Desy Safàn-Gerard's Paper

The Use of Countertransference in Response to Narcissistic Defenses of Group Members.

Desy Safán-Gerard, Ph.D.

B.A. in psychology, Universidad de Chile, 1962; M.A. in psychology, University of California, Berkeley, 1968; Ph.D. in psychology, University of California, Los Angeles, 1974. Certificate in psychoanalysis, Psychoanalytic Center of California, 1995. Associate member, International Psychoanalytic Association. Private practice, Venice, California.

Abstract

Narcissistic defenses constitute the most powerful obstacle to the patient-s development, both in the individual and group setting. These defenses often push analysts and psychotherapists to the limits of their emotional resources. This paper explores the typical countertransference responses to group members’ narcissistic defenses as well as ways of recognizing and transcending the analyst’s own narcissism. Together with the patient’s narcissism, the group therapist’s narcissism accounts for much of the painful impasses in the work. Clinical material from a long-standing therapy group is presented as an illustration. It includes a brief description of the narcissistic defenses of two of its members with an account of how these defenses were revealed in a session. This is followed by material from another session two weeks later where these members and other members expressed the group’s narcissistic vulnerabilities and its defenses.

Although Bion relied heavily on his countertransference reaction to group process, not much has been written about specific countertransference reactions to narcissistic patients in a psychoanalytic group therapy setting. However, there is a large body of literature on working with narcissistic patients in analysis and individual psychotherapy. A number of papers (Alexander, 1981; O'Shaughnessy, 1981; Reisenberg-Malcolm, 1981; Steiner, 1993) give detailed accounts of the course of analysis with difficult narcissistic patients, including the analyst’s countertransference difficulties. In this paper I want to understand some specific countertransference responses to the narcissistic patient's most typical defenses and to explore how one can use this countertransference in order to better help the patient. I hope to extrapolate to the group psychotherapy situation what has been learned from individual analysis of these patients. Finally, I will present material from a psychoanalytically oriented therapy group, including a brief outline of the typical narcissistic defenses of two of its members and an account of how these defenses were employed in a recent session by these and other members.

Introduction

Finell (1985) observed that personal analysis does not always resolve or attenuate narcissistic problems. The narcissistic tendency toward splitting and idealization is a universal pitfall. According to her, the designation of narcissistic personality disorder provides professionals with the opportunity to project their own narcissistic tendencies and then defensively disavow them in themselves by finding them in their patients. Some research evidence from the Menninger Clinic suggests that training and technical skill, while necessary, are not sufficient for a high level of effectiveness in an analytically oriented therapist. The research team evaluated the skill of the therapists and the way in which the therapist’s personality interacted with that of the patient in furthering or limiting the therapeutic goals. They found that “...the whole complex of traits associated with narcissistic orientation interfered with the optimal application of good therapeutic technique...” (Horwitz, 1971, p.18). Group therapists judged by peers as having low-competence "often showed an insufficient capacity for concern and empathy, were easily frustrated when gratification was not forthcoming, and often became authoritarian and controlling. They tended to care more about their own performance than about the plight of the patient and were hampered by an attitude of therapeutic omnipotence" (p 18). In line with this research, Lieberman, Yalom, and Miles (1973) carried out an extensive study of member casualties from a group experience and found that the high-risk leaders of these groups tended to be charismatic, intrusive, and confrontative, as seems also to be the case for leaders of organizations. For Kernberg (1991), the most serious and damaging type of pathological character structure in a leader is that of the narcissistic personality disorder. This observation is corroborated by the study of political leaders who manifest pathological narcissism. Post (1993) concludes that the mirror-hungry personality of the leader complements the idealization hunger of his followers. Sometimes leaders can strengthen the cohesiveness and stability of their own grandiose self by idealizing a group of followers whom they then include in an idealized extension of themselves (Volkan, 1980). They then attack a segment of the population that represents disowned and devalued aspects of themselves, reinforcing their split-off valued grandiose selves.

