Reality Testing and Testing Reality in Group TreatmentPart I: Reality and Reality Testing

This two-part contribution addresses reality, reality testing, and testing reality—how we think about and may technically approach these concepts. Part I provides a topic overview and focuses on reality testing. Part II (in an upcoming issue) focuses on testing reality and how it promotes emergence of new or previously inhibited forms of engagement.

Reality testing and testing reality represent two fundamental, reciprocal manifestations of the drive to know and of tasks of learning: approaching problems and solving them. While testing reality involves approaching reality without necessarily looking for or coming to definition or clarity, reality testing centers on a particular theme or object. It evolves towards organization and rationality, with a goal to define and solve problems—or to avoid them.

Engaging the group and supporting individuals in these two types of approaches to learning requires a well-defined therapeutic focus on process and purpose; at times, different tactics and techniques are appropriate.     

Reality Testing and Testing Reality in Group Treatment

This two-part contribution addresses concepts of “reality,” “reality testing,” and “testing reality,” as they apply to group treatment. Part I provided topic overview and focused on reality testing. Part II focuses on testing reality and how it promotes emergence of new or previously inhibited forms of engagement.

Whereas reality testing centers on a particular theme or object, with a goal to define and solve problems, testing reality involves approaching targets of interest without necessarily looking for or coming to definition or clarity. It is wide open, spontaneous, and unbounded, and may take the individual and group into realms that are uncomfortable and even unwanted. Engaging the group and supporting individuals in these two approaches to learning requires a well-defined therapeutic focus on process and purpose; at times, different tactics and techniques are called for.     

On refusal

Traditionally, all efforts to counter psychotherapeutic work have been captured under the umbrella term, "resistance." However, it is useful to distinguish a concept of refusal. Resistance entails therapeutically a gradual elaboration of unconscious, preconscious, and partially conscious experience. Refusal manifests as a willful nonparticipation in offering or responding to material that can be symbolized. All communication has an element of refusal, which occurs at various levels of persistence, intensity, and legitimacy. Clinical examples are provided to discriminate refusal from resistance proper, and to describe three categories of mental and group experience, (a) refusal to perceive external experience; (b) refusal to think about what one knows, and (c) refusal to think about what one does not know. Therapeutic impasses may relate to limitations of the therapist's creativity and flexibility in thinking about and dealing with refusals, including one's own.     

The class that would not read: utilizing Bion's affect theory in group.

While Bion's group theory continues to inspire contemporary group psychotherapists, his theory of human emotion is not as well known. Bion also introduced a system of alphabetical and mathematic symbols to offer a shorthand for his epistemology in order to make his ideas accessible, flexible, and practical for the working clinician. This article presents aspects of Bion's theory and metapsychological shorthand to conceptualize effectual dimensions of group process, thinking operations, and countertransference. The constructs considered include Klein's paranoid-schizoid and depressive positions; manic defenses; basic assumptions; "proto-mental" and "pre-monitory" emotions; instinctive drives L, H, and K (plus or minus); beta elements; and alpha functioning. With these ideas, the author was able to work through aspects of a group experience in which, as leader, he unknowingly found himself at an opposite affective pole from the members.     

Observing spontaneous metaphor in children

The study considered whether apparent metaphors are a frequent part of child language and whether the child recognizes the metaphoric relation created. Seventy-three nursery and kindergarten children (2 to 6 years of age) were observed for one or two half-hour periods of free play. Naturally occurring utterances in unconventional uses were recorded. The children were then questioned about their possible metaphoric creations to determine their awareness and understanding of their utterances. Results suggest that metaphoric processes exist quite early in development, as exemplified by a high frequency of spontaneous metaphor in the free play of young children. The semantic extensions were often deliberate and used appropriately. On some occasions the child was able to articulate the rationale for the verbal substitution. The content and cognitive features of the figures are discussed. Several hypotheses are offered for the developmental trend of decline in frequency of metaphor use with age.     

