Forty years of group psychotherapy at the Menninger Clinic

Despite the skepticism and indifference to group psychotherapy that existed in the 1950s and 1960s within the psychoanalytic community in general and among the staff and administration of the Menninger Clinic in Topeka, Kansas in particular, a few clinicians there forged ahead in pursuit of incorporating this modality as an accepted treatment. After gaining some acceptance first in the hospital, we experienced a slow rate of growth, except with our trainees who were generally enthusiastic about group work. Many of them were intrigued first by their exposure to the group dynamics seminars and later by the didactic courses and supervised group work that eventually came to be required by the accrediting body for residency programs of the American Psychiatric Association. Visiting senior consultants and teachers, mainly associated with the American Group Psychotherapy Association, as well as an esteemed clinician from the Tavistock Clinic, also lent credibility and legitimacy to our effort. When group treatment began to be adopted by units of the Menninger Hospital in the early 1970s, there was a significant sea change in the attitude of the organization and group psychotherapy became a well established modality.     

My life in testing

This autobiographical essay describes my career as a psychodiagnostician, which began at the City College of New York in 1941 and ended in the late 1970s when I became a full-time psychoanalyst in Manhattan. As a green, 20-year-old psychology undergraduate, I was picked by Gardner Murphy to assist David Rapaport at the Menninger Clinic in Topeka, Kansas, who was developing new methods for using psychological tests to diagnose and treat soldiers during World War II. Our findings were presented in the classic, two volume work, Diagnostic Psychological Testing, published in 1945-1946 (Rapaport, Gill, & Schafer, 1945-1946; 1968), to which I added two clinically enriched monographs: The Clinical Application of Psychological Tests, published in 1948 (Schafer, 1948/1995), and Psychoanalytic Interpretation in Rorschach Testing (Schafer, 1954), published in 1954. After the Menninger Clinic, I continued to hone my assessment expertise at the Austen Riggs Center and Yale University, but I also sought opportunities to develop psychotherapy skills. I completed psychoanalytic training in 1960 at the Western New England Institute for Psychoanalysis and thereafter sought positions that would offer more time for treating patients. A notable highpoint in my testing career was assessing Jack Ruby, killer of Lee Harvey Oswald. I look back fondly at my years as an assessment psychologist, which produced nearly 4 decades of great memories.     

Homogeneous group therapy of borderline personality disorder

The authors maintained a time-limited, diagnostically homogeneous psychotherapy group of borderline patients for one year. The group progressed through prototypical stages of group development, but each phase was marked by variations of the aggressive drive and defenses against aggression that are characteristic of this disorder. The group provided a well-suited forum for the exploration of suicidal and homicidal impulses and the development of an observing ego. Despite the limits on generalizability from this group, it appears that group psychotherapy can be a valuable adjunctive modality for some borderline patients.Paper presented at the American Psychiatric Association Conference, Montreal, May, 1988.     

On Preserving a Legacy: Paul Lerner and the Menninger Rorschach Tradition

Paul Lerner's contributions to the Rorschach test were rooted in a psychoanalytic approach to diagnostic testing that began with David Rapaport at the Menninger Clinic in the 1940s. This article reviews the work of Rapaport, Roy Schafer, and their heirs and shows how Lerner's career was devoted to advancing that tradition and assuring its continuing relevance.     

Dynamically oriented group therapy with alcoholics: Making it work despite the prevailing bias

A bias exists in the psychiatric community against dynamically oriented group therapy with alcoholics. The basis for this bias lies primarily in negative experiences of practitioners who have attempted to use traditional therapy with alcoholic patients who continued to drink. At Appleton Outpatient Clinic, we have found that dynamically oriented group therapy is a highly suitable treatment modality for alcoholic patients when negative biases of treators can be addressed and when initial preparatory work is done with patients. This preparatory work includes: (a) building a working alliance around abstinence and providing adequate supports to make this possible; (b) explicit contracting that establishes clear treatment goals and consequences should the goals not be met; (c) preparatory short-termgroup experiences.This paper was presented at the 1988 annual meeting of the American Group Psychotherapy Association.     

AGAINST RECORDING SESSIONS FOR SUPERVISION

The American Psychological Association’s (APA) 2014 injunction that supervisors must listen to recorded sessions of their supervisees’ work is based on a rich and thorough body of research, and yet it entails a narrative of psychotherapy as a discipline of Science. If psychotherapy is understood as an endeavor also of the Humanities, recording sessions may be anathematic to supervision and training. Developing ideas from Greenberg’s (2015) theory of “controlling fiction,” the writer presents a narrative of psychotherapy in which it is not wise to review recorded sessions in supervision.