In trying to maintain a desired self-image of the ‘selfless helper’, most analysts find it difficult to examine their own egocentric propensities (Saretsky, 1980; Welt & Herron, 1990). Therapists with marked narcissistic vulnerabilities find it difficult to tolerate negative transference, criticism and devaluation. In an effort to counteract their patient’s hostile reactions, these therapists often become unduly nurturant and/or fail to confront patients with their acting out or resistances. On the other hand, grandiose therapists believe that they are imbued with special therapeutic powers and their mere presence is capable of “healing” the patient. They tend to use oracular pronouncements which invite unquestioning acceptance. They also like to convey to their patients that nothing ever takes them by surprise (Ticho, 1972). As Horwitz summarizes, “The all-knowing therapist may provide a measure of comfort to the ideal-hungry patient, but it also impedes personal growth and development (1995, p.21)”.

References to narcissism as such are scarce in Bion’s writings. In his preoccupation with psychosis and his theory of thinking, Bion appears to have overlooked the role of narcissistic defenses. However, a concern with narcissism is implicit in the notion of the basic assumption and in most of his writings. For example, Bion (1959 b) ends “Attacks on Linking” with, "The main conclusions of this paper relate to that state of mind in which the patient’s psyche contains an internal object which is opposed to, and destructive of, all links whatsoever from the most primitive (which I have suggested is a normal degree of projective identification) to the most sophisticated forms of verbal communication and the arts. In this state of mind emotion is hated; it is felt to link objects and it gives reality to objects which are not self and therefore inimical to primary narcissism" (p. 108) (italics mine). A question could be raised as to what constitutes the narcissistic defense of the group as a whole. Insofar as it opposes understanding and development one can see a relationship between Bion’s basic assumption group (1959 a) and the group member’s narcissism, which is also opposed to self-exploration, understanding and development. The narcissism of the group revealed by the basic assumption mentality gives way, through interpretation of its anxieties, to the work group in which curiosity leads to exploration and learning from experience. One could then say that in the group situation narcissistic defenses appear and are dealt with both at the group and the individual level. They can be clearly seen if the group therapist attends both to the group and to the individuals in it.

The group therapist supports the struggling, object seeking, life-enhancing side of the group members against the self-sufficiency of the narcissistic refuge. The emergence of hatred in group members is a sign that a reversal of narcissism is taking place insofar as hate indicates an acknowledgment of the other as other and a breach in the illusion that there is no other but the self. This hatred of the other is accompanied by a hatred of the infantile self that is trying to surface. The movement toward others can reverse narcissism and is fiercely resisted with a desperation stronger than any other obstacle in treatment. Bion (1965) has pointed out the patient’s resistance to self-discovery or what he calls “being what one is.” He believed that it is important to help narcissistic patients discover their hatred of analysis because analytic work leads to awareness of emotions that counters the patient’s megalomania.

Countertransference reactions

Bion states that “In group treatment many interpretations, and amongst them the most important, have to be made on the strength of the analyst’s own emotional reactions” (1959 a, p.149). The group therapist functions, in effect, as the recipient of the group members’ projective identification (Klein (1946). As such a recipient he or she experiences a variety of emotional reactions. Bion was one of those like Racker (1948), Heimann (1950), Little (1951) and others who encouraged the use of countertransference as the starting point for interpretations. These analysts conceived of the countertransference as a research tool, since the analyst’s emotional response could be a means of access to the patient’s consciousness. Bion was the first to demonstrate, in 1952, that projective identification was as valuable a concept for the understanding of the group therapist’s countertransference as for the one-to-one analytic situation.

Forces in a therapy group tend to exacerbate countertransference reactions generally and the group therapist’s narcissism in particular. The analyst's difficulties in responding to negative transference is accentuated in a group. As Horwitz explains, ÒThe transference component of the group's attacks and criticism are more difficult to recognize when they come from more than one person since we are accustomed to gauging the reality of an event in terms of consensual validation” (1995, p 23). Whether negative expressions by group members are justified or not, there is an increased pressure on the group therapist’s narcissistic vulnerability. The group therapy situation highlights the members' egocentrism and self-absorption. Members typically confront each other with failures of empathy, lack of commitment to the group, or a tendency to monopolize group process. Group therapists who are struggling with their own narcissistic issues may overreact to a member’s narcissistic defenses by being excessively critical or by confronting the member prematurely. The analyst may also experience an inhibition in making transference interpretations that highlight the therapist’s importance to the group members. In reproducing family dynamics, the therapist typically stands for the mother, father or the parental couple while the members are the children with all the typical sibling rivalry toward other members. Thinking of oneself as the central person in the group may constitute a threat to the group therapist ’s unconscious wish to be the center of attention and may interfere with his or her capacity to interpret.