Doing Our Work: Words,Deeds, and Presence

Group leadership is an art, with relational tools of words, deeds, and presence. We aim to take our groups to creative places that they—and we ourselves—have never been before. Something needs to happen, fresh experience needs to emerge that becomes relevant to the growth of the members, including the therapist. The therapist's work is done while we are also doing something else. It entails a dual focus, or “binocular vision,” directed to personal discovery, while also focused on the group’s realities and growth potentials. Three case examples illustrate how the work happens to us: we evolve as a person as we do the work.     

Stress, Glucocorticoids, and Damage to the Nervous System: The Current State of Confusion

An extensive literature demonstrates that glucocorticoids (GCs), the adrenal steroids secreted during stress, can have a broad range of deleterious effects in the brain. The actions occur predominately, but not exclusively, in the hippocampus, a structure rich in corticosteroid receptors and particularly sensitive to GCs. The first half of this review considers three types of GC effects: a) GC-induced atrophy, in which a few weeks' exposure to high GC concentrations or to stress causes reversible atrophy of dendritic processes in the hippocampus; b) GC neurotoxicity where, over the course of months, GC exposure kills hippocampal neurons; c) GC neuroendangerment, in which elevated GC concentrations at the time of a neurological insult such as a stroke or seizure impairs the ability of neurons to survive the insult. The second half considers the rather confusing literature as to the possible mechanisms underlying these deleterious GC actions. Five broad themes are discerned: a) that GCs induce a metabolic vulnerability in neurons due to inhibition of glucose uptake; b) that GCs exacerbate various steps in a damaging cascade of glutamate excess, calcium mobilization and oxygen radical generation. In a review a number of years ago, I concluded that these two components accounted for the deleterious GC effects. Specifically, the energetic vulnerability induced by GCs left neurons metabolically compromised, and less able to carry out the costly task of containing glutamate, calcium and oxygen radicals. More recent work has shown this conclusion to be simplistic, and GC actions are shown to probably involve at least three additional components: c) that GCs impair a variety of neuronal defenses against neurologic insults; d) that GCs disrupt the mobilization of neurotrophins; e) that GCs have a variety of electrophysiological effects which can damage neurons. The relevance of each of those mechanisms to GC-induced atrophy, neurotoxicity and neuroendangerment is considered, as are the likely interactions among them.     

A falsifying adolescent

The author describes an adolescent patient who, while often speaking factual truths, maintained an aura of falsity in her life, and in two interludes of psychoanalytic psychotherapy, that functioned as a barrier to psychological insight. To match her falsity, the analyst at times modified his functioning as a "real" therapist and took on her personification of neglectful and false adults. Eventually, the analyst became an object that the adolescent could trust and rely on. In discussing the case, the author introduces and applies Bion's ideas regarding truth and falsity, and three variations of container-contained relationships-symbiotic, commensal, and parasitic-in the context of the case's relational perspective.     

The two faces of the group therapist

The group therapist wears two faces: spokesperson of the Establishment and spokesperson of significant truth. To run vital groups, these two roles of group leadership must stand in dialectic relationship to each other. The therapist introduces principles and practices that normalize group relations and provide a sense of cohesion, continuity, and regularity. However, to be constructive and promote significant truth, the group therapist must also be deconstructive, and encourage and support the group's questioning and challenging the very principles and practices that he or she asserts. A case example illustrates how the group leader is also two-faced in another sense of the term, since he or she may be false and insincere--or perceived as such--when being either the conservator or challenger of group process and culture.     

The therapist's anxiety and resistance to group therapy

When therapists contemplate starting groups, consider placing an individual patient within an existing group, or respond to the group reconfigurations when members are added or replaced, it raises their anxieties and resistances. Under these circumstances, the therapist must contend with many intersubjective factors: dread, fear, and idealization of groups; contagion and amplification of psychological phenomena; absorption in the group mentality; magnification of the therapist's centrality and importance; exposure and disturbance of existing relationships, and utilization of one's own emerging and evolving thoughts, feelings, and fantasies, along with the group's. Therapists learn about themselves and their groups by reviewing their countertransference, being alert to possible enactments, and listening to their patients, whose anxieties and resistances to group often reflect their own.