The emergence of group and community therapies: a metabletic enquiry.
The emergence of 'collective therapies' such as group
therapy and therapeutic communities are explored. It is discovered that
these therapies start emerging around the beginning of the twentieth
century and gain widespread acceptance around the time of the Second
World War. This development is understood using the phenomenological
theory of historical psychology (metabletics) of JH van den Berg. These
'collective therapies' are recast in phenomenological terms
where it is argued that these therapies 'correct' modern
alienated existence and allow for a being-with-others that contemporary
existence makes problematic. Finally it is argued that this form of
therapy is healing to individuals and equally to 'the world'.
Group therapy, therapeutic communities, metabletics, JH van den Berg.
Existential psychology (Research)
|Publication:||Name: Existential Analysis Publisher: Society for Existential Analysis Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 Society for Existential Analysis ISSN: 1752-5616|
|Issue:||Date: July, 2010 Source Volume: 21 Source Issue: 2|
|Topic:||Event Code: 310 Science & research Canadian Subject Form: Group counselling|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
In this paper I wish to explore why group and community therapies emerged historically when they did. This will be attempted using JH van den Berg's phenomenological theory of historical psychology, metabletics. It is within the changes to society of the last two centuries that I place my explication. Allied to this I will explore the history and phenomenology of group and community therapies and suggest that the form these therapies take corrects and heals our alienated modern industrialised way of being-in-the-world.
Certainly this paper is not a work of historical investigation and in many cases will utilise single sources. This is because the aim is not to dispute the current historical account, but to deepen it through a phenomenological understanding. This 'deepening' aims to re-think group and community therapies in a way which opens up the historical events as much as the historical events open up the therapeutic practices. It should also be noted that I will not attempt any sort of new metabletic enquiry. Instead this paper can be seen as an adjunct to van den Berg's various metabletic studies. It could be seen as an additional illustration of his theory now applied to these particular practices.
The Advent of Therapeutic Groups
It is commonly thought that group psychotherapies emerged in the 1930's and 1940's. Yalom begins his famous text on groups by stating that "group therapy was first introduced in the 1940's" (1995, p.xi). This belief about the origin of group therapies is instructive, but is incorrect. Ettin (1999) shows that modern therapeutics via groups can be dated to 1906 and the publication of Hersey Pratt's "The 'Home Sanatorium' Treatment of Consumption". Ettin comprehensively reviews how groups developed from Pratt onwards with the early group pioneers having mostly educational aims. These pioneers began however to note non-educational aspects of their treatment. Later Edward Lazell, a psychiatrist, reported on a psychoanalytically informed didactic group begun during World War I. Some of the topics taught included fear of death, conflict, masturbation, self-love, inferiority and symptom explanations. Lazell later added Jungian elements to his groups and began experimenting with heterogeneous groups. Another pioneer, Cody Marsh, began giving academic and inspirational lectures to psychiatric patients as early as 1909. Marsh, a minister turned psychiatrist, contrasted his method to that of Lazell and believed group processes played a larger role than his predecessor. This work was developed and Marsh used techniques including homework, readings, singing, role-playing, testimonials and question-and-answer sessions. He would refer questions to the group for consensus and found groups developed with time 'sound mental hygiene'.
British group psychotherapy starts when S.H. Foulkes came to Britain in the 1930s and started experimenting with group analysis in 1940 (Foulkes, 1984). Later, along with others, the Group Analytic Society and the Institute of Group Analysis were formed. The other major stream of group work in the UK was that developed out of the work of Bion (1961) at the Tavistock. While smaller in numbers, the developments in the UK can be found to have arisen at roughly the same historical moment as similar developments in the USA. Early efforts gained momentum in the 1920s and 1930s, but were in full swing by the 1940s. It is argued that the perception, such as that of Yalom cited earlier, that group therapies began in the 1940s is really about the 'maturation' of this form of therapy. Group therapy 'took off' and was accepted in the forties. The world was moving towards this event. The question being posed here is why this development occurred when it did and in several places around the western world almost simultaneously. Let us postpone the answer to that question and explore briefly what makes therapeutic groups effective.
