2025-S-Review: Advances in Group Therapy Trauma

Advances in Group Therapy Trauma Treatment

? Reviewed by R. M. Billow, Ph.D

TTrauma—the metapsychology of trauma and the reality of trauma and its clinical syndromes and treatment–has come to occupy central stage in twentieth-first century psychology As its title suggests, Advances in Group Therapy Trauma Treatment (edited by Leonardo M. Leiderman and Bonnie J. Buchele) focuses specifically on group treatment.  Eleven chapters broach the topic with depth, clarity, and up to the minute scholarship, making this volume an excellent reference both for practicing clinicians and academics. Accompanied by illustrative case examples, the text focuses on brief and structured group interventions, psychodynamic and process-oriented longer-term groups, and large group perspectives.  As with other publications in the AGPA Group   Therapy Training and Practice Series (Routledge), the authors are acutely aware of working in culturally competent and culturally responsive fashion in addressing social trauma due to racism, discrimination, prejudice, and the psychological impacts of dehumanization of the other.

Leiderman, Buchele, and Klein’s introductory chapter,  Creating a Container for Healing Trauma,” provides a comprehesive overview of the psycholgical correlates of trauma.  The inclusive topics cover developmental/neurologicial/somatic persectives, loss and grief, shame, systematic and structural racism, and social system (“social unconscious”) factors.   The authors usefully distinguish two prevalent treatment approaches: the open-ended psychodynamic and the cognitive behavioral, which are structured and often manualized.   The chapters that follow are Leiderman’s strikingly titled “The Fear-Driven Brain,” which offers an interpersonal-relational-neurophysiological model to foster cohesion and coherence in trauma-centered psychotherapy groups.  (In my opinion, all psychodynamic psychotherapy is trauma centered; more about that below.).  Marmarosh, Yi Liu, and Yifei Du’s, “Attachment and Trauma” informative chapoter follows, then Treadwell and Abeditehrani’sCognitive Behavioral Therapy With Psychodrama Theory and Practice,” providing a needed focus on short term groups; Schermer’s conceptually sophisticated,  “Dissociation, Regression, and Primitive Defenses in Both Group Members and Therapist,” Grossmark’s in-depth psychoanalytic approach involving “witnessing” and “being with,” “Trauma and Enactments in Group Psychotherapy;” Watkins-Northern and Reginald Nettles’“Group-as-a-Whole and Psychodynamic Group Psychotherapy in Treating Trauma With the African American Population at Howard University Counseling Service,” a harrowing report on the history and consequences of racism and the prejudices regarding suitability of psychodynamic groups for minority populations.  Canales’ “Treating Racial Trauma” follows, then Hu and Kyei’s“Sexual Abuse;” and Weinberg’s “The Large Group, Social Trauma, and the Social Unconscious;” and a closing summary by Leiderman and Buchele, “Attachment-Focused Therapy and Racial Inequalities – Who Speaks and Who Listens.” 

In this brief review, I offer some thoughts on topics that might be further developed in the next edition of this series entry.  I briefly consider three factors: narration and empathy, the therapist’s subjectivity, and sibling trauma.  

  • Fixed narration and hyper-empathy:  The Scylla and Charybdis of group.

A group is constantly inundated with fixed narratives, naïve historiographies, and self-analyses that can wreck an emotionally-alive group.  People anchor themselves in place and time, shaping experience into stories. And then, they come to tell stories about stories that are emotionally contagious but have limited success in furthering understanding.   One problem underlying repetitive narration is that even in telling one’s stories of trauma, the narrator has difficulty in believing it. Describing the terrors of Auschwitz, Primo Levi (1958, p. 161), expressed profound self-doubt: “As I sit writing at the table, I myself am not convinced that these things really happened.”  Pain may remain unaltered and unbearable, as with Primo-Levi who eventually committed suicide.  As many chapters noted, both patients and therapist tend to relay on avoidance, denial, dissociation, intellectualization, and dramatic enactments—all in the service of protection from the full emotional impact of overwhelming, frightening and fragmenting experiences that characterize trauma.  All of us find ways to evade, minimize, and compartmentalize which we believe and refuse to believe. 

  It remains among the primary tasks of the therapist to be with and not be with other members, for not all of the work of the group can be done by the group itself.  Compassionate understanding (see Bloom, 2016; Singer & Klimecki, 2014). does not imply empathic congruence or blanket acceptance of the other’s point of view.   At times, it can be therapeutic to disrupt narratives of established patterns of victimhood, even though they represent significant trauma (Meissner, 1976).  When inhabiting or narrating established patterns of victimhood, members may maintain attitudes of passivity and helplessness yet also dominate the group and demand special recognition (see Berman, 2014; Meissner, 1976). 

