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 CONTRIBUTIONS OF SELF
PSYCHOLOGY TO GROUP
PSYCHOTHERAPY

6005TS-STONECON-0907-01.indb i 8/11/09 1:07:39 PM

 THE NEW INTERNATIONAL LIBRARY OF GROUP ANALYSIS SERIES

Series Editor: Earl Hopper

6005TS-STONECON-0907-01.indb ii 8/11/09 1:07:40 PM

 CONTRIBUTIONS OF
SELF PSYCHOLOGY
TO GROUP
PSYCHOTHERAPY
Selected Papers

Walter Stone

6005TS-STONECON-0907-01.indb iii 8/11/09 1:07:40 PM

 First published in 2009 by
Karnac Books Ltd
118 Finchley Road
London NW3 5HT

Copyright © 2009 by Walter Stone

The right of Walter Stone to be identified as the author of this work has
been asserted in accordance with §§ 77 and 78 of the Copyright Design and
Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior
written permission of the publisher.

British Library Cataloguing in Publication Data

A C.I.P. for this book is available from the British Library

ISBN-13: 978-1-85575-734-9

Typeset by Vikatan Publishing Solutions (P) Ltd., Chennai, India

Printed in Great Britain

www.karnacbooks.com

6005TS-STONECON-0907-01.indb iv 8/11/09 1:07:41 PM

 CONTENTS

FOREWORD ix

PREFACE xi

ACKNOWLEDGEMENTS xvii

INTRODUCTION xix

SECTION I: THEORY
CHAPTER ONE
Contributions of the psychology of the self to group
process and group therapy 3
W.N. Stone and R.M. Whitman

CHAPTER TWO
The group self: A neglected aspect of group psychotherapy 19
S. Karterud and W.N. Stone

6005TS-STONECON-0907-01.indb v 8/11/09 1:07:41 PM

 vi CONTENTS

CHAPTER THREE
Group-as-a-whole: A self psychological perspective 35
W.N. Stone

CHAPTER FOUR
Dreams as portraits of self and group interaction 55
W.N. Stone and S. Karterud

CHAPTER FIVE
A self psychological perspective of group development 67
W.N. Stone and G. Spielberg

SECTION II: CLINICAL APPLICATIONS

CHAPTER SIX
A self psychological perspective of envy in group
psychotherapy 91
W.N. Stone

CHAPTER SEVEN
Frustration, anger, and the significance of alter-ego
transferences in group psychotherapy 107
W.N. Stone

CHAPTER EIGHT
Self Psychology and the Higher Mental Functioning
hypothesis: Complementary theories 123
W.N. Stone

CHAPTER NINE
The role of the therapist’s affect in the detection
of empathic failures, misunderstandings and injury 137
W.N. Stone

6005TS-STONECON-0907-01.indb vi 8/11/09 1:07:42 PM

 CONTENTS vii

SECTION III: SEVERE DISORDERS

CHAPTER TEN
Technique in group psychotherapy of narcissistic
and borderline patients 155
W.N. Stone and J.P. Gustafson

CHAPTER ELEVEN
Affect and therapeutic process in groups for chronically
mentally persons 173
W.N. Stone

CHAPTER TWELVE
Strivings and expectations: An examination of process
in groups for persons with chronic mental illness 189
W.N. Stone

CHAPTER THIRTEEN
Saying goodbye: Exploring attachments as a therapist
leaves a group of chronically ill persons 207
W.N. Stone

