done invisibly, around the clock, every day of the year, come rain or shine, since 1968. As Alan Walker (1967) so eloquently put it 'No one can estimate how many lives have been saved through the availability of a telephone referral point' (p. 65) nor, I would add, how much human suffering has been relieved, albeit temporarily, simply because there was someone to listen.
Private Practice, Stellenbosch
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(1) Throughout this paper my personal experience with LifeLine refers specifically to LifeLine Western Cape, based in Cape Town.
(2) Given LifeLine's Christian origins, volunteer counsellors were originally drawn from church laiety and were called 'lay counsellors' to distinguish them from clergy and pastoral counsellors. Today LifeLine is a secular organisation and I use the term 'lay counsellor' to distinguish them from professionally-trained counsellors.
Lisa Padfield is a clinical psychologist working in private practice in Stellenbosch. She has taught post-graduate students on a part time basis at Stellenbosch University and served as an executive committee member of the Cape Town Psychoanalytic Self Psychology Group from 2012 to 2015. Lisa has a longstanding relationship with LifeLine Western Cape, as a volunteer counsellor, facilitator and supervisor. Theoretical approaches which resonate include the self psychological, relational and intersubjective schools of thought. Lisa's interests include psychodynamic adult and group psychotherapy, academic writing as well as contributing to the training of tomorrow's lay counsellors and clinical psychologists.
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|Publication:||Psycho-analytic Psychotherapy in South Africa|
|Date:||Dec 22, 2016|
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