Trauma affects personality development. character, and characterological defences.   The therapist has to understand the difference between dissociative “enactment” and the old-fashioned but still relevant term, “acting out.”  Any type of trauma may lead to misuse of the group and has to be faced head.  The therapist is left with the task of being with yet not mindlessly complying, without being unduly jarring or appearing unempathic.   

The psychodynamics of an individual member, the origins and expression of a member’s trauma(s)–may capture the group’s attention and stimulate hyper-empathy as well as other dramatic expressions:  bewilderment, anger, anxiety, or excessive concern.  What is epochal and traumatic for one member may represent a normative developmental experience for another.  Sometimes the therapist must step in, to protect, give space, or explain the traumatized outlier.   Trauma is subjectified by the history of each member (including the therapist), by the dynamic intensity of the group, and one’s roles within the group.    

(2) The analyst’s subjectivity. 

 As do most contemporary therapists of all persuasions, the authors advocate an experience-near, interpersonal relational approach, which, as they emphasize heightens the level of emotional exposure and stress the therapist must endure.  Patients want us to experience trauma with them, so they can feel understood.  A fair request, even though it asks a lot of ourselves.  Many individuals entering treatment do not comprehend the complexity of trauma: They do not know that they were traumatized or about the history and development of their trauma.  They may have deep aversion to exploration of any source of psychic pain.   One reason the work is exhausting is that we dysregulate along with the patient—and sometimes, instead of the patient.  Grotstein (1995) suggested “the analyst’s actual trial suffering of the patient’s pains as his or her own is the transference, from the patient to the analyst” (p.483).   The limited and varied capacity to experience and bear pain is an essential element in the therapist ‘subjectivity and influences our moment-to-moment work with others.   Guilt, remorse, passivity, hyperactivity, over-identification, emotional contagion, dissociation, these are the common emotional denominators of trauma and of those who treat trauma.

In almost all of the clinical anecdotes, while referring to the inevitability of being caught up in what Schermer referred to as the “dissociative matrix” of group, the authors demonstrate judicious, well-balanced uses of the therapeutic self.  An admirable exception is Canales, who presented us with aspects of his ethnic-racial subjectivity:

 I see myself as containing vital Latin psychological organs that inhabit and organize me. I am, in essence, different from White, a self-awareness that provides an interoceptive homeostasis or a stable, sheltered, felt sense about me in relationship to my social environment.  When around Latino groups, I feel my internal organs rest. When surrounded by Whites, I hold myself differently. 

I found his case anecdotes memorable and deeply affecting, as he rebalanced and partially regained insight into his own traumas.   Canales inserted himself in one of the groups he led, after a member reported a dream of being caught in a Mexican market in which he sought to flee (unsuccessfully) from the gunshots of a “scruffy, shady Latino.”  Responding to the group’s anxious laugh and unconfortable silence, Canales provided himself and the group a place to face anxiety and pain:  “Unable to ground, I invited the group into my considerations: ‘Was this dream [involving an offering to an all-White group about its leader in the public market of emotions? Do you want to be here, in a place where someone from another race and culture is in charge? Am I threatening in some way?’”

A bi rather than uni-directional focus allows access to a crucial source of data:  our subjectivity, of which we have limited understanding but which affects everything that takes place.  At the core of this difficult work is the therapist’s struggle to be “in charge;” as with Canales, who dealt with resurgences of his own traumas in dealing with Whiteness and underlying racial and ethnic prejudices.  

(3) Sibling trauma.

Freud (1916-17) had stated that “when other children appear on the scene the Oedipus complex is enlarged into a family complex” (p. 333). Lacan (1938), per Klein, emphasized two successive traumatic developmental stages that contribute to an earlier (or pre-) Oedipal complex (Benhaim, 2008; Chiesa, 2007) and inaugurate a “sibling complex.”  The earliest “weaning” stage revolves around the harmonious symbiotic relationship between the newborn and mother, the traumatic separation process, and consequent feelings of abandonment.  The following “intrusion” or “fraternal” stage presents the child with the traumatizing reality of an “other,” any other:  a “like me,” a father, the world out there.

 “Then came another baby and brought you grave disillusionment” (Freud, 1937, p. 261). “Something happened, after which nothing was the same again (Winnicott, 1965, p. 50).  It does happen again in every group session.   Confronted with the group, the instantaneous experience is that of massive loss (Debbane et al, 1986, p. 523).   Members discover a therapist involved with many “like Me’s,” raising possibilities of no longer being “cared for and loved” (Freud, 1905, 194ff).   Peers are rivals, loved as an extension of oneself and hated as its replacement (Mitchell, 2013; also, Ashuach & Berman, 2022; Magagna, 2014).   Living in a world of like others, we mourn the loss of exclusive claims on love and attention and struggle to recover from the fantasy that we ever had it (Lacan’s “jouissance”).     