REFERENCES 227

INDEX 245

6005TS-STONECON-0907-01.indb vii 8/11/09 1:07:43 PM

6005TS-STONECON-0907-01.indb viii 8/11/09 1:07:43 PM
 FOREWORD

From self-psychology to group

psychotherapy: Selected papers
By Walter Stone

I am pleased and privileged to introduce this selection of papers by

Dr. Walter Stone. It is the first volume to be published in the New
International Library of Group Analysis. A Distinguished Fellow
and former President of the American Group Psychotherapy Asso-
ciation, Walter Stone has also served on the Board of the Interna-
tional Association for Group Psychotherapy and Group Process, and
is a Member of the Group Analytic Society (London). He has been
an active participant in professional conferences and workshops.
A teacher of international renown, Stone has developed and clari-
fied several important ideas in self-psychology, and has introduced
this theoretical and clinical orientation to psychoanalytical group
therapists and group analysts.
Stone’s central interests include the development of the self,
empathy, narcissism, shame, envy, rage and the group-self. He is
concerned with several aspects of clinical technique, such as the pat-
tern of attending or missing sessions, alter-ego transferences, and
countertransference processes in general. He is especially sensitive
to our co-creation of so-called ‘difficult patients’. His understand-
ing of dreams as both personal and group products which manifest

ix

6005TS-STONECON-0907-01.indb Sec4:ix 8/11/09 1:07:44 PM

 x FOREWORD

visual narratives will be of particular interest to students of the social

and collective unconscious.
Stone’s work with narcissistic and borderline patients developed
in parallel with his work with the chronically mentally ill, who are
often institutionalised. He demonstrates that group therapy for such
patients is not only a matter of containment and holding in the serv-
ice of administrative control, but also involves interpretative work
based on an understanding of the primary need for a good enough
self-object. In general his clinical work is directed towards providing
nurturing experience as a context for facilitating the achievement of
insight in the service of the maturation of the self. Clearly, Stone has
contributed to the development of an authentic relational perspec-
tive in psychoanalytical group therapy.
Group analysts will be able to connect these ideas with their
own theories of ego training in action, the complementarity and
reciprocity of transference and countertransference processes, the
maintenance of an optimal balance of involvement and detachment
in conducting and convening groups, and finding crucial areas of
engagement between the group-as-a-whole and the members of it.
I am especially interested in Stone’s conceptualisation of envy, shame
and helplessness, which is very similar to my own understanding
of envy as a defence against the fear of annihilation rather than as
a manifestation of the death instinct. This work locates aggression
within the system of aggressive feelings, frustration and failures in
empathy and care.
More personally, I very much appreciate Walter’s colleagueship
and friendship. He always finds time to listen with generosity and
attention. These qualities are apparent in this selection of papers,
which have contributed to the theoretical underpinning and clinical
techniques of our profession.

Earl Hopper, Ph.D.

13 July 2009

6005TS-STONECON-0907-01.indb Sec4:x 8/11/09 1:07:44 PM

 PREFACE

In more than a century since Freud’s monumental contributions

to understanding human behavior, the psychotherapeutic field is
replete with competing innovations in “how psychotherapy works.”
This monograph follows my writings from 1977 until the present as I
have applied self psychology to group psychotherapy.
I was initially trained in a therapeutic paradigm heavily flavored
by traditional psychoanalytic thinking, with the therapist’s role as
abstinent interpreter of unconscious processes. Self psychology pro-
vided a model, one that added a new dimension to my understand-
ing of the phenomenon I was observing and loosened constraints
that I felt with the classical model. Moreover, applying the theory to
practice seemed to invigorate the groups and seemed more helpful
to the members.
My psychiatric career began with residency training at the Uni-
versity of Cincinnati in 1961, four years following graduation from
Vanderbilt Medical School. In the interim, I had a year internship
and a year of internal medicine residency at the University of Wis-
consin. My formal training was interrupted by the draft, and I served
from July 1959 through June of 1961 as a partially trained internist
in United States Air Force. The experience freed me to reflect upon
xi