Yalom (1995) has described these factors as; 1) installation of hope, 2) universality, 3) imparting information, 4) altruism, 5) the corrective recapitulation of the primary family group, 6) development of socialising techniques and 7) imitative behaviour. Yalom's phenomenological sensitivity means we can accept these labels but perhaps interpret them for the purposes of our thesis. Except for the first (hope) and third (information) factors, all the others involve identificatory and interpersonal processes, which could only be established in a group. Others in the group help and are helped at the same time, including the therapist. For this to happen there needs to be management of the group and interaction and communication within the group. The therapist is responsible for the former, while facilitating the latter. Where in their daily lives, individuals can escape interacting and communicating, in the group this is all that happens. It is a space only for talking and being-with.
If these were the qualities that were therapeutic and there seems little major dispute, then perhaps these factors are our first clue. Perhaps what these factors suggest is that there is something lacking in contemporary existence which the group provides. We will again delay pursuing this idea until we have explored the history and mechanism of therapeutic communities.
The Emergence of Therapeutic Communities
Therapeutic communities (TC) gain great momentum after the Second World War and these innovations grew widely throughout western psychiatry (Clarke, 2004). Malcolm Pines argues that the "idea of running a psychiatric hospital as a therapeutic community can be given a date of birth, it was May 1946" (1999, p. 23). On this date the Bulletin of the Menninger Clinic published a collection of papers from Northfield. It included Tom Main's paper 'The hospital as a therapeutic institution'. This is similar to Yalom's dating of group therapies, it is instructive but incorrect. There were early attempts at therapeutic communities dating back at least thirty years prior to this (Fees, 2007). However, again, it is a widely held opinion that the TC movement began after the Second World War and perhaps is indicative again of how much momentum was gained by this approach around this time.
Northfield (during Second World War), Mill Hill (Effort Syndrome Unit established in 1941), Withymead (a Jungian TC established in 1941), the Cassel Hospital and what later became the Henderson Hospital (1947 to present) were the forerunners and early experiments in this sphere (Pines,1999; Whiteley, 1980). Maxwell Jones was an early and enthusiastic pioneer who travelled widely internationally as consultant in mental health to the World Health Organisation (Whiteley, 1980). Perhaps this helped spread the word, but it does not completely account for the sudden uptake. In the USA modified forms of TC became powerful tools in the treatment of addiction. But our question here is why this method of psychological healing emerged when it did.
To help us it may perhaps be helpful to ask what are these qualities, which make therapeutic communities indeed therapeutic? For this we will rely on a recent explication by Rex Haigh (1999). He describes five qualities; namely attachment, containment, communication, context and agency. It may be useful to explore these qualities and attempt (mischievously perhaps) to phenomenologically re-name them. Haigh describes attachment in the classical psychoanalytic sense of being attached to the mother and needing to negotiate separation and other complex emotions such as anger, envy and frustration.
Phenomenologically, in the TC sense, this is experienced as 'belonging' to the community. The attachment is not to a therapist, but to the whole community. And it is the community, which contains (the second quality) feelings towards this 'belonging' (or attachment). Again Haigh explains this second quality in terms of a maternal containing function, but in the therapeutic community this is created by holding the boundaries. This creates a safe environment in which healing can occur.
Phenomenologically we could describe this as 'governance'. It is only when the rules are clear that play can begin and symbolic development proceeds. The third quality is communication and is allied to an openness of discourse. This requires "stable, dependable groups with clear membership, protected time and space, and a mutual agreement of boundary issues" (Haigh, 1999, p.252). There is no need to rename this quality as communication appears phenomenologically accurate. The fourth quality is that of context, which Haigh feels could also be known as 'living-learning'. This entails that every aspect of communal life is available for therapeutic effect.