           Freud wrote that:

the fact that the younger child is loved by the parents as much

as he himself is…. he is forced into identifying himself with

the older children… which is then further developed at

school…. What appears later on in society in the shape of

… “group spirit” does not belie its derivation from what was

originally envy…. Thus, social feeling is based upon the

reversal of what was a hostile feeling into a positive-toned tie

in the nature of an identification. [1921, p. 120] 

Group psychotherapy presents a methodology uniquely suitable to reveal derivatives–and reactions formations against derivatives-of pre-Oedipal and sibling trauma.   The presence or absence of fantasy as well as actual siblings, birth order, and the developmental shifts in the complex system of family and social dynamics all participate in what Schermer referred to as the “dissociative matrix” of each session.   Omitting sibling relationships from group process considerations (regarding group-as a whole, subgroupings, racism, prejudice, scapegoating, etc.) may contribute to intervals of hyper-reactivity, deadness, stalemate, and partial or outright failure.  “Envy and jealousy,” Kaës (1993) reiterates, “as heirs of the sibling complex, occupy a substantial part of the subjective positions and intersubjective conflicts in groups and institutions” (pp. 196–197; Benhaim’s [2008] translation).   To avoid being caught up in naïve historiography (“narrativity,” see Laplanche, 2002-2003) or hyperbolic empathy, the therapist must get close in body, affect, and fantasy some of the disguised  symbiotic, sexual, masochistic, aggressive, fratricidal, patricidal, matricidal, and cannibalistic urges that cluster at the nucleus of a group’s here-and-now (Kaës, 2016; see also, Billow, 2024).   This is a tall order, but I think the next edition would benefit from more attention to how we therapists struggle with primal traumas–of separation, non-recognition, sibling and Oedipal rivalry– and more acknowledgment of our limited success in bearing these traumas with others. 

References.

Ashuach, S. and Berman, A. (Eds.) (2022).  Siblings Relations and the Horizontal Axis in Theory and Practice.  London: Routledge.

Benhaim, D. (2008). Is there a sibling complex? Can. J. Psychoanal., 16: 246-253.

Berman, A. (2014). Post-traumatic victimhood and group analytic therapy: Intersubjectivity, empathetic witnessing and otherness. Group Analysis, 47: 242–256. 

Billow, R. M. (2024).  Kaës’ internal groups and actual groups: A relational perspective. Psychoanal. Q., 93(3): 473–496.

Bloom, P.  (2016). Against Empathy: The Case for Rational Compassion.  NY: Harper Collins.

Chiesa, L. (2007) Subjectivity and Otherness: A Philosophical Reading of Lacan.  Cambridge, MA: MIT Press.

Debanne, E. Decarufel, F., Bienvenu, J. and Piper, W. (1986). Structures in Interpretations: a group psychoanalytic perspective. Int. J. Group. Psychother., 36: 517–532.

Freud (1905). Three essays on the theory of sexuality.  S. E. 7.

Freud, S. (1916-17) Introductory Lectures on Psychoanalysis (Part III).  S.E. 16.

Freud, S. (1921) Group psychology and the analysis of the ego.  S.E. 18.

Freud, S. (1937). Constructions in analysis. S. E. 32.  

Grotstein, J.  (1995) Projective identification reappraised.  Contemp. Psychoanal., 19: 389-421.

Kaës, R.  (2007) Linking, Alliances and Shared Spaces.  Groups and the Psychoanalyst. London: International Psychoanalysis Library.

Kaës, R. (2016). Link and transference within three interfering psychic spaces. Couples & Fam. Psychoanal., 6: 181-193.  

Lacan, J. (1938). Family. 1. The complex, a concrete factor in psychology. Family. Encyclopedia Francaise, 8: 840-848.

Laplanche, J. (2002-2003).  Narrativity and hermeneutics:  Some propositions.  In Jean Laplanche and the Theory of Seduction.  Winter issue of New Formations:  A Journal of Culturte/Theory/Politics.  Cambridge, UK: Cambridge University Press, pp. 26-29.  

Levi, P. (1958). Survival in Auschwitz: The Nazi Assault on Humanity. New York, NY: Orion Press.

Magagna, J. (2014) Envy, jealousy, love, and generosity in sibling relations: the impact of sibling relations on future family relations.  In Siblings: Envy and Rivalry, Coexistence and Concern, ed. K. Skrzypek, B. Maciejewska-Sobczak, & Z. Stadnicka-Dmitriew.  London  : Karnac, pp. 195-217.

Meissner, W. (1976). Schreber and the paranoid process.  Annual of Psychoanal., 4: 3–40.

Mitchell, J. (2013). Siblings: Thinking theory. Psychoanal. St. Child, 67: 14-34.

Singer, T. and Klimecki, O.  (2014).  Empathy and compassion.  Current Biology, 24(18): 875878.

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