     

Manualizing psychotherapy: Aaron T. Beck and the origins of Cognitive Therapy of Depression

Abstract

This paper examines the origins of psychiatrist Aaron T. Beck’s 1979 Cognitive Therapy of Depression (CTOD). CTOD was the first psychotherapy manual designed to be used in a randomized controlled trial (RCT). Making psychotherapy amenable to the RCT design had been a ‘holy grail’ for leading American psychotherapy researchers since the late 1960s. Beck’s CTOD – which standardized his treatment so it could be compared with drug treatments in a clinical trial – delivered that holy grail, and ushered in the manualized treatment revolution. Manuals are now a sine qua non in psychotherapy research. In this paper, I explore some of the personal, political, and economic variables that made the idea of a manual irresistible to Beck and to those who first championed him.     

In defense of the Ethics Code: a comment on O’Donohue (2019)

ABSTRACT

This article is a commentary on O’Donohue’s2019 37-point critique of the American Psychological Association Ethical Principles of Psychologists and Code of Conduct ([Ethics Code] 2017). In this brief paper, we respond to the article by addressing our most important disagreements with O’Donohue’s arguments as well as areas of agreement. While we disagree with many of O’Donohue’s points, we also view his critique as being important and timely given that the 2018 APA Ethics Task Force is currently exploring potential revisions to the Code.     

The differential effect of psychotherapy and psychoanalysis with anaclitic and introjective patients: the Menninger Psychotherapy Research Project revisited.

Analyses of the data from the Menninger Psychotherapy Research Project (MPRP) have consistently indicated little difference in the therapeutic outcome between patients seen in psychoanalysis and those seen in psychotherapy. Reanalysis of the data from the MPRP, utilizing a distinction between two broad configurations of psychopathology (Blatt, 1974, 1990a; Blatt and Shichman, 1983), however, indicates that patients whose pathology focuses primarily on disruptions of interpersonal relatedness and who use primarily avoidant defenses (anaclitic patients), and patients whose pathology focuses primarily on issues of self-definition, autonomy, and selfworth and who use primarily counteractive defenses (introjective patients) differ in their responsiveness to psychotherapy and psycho-analysis. Based on recently developed procedures for systematically evaluating the quality of object representation on the Rorschach, reanalysis of the Menninger data reveals that anaclitic patients have significantly greater positive change in psychotherapy, while introjective patients have significantly greater positive change in psychoanalysis. These statistically significant patient-by-treatment interactions are discussed in terms of their clinical implications as well as the importance of differentiating among types of patients in studies of therapeutic outcome and of therapeutic process.     

The Hispanic Female Adolescent: A Group Therapy Model

This essay serves as an introduction to a collection of articles on group psychotherapy for children that appears in the following pages. These articles are an outgrowth of a symposium on children's group treatments presented at the 1990 Annual Conference of the American Group Psychotherapy Association. The present author provides a general overview of relevant literature and offers an orientation to the subsequent theoretical and practical integrations.     

Gender/ed identities: an overview of our current work as child psychotherapists in the Gender Identity Development Service

Abstract

This paper is adapted from a presentation first given at the 2017 Association of Child Psychotherapists (ACP) Conference. We hope to give a feel of our work as psychoanalytic child psychotherapists working in a Tier 4 national assessment service for gender variant children and connect with our colleagues working therapeutically with these families in Child and Adolescent Mental Health Services (CAMHS) and other settings. Gender variance does not have a single cause, or straightforward developmental pathway; rather it is a complex interplay of multiple factors, akin to sexuality in the diverse manifestations and ‘tributaries’ taken. This paper is given as a plea for complexity, to counter the current intense focus on gender identity and the consequent reductionism this can lead to. To this end, three case studies from the clinic, taken from Under Five, Latency and Adolescent phases of development, are explored. The complexity of the cases is then discussed, followed by parallel issues of development, divergence and difference. These three ‘average’ cases from the Gender Identity Development Services (GIDS) serve to demonstrate the need for child psychotherapy as part of multi-disciplinary thinking about gender variance and how attention must be maintained to each unique story and process of identity development; as well as our clinical task to establish and encourage depressive functioning and secondary processes where possible.     