Haigh argues that "the meaning of an individuals existence is as much in the minds of others as in the physiological or biochemical reality of an isolated person: we are mindful of others and they are mindful of us" (p.253). This 'holding in mind' is the very concrete operation of the community. People mean something to each other; they care and are cared about. Individualism recedes while 'interdependence' comes to the fore and the separation of individual from society becomes seen as truly impossible. Each member, whether patient or staff, is both affector and affected; both the helped and the helper. The attachment is a dependence, which is an 'interdependence' and this would be our phenomenological description. Haigh's final quality is agency, which entails the empowerment of members of the community. Differences are accepted, but superiority is rejected. Every member contributes to the community in their own way--but it is still a contribution to be valued. Authority is fluid, negotiable and questionable. It resides in the community and not in any individual. It is a form of empowered and lived democracy. This form of democracy is not representative, but concrete and the consequences of choice are visible and open for reflection. We shall describe this phenomenologically as 'participation'.
In summary we are describing therapeutic communities as having qualities of belonging, governance, communication, interdependence and participation. It is perhaps in re-naming these qualities that it becomes clearer how they apply to real communities. It would not be surprising that people would want to belong and actively participate in their home communities; feel valued in their role and contribution to life; and be able to communicate and be protected (governed) within this environment. Spirituality, through mythologies, societal customs, and community churches, played an important role in this process for countless millennia. Giddens (1991) calls these forces 'tradition'. It bound social groups together in shared understanding of purpose and meaning (Campbell, 1969). Today in our 'God is dead' culture this is no longer true.
It is also fairly obvious how little of this way of being-in-a-community is available in modern communities. Alienation, isolation and disillusionment with politics prevail. Separation, privacy and 'individual rights' dominate. Most people don't know their neighbours, don't want to know their neighbours and contribute to good causes through monthly direct debits to national charities who help anonymous others "somewhere else".
Van den Berg and Changes in Society
In an attempt to answer the questions posed here we now turn to the theory of metabletics. Jan Hendrik van den Berg was a Dutch psychiatrist, psychotherapist and phenomenologist. Now in retirement, he held various academic positions in Holland, principally at the Universities of Leiden and Utrech. Although heavily influenced by psychoanalysis, van den Berg came to believe that phenomenology was the most important development of the last century. Inspired by Husserl and Heidegger, van den Berg went on to develop a distinct approach to psychopathology through phenomenology. But he was also very interested in social phenomenon and began to explore how certain changes in experience were reflected in social and material changes. Van den Berg believed these changes arose in an interactive and emergent way out of the flow of history. In this sense he was articulating ideas inherent in Norbert Elias' work and implicit in group analytic theory (Delal, 1998). Van den Berg's position, in contrast to the usual phenomenological pursuit of essences, is that change is an essential and fundamental aspect of existence (Spiegelberg, 1972). Van den Berg explored a number of issues in this way including work (1974), the body (1959; 1961), sickness (1966) and our relationship to material reality (1968).
Van den Berg came to believe that there was a 'divided' aspect to our modern relation to the world, others, time and the body. This divided way of being had not always existed but emerged with historical changes arising with the advent of science and industrial society. Again it was a complex interacting relationship which allowed science to inform life and industry and thus to generate further scientific advances. The advent of these ways of understanding and 'knowing'--scientific ways of seeing the world--became 'embodied' and would have subtle but noticeable effects on the nature of being.
Phenomenologists argue that 'truth' is manifest in the experience of the subject. This is experience as it is lived and embodied and how this then reveals a meaningful world. Throughout history, the world, relationships and the body have been lived as they are experienced, as perhaps safe, dangerous or exciting amongst many others. Science, or perhaps the scientific attitude, began to alter this way of being. Science argued, for example, that the world was round. The world has always been lived as flat. Experientially this is vital. Although there are ups and downs to the earth, we do not experience this ground of our experience as curved. Similarly our relation to our body altered. Van den Berg (1959) carefully shows how prior to Harvey's description of the heart as a pump, the heart was never experienced in this way, even though it was extensively studied. The split is thus between a lived reality and a scientific reality. With the rise of science experience is distrusted and in a sense over-ridden by 'knowledge'. Reality has to be found 'hidden' behind experience--not latent within it. This attitude can be seen in Freud's hermeneutics of suspicion (Ricouer, 1977). The truth is not embodied in the symptom but is concealed 'in' the unconscious. Science was becoming 'embodied'. This way of embodied being results in a split, separated, divided subject.