6005TS-STONECON-0907-01.indb Sec1:xi 8/11/09 1:07:45 PM

 xii P R E FAC E

what aspects of a medical career most appealed to me. I chose to get

a fresh start and shift my specialty choice to psychiatry.
I was accepted for training at the University of Cincinnati, one
of the premier dynamically oriented programs in the country.
A department wide enthusiasm for group treatment had been stimu-
lated during the late 1950’s by a six-month Sabbatical visit of British
psychoanalyst Michael Balint. He had engaged many of the young
faculty with a group training/treatment experience, which they
transported to their supervisory work in the hospital settings and in
their private practice. An additional stimulus to group work was the
presence on the full-time faculty of Roy Whitman, M.D., author of
a series of papers formulating the Group Focal Conflict as a way of
understanding the treatment process in group therapy.
Residency began with a year of inpatient work, divided between
the Veterans Administration Hospital and Cincinnati General Hos-
pital. In the early 1960’s, patients often remained in the hospital for
three to six month periods. Hospital stays emphasized the impor-
tance of the milieu, and the use of groups as providing an important
window into patients psychic functioning.
Outpatient clinical work was the major focus of the final two years
of training. Almost all senior residents co-led groups; with younger
trainees serving as recorder/observers. As a group recorder, my task
was to take detailed process notes during each session, formulate
the process in the model of a group focal conflict and present to the
supervisor. It was a rigorous assignment. I learned to think process
and hear metaphors that I was having difficult discerning in dyadic
work. Moreover, I found myself often times profoundly impacted
by “affect contagion,” which deeply impressed me of the power of
group treatment. I remain particularly appreciative of the two super-
visors that year, Murray Tieger, Ph.D, and Stanley Block M.D.
Following my apprenticeship, I co-led an outpatient group for my
final two years of training and as a senior resident a long term group
of patients at the VA hospital. From this experience, I wrote my first
group paper with my co-residents, “The treatment of a homosexual
woman in a mixed group,” published in 1966.
Upon completing my training in 1964, I chose to continue as a
faculty member of the Department of Psychiatry assigned as ward
supervisor at the Veterans Administration Hospital. I was also in
part-time private practice. Bill Powles, M.D., a VA faculty colleague,

6005TS-STONECON-0907-01.indb Sec1:xii 8/11/09 1:07:46 PM

 P R E FA C E xiii

generously asked if I would co-lead his private outpatient group,

which I continued when he departed a year later for a university
position in Canada. In 1970, I had an opportunity to move to Central
Clinic, the primary outpatient service of the Psychiatry Department.
With that move I was appointed coordinator of the department
group psychotherapy program, a position I held until my retirement
and departure from Cincinnati in 2002.
My early horizons were expanded by the twice yearly regional
group therapy conferences, conducted across two days. The six-
ties, a period of considerable social turmoil fueled by the civil rights
movement and the Vietnam war, was also filled with innovation and
at times seemingly dominated by the controversial t-group move-
ment, gestalt and transactional analytic approaches. I was exposed
to many of these innovations as I gradually became involved with
the American Group Psychotherapy Association, Beginning in the
early 1970’s attending an annual meeting became a fixture on my
calendar.
During my early years in Cincinnati, aspiring psychoanalysts
commuted to the Chicago Psychoanalytic Institute for training. This
period coincided with Heinz Kohut’s developing self psychology
into a coherent theoretical framework. Paul and Anna Ornstein, fac-
ulty colleagues in Cincinnati, were early leading followers and advo-
cates of Kohut’s rather revolutionary ideas of the self, the emphasis
on the empathic stance and the increased attention to manifestations
of narcissism and narcissistic vulnerability in the therapeutic setting.
Their enthusiasm for self psychology was re-enforced by Kohut’s
frequent visits and lectures in the Department of Psychiatry.
I then began thinking about how the theory might apply to my
work with groups. At that point I felt I still had insufficient knowl-
edge of this knew paradigm, and I began discussions exploring appli-
cations to group therapy with Roy Whitman, Together we wrote the
original two papers applying a self psychological approach to group
process and therapy. Later, Roy as Department Chair, asked me to be
his co-chair, which provided me with an experience in larger group
and system dynamics which enriched my understanding of those
structures.
In the 1970’s I began participating in Tavistock group relations
conferences and became acquainted with James Gustafson, from
Madison Wisconsin. His work on “Unconscious Planning in Small