The Lonely Crowd: A Study of Changing American Character by David Riesman; in collaboration with Reule Denny and Nathan Glazer

This paper describes a form of combined psychotherapy in which the individual sessions are used as an adjunct to group therapy. Each group member is seen regularly in individual sessions to focus primarily on the member's ongoing group work. The individual sessions are scheduled on a rotating basis. Typically, each group member is seen in an individual session once every four weeks. Additional individual sessions are available only when immediate attention is appropriate and necessary. The group is viewed as the primary therapeutic component. A cost-effective therapeutic approach that uses both individual and group methods, this modality lends itself well to a clinic and to a private practice setting.     

Ethical Considerations for Providing In-Home Mental Health Services for Homebound Individuals

The number of homebound individuals in the United States is on the rise, causing health-care professionals to expand in-home health services to help meet the increased demand. Due to the prevalence of feelings of isolation and depression in this population, it is imperative that mental health professionals join this effort to increase access to mental health services. Delivering psychotherapy in clients’ homes presents many advantages to these homebound individuals, but there is a dearth of literature addressing how therapists should handle unique ethical issues that arise in this type of setting. This article addresses ethical considerations and guidelines for in-home provision of mental health services. General ethical issues related to home-based psychotherapy include boundaries, confidentiality and privacy, competency, insurance coverage, and autonomy. Issues pertaining to different categories of homebound individuals, including persons with agoraphobia, chronic illnesses, and older adults, are then discussed in turn. Recommendations on how to best manage these issues by applying the American Psychological Association’s, the American Counseling Association’s, and the National Association of Social Workers’ Ethics Codes are provided.     

Implications of the Empirically Supported Treatment Movement for Psychoanalysis

In this article, I critique the empirically supported treatment (EST) movement and discuss the limitations of traditional psychotherapy research from a psychoanalytic perspective. The EST movement is based on a medical model that assumes that a psychotherapeutic treatment can be conceptualized independent of the human relationship in which it takes place. Psychotherapy and psychoanalysis are, however, treatments only in a metaphorical sense and are more akin to educational processes than medical treatments. Every therapeutic dyad is unique, and research that treats therapy as a standardized, disembodied entity will not contribute to our understanding. Nevertheless, there is a real need for psychoanalysts to become more actively involved in psychotherapy research both for political and scientific reasons. Although I do not believe that “empirical validation” in the form envisaged by the American Psychological Association task force is a realistic goal, I do believe in the value of microscopic studies of therapeutic process, particularly in the context of research-informed case histories.     

Individual psychotherapy as an adjunct to group psychotherapy

This paper describes a form of combined psychotherapy in which the individual sessions are used as an adjunct to group therapy. Each group member is seen regularly in individual sessions to focus primarily on the member's ongoing group work. The individual sessions are scheduled on a rotating basis. Typically, each group member is seen in an individual session once every four weeks. Additional individual sessions are available only when immediate attention is appropriate and necessary. The group is viewed as the primary therapeutic component. A cost-effective therapeutic approach that uses both individual and group methods, this modality lends itself well to a clinic and to a private practice setting.     

Group psychotherapy with alcoholics: Interface with self-help groups

This paper addresses recovering alcoholics' concurrent involvement in psychotherapy groups and self-help groups. A developmental model of alcoholism group psychotherapy is presented, differentiating between early and advanced sobriety. Psychotherapy and self-help groups are compared and contrasted. Multiple group membership entails various areas of compatibility. Divergence and conflict result from differences in underlying conceptual framework and approach. Clinical implications of members' involvement in partially discrepant group settings are explored with an emphasis on transference and countertransference reactions. Multiple group membership is identified as a salient factor in alcoholism group psychotherapy at all levels of recovery.She is also in private practice.This paper was presented at the American Group Psychotherapy Association Annual Conference, Boston, February 1990.     

Juegos en Dinamica de Grupo (Games in Group Dynamics)

Abstract

It is widely recognized that military service during wartime can take a toll on a soldier’s psychological health. Recent work has revealed effects on the families left behind as well, as reflected, for example, in an increase in child abuse and neglect in these families. My interest in studying the transgenerational transmission of trauma led me to offer the National Guard a pro bono group therapy for women whose husbands had been deployed overseas. A slightly unorthodox approach paved the way not only to group treatment but, ultimately, individual treatment for these women and their children. My hope is that this work can serve as a model for other therapists who share my interest in treating the intergenerational transmission of trauma by implementing group and mother-child psychotherapy.