Van den Berg (1974) argues that to understand modern states of being we need to examine the trends from the beginning of the modern age. He thus begins his analysis of this trend in the eighteenth century with the rise of the doppelganger theme of literature and the emergence of hypnotism as a medical treatment. He argues that this type of literature, which caused a sensation and was extremely popular at the time, reflected the experience of the populations of Europe. The doppelganger is a double, a shape changing and mostly dangerous creature. The dual nature of nineteenth century existence was being reflected here. Hypnotism is a phenomenon, which is completely about different modes of consciousness and van den Berg shows how this strange science took hold of Europe in the nineteenth century. Coupled with this was the increasing industrialisation of society. People were flocking to the cities in search of jobs. Traditional ways of life were ending very rapidly. In factories individuals were also increasingly divided from their products (van den Berg, 1974). Indeed the science of manufacturing separated the production of goods into different tasks to such an extent that workers were often unsure what they were actually manufacturing. Workers were thus separated from their traditional lands, their communal ways of life, often their families and even from the products they made. It should therefore not be surprising that a powerful philosophy might emerge which would challenge this form of existence Marxism and its derivative Communism.
In this climate of alienation it should also not be surprising that new psychiatric illnesses were emerging and older ones showing themselves in greater numbers. It should also not be surprising that Freud (and others) were creating theories about the divided nature of being. Freud, who had begun with hypnotism, was at the end of the nineteenth century developing his theories of the unconscious. The subject was split into conscious and unconscious parts. William James described 'parts of the self. The experiential nature of the world was becoming split and this was reflected in psychological theory itself (van den Berg, 1974).
The shift of living from small rural communities also had its effect. Although this phenomenon took several centuries by the beginning of the twentieth century western society was largely city based. Van den Berg follows Sullivan's (1940) notion of parataxic relationships and how this change in living arrangements led to multiple relating 'selves'. Primordial man, based in small containing communities, would have related to a small number of well-known individuals. Choice was limited, as were resources. Sons took on the skills of their fathers, or of other men in their communities. Modern existence however calls for the ability to relate to a greater number of different individuals. There is choice in all aspects of life. These required ways of relating are by necessity plural, multiple and reflexive. This flexible relating, to both other individuals and the world, sediment into multiple selves, further dividing the modern individual. As society becomes more complex, more demands are placed on individuals to meet these complex interactional moments. Relatedness is increasingly complex. It could be argued that modern psychopathology reflects the difficulty of this task (van den Berg, 1972).
Van den Berg developed a complex, yet enthralling conception of psychopathology and psychotherapy, which built on his metabletic theory. Here we can only briefly outline the main tenants of this theory. We can however note that for van den Berg psychopathology was the result of 'loneliness' (van den Berg, 1972). The modern subject suffers through his alienation, he "has few relationships or perhaps no relationships at all. He lives in isolation ... apart from the rest of the world. This is why he has a world of his own" (ibid. p.105). The modern mentally ill person lives a truncation of relatedness. In the past this may have been survivable, but not in modern western society. Modern life demands a capacity for plural relatedness. Without it the modern person is sure to be ill. Thus for van den Berg neurosis became sociosis, in that it reflected the changing nature of existence.
The nature, the frequency, even the occurrence of neurotic disorders are dependent on time and place ... [and] the cause of these disturbances must be sought in the continuously changing nature, structure, form and organisation of that country, of that time ... The society provides the factors which induce neurosis; these factors will influence every individual in that society, but only those, already by nature predisposed, will become manifestly ill. Neurosis is a social disease ... neuroses are socioses
(van den Berg, 1971 p. 341 emphasis in original).