There are two basic groups of countertransference responses to narcissistic defenses: some form of anger or hostility and some form of boredom. Anger is the most typical countertransference response to the patient’s arrogance and omnipotence while boredom is the general countertransference response to the patient’s emotional withdrawal. Feigned self-sufficiency awaken strong countertransference reactions both in the group therapist and group members because of the nature of the projective identification involved. The narcissistic patient projects his small, incompetent, ineffectual infant into the other while he or she can then be all-knowing and superior. The group therapist and/or other members receive the patients’ projections and, by counterprojective identification, may come to feel temporarily incompetent and ineffectual. This “becoming” the infantile part of another leads group members involved to angry attempts to free themselves of the projections and restore equality with the arrogant member. Becoming de-skilled by the projections, the group therapist may feel compelled to assert his or her authority through confrontative interpretations. In this know-it-all state of mind, the narcissistic member typically refuses to receive help either from the group therapist or from group members. A typical “yes but” response is the rebuff to other members’ efforts to help.

Attempts by other group members to challenge the member’s omnipotence often elicit an angry response and a threat of leaving the group. Perhaps the worst case scenario of this kind occurs when the member in question announces that he or she is .leaving the group. The reason usually given is that the group is not helpful or that he or she no longer needs the group. The group therapist’s tendency to go along with what the patient is saying reveals the analyst’s fear of the patient’s rage at having the analyst or the group members disagree with him or her and challenge his or her omnipotence. On the other hand, the analyst’s hurt at the patient’s implied criticism may reveal the workings of the analyst’s own narcissism, especially when the criticism is genuine and not an expression of envy. A tit for tat response from the analyst can lead to punishing interpretations. In this case the question the group therapist and members have to face is how to overcome the natural tit for tat response to a narcissistic patient and help him or her take back the sane projected infantile part.

Narcissistic patients withdraw from a relationship in various characteristic ways, which create slightly different countertransference reactions. They consciously want to find out about themselves but unconsciously eschew such knowledge. This -K may be manifest when the patient seems to carry out his or her own analysis; the analyst or group therapist who has become superfluous becomes bored. The deadening effect is also experienced in the group, which becomes stale and lifeless as members become bored and distracted. The analyst can experience a loss of a sense of identity when the patient projects his or her own non-existent self. Similarly when the patient dissociates as a way of avoiding others as sources of information, an unconscious retaliatory response is elicited in the group members who begin to withdraw their attention from the member in question and attempt to move on to someone else.

A related attitude is revealed by the group member talking aimlessly and “drifting.” This behavior seems to express hostility toward twoness, toward the idea that there is more than one person in the room. In these cases the patient’s speech seems designed to frustrate contact. The group therapist's inattention, another unconscious retaliatory response, becomes a collusion with the patient’s denial of twoness. Sometimes the group therapist experiences a deep void in response to the patient’s mindlessness and withdrawal. In this situation group members withdraw and become irritable while the group therapist, hopefully recovered from a countertransference-based need to retaliate, may find himself or herself renewing efforts to rescue the patient from the narcissistic cocoon through interpretations. A word of caution is necessary here: this enactment to rescue the member can be a reaction formation to the impulse to retaliate.

Another response to the patient’s drifting is the group therapist’s drowsiness, which seems to be a response to the patient using empty words in an effort not to communicate (Alexander, 1981). However, drowsiness is more often a countertransference enactment in individual treatment since it is difficult to give in to drowsiness in a group situation. Such drifting by a member is likely to produce irritation toward the member’s apparent attacks on linking. The narcissistic members’ speech patterns seem to interfere with the thought process of others who find themselves derailed by their communications.