6005TS-STONECON-0907-01.indb Sec1:xiii 8/11/09 1:07:46 PM

 xiv P R E FAC E

Groups” (Gustafson and Cooper, 1979) later to be labeled the

Hypotheses of Higher Mental Functioning, like Self Psychology,
was a growth theory. Our work seemed to overlap and we agreed
to collaborate on the problems of treating narcissistic and borderline
patients. This led to Jim and I writing about group treatment for this
difficult population from a self psychological perspective.
Through my regular involvement with the American Group
Psychotherapy Association annual meetings, I was exposed to the
breadth of the group therapy field. Among many others, I met Scott
Rutan, and we developed a life long friendship and collaboration
resulting in our authorship of Psychodynamic Group Psychotherapy.
Scott has read and thoughtfully edited every one of my manuscripts,
always with a careful eye to making my sometimes convoluted lan-
guage more readable.
Beginning in the 1980’s with the advent of managed care, the psy-
chotherapeutic landscape changed. The public mandate shifted to
provide greater care for the relatively neglected large population of
chronically mentally ill persons. The clinic had to shift therapeutic
resources from the traditional population of primarily uninsured
workers or homemakers with Axis I or II disorders, to individuals
with persistent and severe mental illness.
I saw an opportunity to maintain and perhaps energize the group
program by shifting the focus to working with persistently ill per-
sons. I thought that application of a self psychologically informed
treatment to this population might be therapeutically effective, and
increase the enthusiasm for doing this work. This model presented
an attractive alternative to the somewhat derided “supportive”
treatment approach that had been the mainstay of groups for the
chronically ill population.
I assumed responsibility for co-leading two groups as well as
supervising three others. One of the groups I supervised had been
videotaped from its inception. When the staff therapist left the clinic
in the middle of an academic year and no therapist was available,
I assumed the leadership. I recruited residents and later social or
psychology graduate students to run the video camera. In exchange,
I spent time after each session plus an hour each week reviewing the
tapes with the student and teaching about group processes. This was
not an altogether altruistic teaching exercise, since the arrangement
forced me to find time to consistently review sessions. These reviews

6005TS-STONECON-0907-01.indb Sec1:xiv 8/11/09 1:07:47 PM

 P R E FA C E xv

provided wonderful feedback in how I worked, and resulted in the

publication of Group Psychotherapy for Persons with Chronic Mental
Illness (1996).
In order to further deepen my perspectives on group analytic psy-
chotherapy, in 1992 I took a three month sabbatical to the UK. There,
I became more deeply acquainted with the Group Analytic theory
and subsequently joined the International Association of Group Psy-
chotherapy, participating in International Congresses across Europe,
Israel, and South America.
I retired from the University of Cincinnati in 2002 and moved to
the San Francisco Bay area. In this new location I have continued
my active involvement in group psychotherapy through association
with the Northern California Group Psychotherapy Society and as
a volunteer member of the faculty at the University of California
San Francisco Department of Psychiatry and at California Pacific
Medical Center.

6005TS-STONECON-0907-01.indb Sec1:xv 8/11/09 1:07:48 PM

6005TS-STONECON-0907-01.indb Sec1:xvi 8/11/09 1:07:48 PM
 ACKNOWLEDGEMENTS

I have tried to be careful in acknowledging those individuals who

have contributed to my career and my understanding of the human
condition. I apologize to those I have inadvertently neglected.
Maurice Levine, former Departmental director, who created a
truly broad based, intellectually stimulating dynamic department of
psychiatry, played a critical element in nurturing myself and many
others in a respectful appreciation of the impact of unconscious con-
flict on how all of us feel and think.
I was able to enlist editorial assistance of Paul and Anna Ornstein
particularly when I had questions regarding theory. Of course, my
wife, Esther Stone read early drafts of my manuscripts, with a par-
ticularly keen eye to redundancy and excessive detail.
Other colleagues deserve particular mention. Robert Stewart, MD,
director of Central Clinic when I joined the staff in 1990, honored me
with the responsibility for the group psychotherapy training pro-
gram, which provided a breadth of experience that I might never
otherwise have had. Edward Klein, Ph.D. who had left Yale for a pro-
fessorship in the Psychology Department at Cincinnati was a close
friend. Ed taught me a great deal about the continuing evolution
of the Tavistock model of group relations, about adult development
xvii