If neuroses are intimately connected to societal structure and change, what can the psychotherapist contribute? For van den Berg the task of the psychotherapist to embody those elements of society which are 'missing' or unlived. For patients in Freud's time this was sexuality and aggression (van den Berg, 1971), but in modern times a different stance is required of psychotherapists. This stance requires that the divided, individualistic, lonely patient be allowed to take up his existence as a socially related being. It allows for the development of reflexive relational skills. This form of therapy implicitly acknowledges that being is constituted by others and by 'the world', and must be cured equally by others and 'the world'. It is a stance, which accepts the transpersonal nature of being. The answer to suffering does not lie in the individual. This answer goes beyond the individual, beyond the ego. It is a solution that acknowledges 'otherness' not only as constituting being, but 'otherness' as constituting cure. The ultimate other is often termed 'God' and this approach is therefore inherently a spiritual (van den Berg, 1971). And to describe its relation to the 'world' in the narrow and widest sense van den Berg (1980) has referred to his approach as cosmotherapy.
In conclusion let us summarise van den Berg's position on the modern individual. This subject is born into a complex, taxing and changing world, requiring the ability to relate in multiple and reflexive ways. Lived-being has to be born alongside scientific reality, which is known but not always experienced. Societal changes have brought new forms of distress socioses --which need to be addressed with social existence in mind. Therapy is therapy for the individual, but it is therapy via the world and as such it must also attend to and attempt to heal the world. It must attend to the anima mundi--the soul of the world.
What becomes clear from the above historical exposition is the gradual emergence of several therapy groups during the period 1915 to 1930, with a dramatic uptake after the Second World War. Similarly the therapeutic community as treatment, also with precedents between the world wars, emerged fully around the same time. The question we are posing here is: what brought these practices into being? Why were groups, even communities--suddenly therapeutic? And the effect was indeed sudden. These methods did not exist then suddenly only two decades later they have exploded into wide and powerful use.
The answer we will advocate is the following: the world called these practices into being. And it did so as modernity and industrialisation was in full flourish. We can perhaps speculate that the further damage done to traditional communities by the two world wars, particularly
the second, turned the world into a distinctly inhospitable place. The Second World War took around fifty million lives, destroying families and displacing millions of people. This, coupled with the increasingly alienation of modern life, edged western humanity towards new dis-eases and maladies. And it was then discovered these could be helped through establishing therapeutic groups and communities. The world was looking for the balanced to be corrected because our communal nature as being-in-the-world that was at stake.
Despite knowing we are communal animals, we in the western world continue to create a world of separatism and individuality. Yet we are paradoxically closer together than ever before--crammed into massive multicultural cities. We need at the very least to be able to cope with this being-with, perhaps coming to terms with it or indeed eventually even revelling in it. And the therapeutic group/community moves us towards this goal. In a group or a community we are 'with' others, they help us and are helped by us. These 'places' are structured so as to make it virtually impossible to be alone, to detach and to isolate. It is therapy to expose our communality through collective attention, whether this is all day long or for an hour and a half or so.
Of course it is possible to argue, as Pines (1999) and Clarke (2004) do, that there were clear theoretical antecedents to the emergence of therapeutic communities. These cannot be denied and no doubt they played an important role. But that does not explain why this method of treatment worked and why it worked at this moment in history. It does not explain why the theory itself emerged. We can explain the working of therapeutic communities by basing its elements on psychoanalytic theory, as Haigh (1999) does. Yet as a praxis, both group and community therapy, are markedly different from psychoanalytic treatment. I am not sure that Freud would have recognised Yalom's (1995) healing factors, except perhaps for the corrective recapitulation of primary family group factor. Nor did Freud feel that groups could be healing. I feel the attempt to explain both group (per Foulkes and some of his followers) and community (via Haigh, Pines and others) therapy solely in terms of psychoanalysis is untenable. As Dalal (1998) has cogently argued, the group (and the community) must be addressed at their own phenomenological level. And this paper serves as a contribution to this process.