Group members often carry the élan vital for the passive narcissistic patient who seems dominated by the death instinct. At times there is a tug of war when the group therapist or other members try to pull the passive member out of his or her cocoon. In other situations the group therapist feels shut out when he or she is not treated as someone else in the room. The group therapist’s own narcissistic vulnerabilities lead to angry feelings toward the member when he or she is not acknowledging his or her presence and leads to the tendency to use interpretations as retaliation. Anger and defeat are also countertransference responses when the member does not acknowledge or appreciate the group therapist’s containing function.

In my work with groups I make interpretations to the group as a whole as well as to its individual members (Safán-Gerard, 1991). Along with Bion (1959 a), I consider the group’s psychotic anxieties as clustering around three basic assumptions: dependency, fight-flight, and pairing. When the members are caught up in one of these basic anxieties, they collectively oppose understanding and development. The group does not recover its intellectual curiosity and its capacity to learn from experience until they become what Bion calls a “work group”. My attention therefore is focused on the group when a basic assumption mentality is present and on the individual members when the group has properly become a work group (Saf‡n-Gerard, 1996). As Bion (1959 a) states, ÒThe more disturbed the group, the more easily discernible are these primitive fantasies and mechanisms: the more stable the group, the more it corresponds with Freud's description of the group as a repetition of family group patterns and neurotic mechanismsÓ (p.165). Even a stable group can be pervaded by basic assumption phenomena, and at these times my attention will shift to the group as a whole. I therefore keep in mind at all times both the individual and group perspectives. I will be dealing here with my countertransference to the individual members and the reactions of members of the group to that member. I am also assuming that the member in question is the spokesperson for the group's anxieties and defenses.

In the group therapy situation we hold on to the idea that members can take chances to alter the pseudo-adulthood of the narcissistic option. As we know, the narcissistic structure is committed to self-sufficiency and is directed against object relatedness (Freud, 1914). I hope to show how at various points many of the narcissistic defenses are revealed and interpreted, along with the underlying anxiety about depending and needing the group therapist and the other members.

Clinical illustration
(omitted here)

Conclusion

I hope it has become apparent that if the group therapist is not aware of his or her own narcissistic defenses or has a limited understanding of them he or she will be at great peril that his or her countertransference will constitute an impediment in treating patients with narcissistic defenses, which means most patients. The risk is increased in a group situation where members make use of projective identification with other members as much as with the group therapist and they respond to these projections with their own countertransference.

As members take turns to display a variety of narcissistic defenses, they represent the group’s wish to oppose self-exploration, understanding and development. Concurrent with the material I have presented, there is evidence of basic assumption mentality. In the first session, Pairing was in evidence as John, the sculptor, and Gina, the actress, were discussing their relationship while others seemed absorbed in their dialogue. In the last session Fight-Flight was in evidence as members were bickering over Gina’s mocking and some became paranoid. But for the most part, now in its eight year, the work group mentality prevails; in response to interpretations, basic assumption mentality tends to be resolved giving way to exploration, understanding and development.

I have examined various situations where the unresolved narcissism of the group therapist can be triggered and can lead to countertransference enactments. Among these, such is the case when the group member is using, fooling and controlling the group therapist and other members, when the group member is drifting in an effort to avoid emotional contact, or when he or she treats the group therapist as non-existent, devalues the help offered and decides he or she doesn’t need any help. I have attempted to show how in each of these cases retaliatory interpretations can be avoided once the narcissistic tit for tat impulse is acknowledged. In this case the group therapist can retain a curiosity about the group member’s behavior by remembering the points of pain, abandonment and loss related to the need of the object and the necessity to return to those points in the session to help the member bear the pain.

In their attempts to transcend their own narcissistic defenses, therapists may benefit personally in the interchange with group members by potentially overcoming these defenses. This is in line with Bion’s (1959 a) contention that group therapists grow and develop as a result of the interchange with the group (p. 119). If we are to be able to help group members get closer to what they are, as Bion put it, it is imperative that we as therapists do the same.

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