6005TS-STONECON-0907-01.indb Sec2:xvii 8/11/09 1:07:49 PM

 xviii ACK NOWLEDGEMENTS

and gender issues. Shirley Carroll, M.S.W and Bernard Foster, MD,
who had offices adjacent to mine in the clinic were available for me
to blow off steam after a difficult group session or just listen as I
reviewed an interesting meeting. Lou Spitz, MD and Jack Lindy, MD
were always available to listen and help me listen to myself. Milt
Kramer, MD had a particularly effective manner of helping me see
where I was not putting my ideas together clearly. A very impor-
tant collaborator and close friend, Dianne McIntosh, RN, Ph.D.
was of special support as we worked to provide dynamic groups
to patients with chronic mental illness. Molly Cassady, RN and Rita
Johnson, RN were faithful staff clinicians who co-led groups with
the residents for many years, providing service as well as a wealth
of understanding of the treatment process with the chronically ill.
Walter Smitson, Ph.D., the director of Central Clinic supported my
work both administratively and financially.
There were very many other influential colleagues in AGPA, and
I know that I can name them all, but I want to make special mention
of Howard Kibel, who taught me a great deal about object relations
theory, and others working with self psychological concepts includ-
ing Irene Harwood, Marty Livingston, and Rosemary Segalla. At an
AGPA conference in the 1980’s I also met Sigmund Karterud and
Thor Kristian Island who became leading exponents of a self psy-
chological approach to groups in Norway and throughout Europe.
This led to subsequent collaboration with Dr. Karterud, particularly
related to the concept of the group-self. I would be remiss, if I did
not mention my group of British colleagues who I consider good
friends, who were available during my sabbatical in UK and have
remained so. These individuals include Earl Hopper, Malcolm Pines,
Dianne LeFevre, and Beau Stevenson.
Finally, and I am dedicating this book to my patients who so gen-
erously allowed me to glimpse into their personal worlds which
few are privileged to hear, and to my dear and special friend Robert
Kunkel, M.D., with whom I had lunch almost weekly for more than
thirty years. Bob a talented individual and group clinician and
administrator listened to my struggles trying to understand my
groups and my work. He was always available and encouraging, but
also helpfully critical when necessary. I do not believe that I could
have been as productive as I was without his valuable help.

6005TS-STONECON-0907-01.indb Sec2:xviii 8/11/09 1:07:49 PM

 INTRODUCTION

Section I: Theory
The section on theory spans the entire period of these writings. The
papers begin with the initial publication applying self psychologi-
cal ideas to the theory of group process and group therapy in 1977.
However greater consolidation of theory awaited several decades
until I had accumulated considerable clinical experience and had
written about the therapeutic process. These papers provided firmer
grounding before moving to writing experience distant theory.
The final four papers in this section, all published in the new mil-
lennium, address my most recent thinking regarding central aspects
of group theory, including Kohut’s original formulation of the group
self, and more in-depth considerations of group-as-a-whole, and
dreams and group development.
The initial paper “Contributions of the psychology of the self to
group process and group therapy,” (1977) written in collaboration
with Roy Whitman, was based on the theory available at the time
Kohut’s first book, The Analysis of the Self (1971). Narcissism was
still considered as a structure within the ego, with its own separate
developmental line. In the therapeutic process of rupture and repair,

xix

6005TS-STONECON-0907-01.indb Sec3:xix 8/11/09 1:07:50 PM

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