We should now explore the qualities of both therapeutic groups and communities and how they relate to our argument. Both the qualities which are therapeutic in groups and communities involve relating, communicating and helping others. There are also issues of governance or boundary keeping. To be safe allows the relating and the communicating. It is these issues that are lacking in the modern alienated subject. They suffer in their relating and communicating. Therapy affords an opportunity to build ways of being-with that sociosis makes difficult to acquire. Remembering that sociosis is not in the individual but in society, and that the individual can never be separated from society, the therapy is as much a therapy for the individual as it is a therapy for society. It is not just the individual who is changed, the world is also changed. It is therefore not surprising that group therapists are also effected by the groups they lead.
The therapeutic group conductor must therefore have the ability to relate widely and flexibly. This draws others in, and in his or her presence, they experience this way of relating to others. They experience flexible, reflexive ways of relating and communicating. This allows them to function reflexively in society and to be relatively free of sociosis. In the group and in the therapeutic community other patients are also encountered and they must be related to as well. It is here that these forms of therapy differ from individual psychotherapy. It is contended that these collective forms of treatment, by their very constitution, form 'a world'. And it is through this encounter with a specifically constituted therapeutic 'world' that healing occurs. Eventually however this must be lived in real groups and naturally occurring communities in the social world.
Thus it is vital that the gains of group and community therapy extend into the world, because we are ultimately concerned with being-in-the-world. To be fully human is to be fully in the world. Kruger (1984) argues that 'the world cures' as the suffering of sociosis is alienation from the world. Both group and community therapies are 'worldly', but at the very least inhabiting our place in the world frees us from an isolated, alienated, divided alternative. It also acts as a cure for the ills of the world, it is a societal therapy, a cosmotherapy. Effective group or community therapy allows for the world to function as a meaningful and therapeutic place. The world is rehabilitated. It can now be fully inhabited. The rehabilitated world can then be container to our emotions, the rhythm of our lives, the site of our embodied relationships and temple to our souls.
The basic contention of this paper is that humanity and the world change and that a particular change happened in the late nineteenth century, early twentieth century. This change, a change in relatedness, a change in social communal existence, brought about, or 'called' collective therapies into being. These collective therapies, both group and community, became healing because of the change in our being-in-the-world.
It is worth being clear that there is no attempt here to idealise the past. There is much to criticise in the way man suffered prior to this century. Progress in dealing with many aspects of life, from health, to education, to hunger, to democracy has improved man's general existence greatly. We must however note the price of these advances. And the price includes the death of communities and the rise of individualism. These costs arise in many aspects of life, but perhaps most notably in mental health services. Group/community treatments are attempts to address this cost. It is an attempt, which in a way rights one of the effects which progress has wrought.
Humanity's being-with others and our dwelling in the world has altered. Group therapy and therapeutic communities both attempt to heal through constituting 'a world' which is an encounter with others. And this being-with-others replicates an older form of existence. This form of therapy hopes to allow individuals to correct today's modern lonely, isolated, alienated, individualistic world. It hopes to inaugurate a different more communicative and reflexive being-in-the-world. At the same time the world's soul is healed.
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Ryan Kemp is a Consultant Clinical Psychologist and Head of Psychology in the Addictions Directorate of CNWL NHS Foundation Trust. He has responsibilities in two community teams, the regional detoxification ward, The Max Glatt Unit and in the National Problem Gambling Clinic. In addition to his interest in addiction, he has an interest in psychoanalysis and group analysis and how these practices can be dialogued with existential-phenomenology.
Address: Gatehouse Community Alcohol Team, St Bernard's Hospital, Ealing, UB1 3EU, London, UK. Correspondence to email@example.com.
Everything that happens in the community--from the washing up, to the board games, to the requests for leave--can be used to therapeutic effect. A disagreement in the ward kitchen can be more important than a therapeutic exchange in a group; it is as much part of the working day for a junior doctor to go swimming with the community as it is for him to formally assess patients' mental states (p.253).
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