Group Psychotherapy for PatientsWith Psychosomatic Illness

ALBERT L. DEUTSCH, M.D. and ABBOTI LIPPMAN, M.D.

• The treabnent of a patient with a psycho-somatic illness presents a particularly com­

plicated problem. The urgent somatic staterequires prompt attention. The patient be­comes so preoccupied with his physical com­plaints, symptoms and incapacitation thatthere is little incentive, opportunity or in­clination to come to grips with the anxietyregularly present. If there is present a seriouscharacter disturbance, as often is the casein the more malignant somatic disorders, thedifficulties are further increased. It is asthough the individual is blotted out by theillness. The magnitude of the problem isfurther complicated by the contradictory in­conclusive and even mystical nature of theconcepts which have been invoked in treat­ment.

Our present intention is not to enter thefield of controversy regarding the broad areaof etiology, constitutional predilection, psy­chosomatic interplay, or nosology. An at­tempt to classify and perhaps thus to predictthe occurrence of some somatic state as linkedto some specific emotional state seems pre­mature. vVe have adopted a point of viewwhich while undoubtedly an over simplifica-"tion is pragmatically useful. We begin withan individual whose personality is evaluatedfrom a traditional psychiatric frame of ref­erence-namely, psychoneurotic or anxiety re­actions, character disturbances as seen in theusual obsessive states, and personality traitdisturbances of the mixed passive-aggressivetypes.

Do<:!or Deutsch is Assistant Clinical Professor(Psychiatry) Downstate Medical Center, State Uni­versity of New York; Associate Neuropsychiatrist,Jewish Hospital of Brooklyn.

Do<:!or Lippman is Assistant Clinical Professor(Psychiatry), Downstate Medical Center State Uni­versity of New York; Attending Neur~psy(..hiatrist,Jewish Hospital of Brooklyn.

14

Further, we attempt, within these groups,to assess ego-strength and defenses, ability torelate, contact with reality and degree ofanxiety. In this process the relationship be­tween the core problem present and thenature of the somatic state is approximated.Without this preliminary evaluation and anysubsequent modifications which may be made,no appraisal of personality and the potentialsand goals of the individual can he reached.This would be a significant omission.

Perhaps the basic factor, in the selection ofpatients for group therapy is the presence ofconstructivity and creativity, the desire to getwell, and the ability to withstand pain andsuffering. There is a need for the patients towant to look into themselves and therefore,they possess the desire to question the soma­tization process, their vitality and their de­sire to get well. Selection is, therefore, notdependent on the type of disease or theseverity of the disease, but on the desire ofthe patient to change.

That the illness may be an expression ofthe unresolved conflicts of the individual ap­pears to be generally valid. However, it doesnot follow that an elucidation or resolutionof these conflicts results in clearing up theillness or cure. It is noted that certain serious­ly ill patients with character difficulties arenot too frequently aided by "insight therapy."In addition, the attempt to develop insightin these individuals is fraught with consider­able danger and is to be carried out onlyunder the strictest precautions, since exacer­bations of the somatic state may readily oc­cur under the stress of such therapy. Further,it has been recognized that under psycho­analytic treabnent, an anxiety reaction issometimes disclosed as an ego defense againstsome more profound psychic state and the

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GROUP PSYCHOTHERAPY-DEUTSCH AND LIPPMAN

However, we do not believe that these lasttwo (Group-Doctor and Group-Patient) indi­cate that the group is a homogeneous entityreacting and acting as a unit separate fromone individual in the group. It is an attemptto operate on two levels-affecting the intra­psychic life of the individuals and investigat­ing the interpersonal relationships. It is aprocess using the dynamics of rapport andtransference, the technique of free associa­tion and dreams and the understanding ofabreaction and acting out. In this process,the nature of the healthy behavior and illnesswill be perceived.

In addition, the atmosphere in the grouptends to reduce, hy its more accepting tone,the degree of guilt associated with unrealisticvalue judgments arising from earlier experi­ences and to encourage a sense of greater egostrength and awareness of Self. In either case,the degree of sado-masochism or self-de­structiveness so universal a feature, is fre­quently diminished, permitting more realisticrelationships.

How the individual sees his self determineshis behavior. If it is as self-actualization, hetends to perpetuate his neurotic imagery-hisdistorted concept of himself. In the groupprocess, there is a re-evaluation of thisneurotic self-image and a movement towardsself-realization (healthy concept of self) '.

The matrix out of which such re-evaluationand growth may occur is supplied through thecreation and growth of a therapeutic atmos­phere based on rapport and empathy. Achange in ways of dealing with one's innerconflicts results. In this context, the precise

15

results which may ensue from the weaken­ing of such defenses must be anticipated.

And so, given these preliminaries and pre­cautions and proceeding from the conceptof the non-separateness of the psyche andsoma we have assumed that it is reasonableto deal with this person who is ill as well aswith the illness itself. The essential implica­tion of this, it seems, is that we must firstknow the person in his pathology and in hislwalth so that we may truly assess each andguide his attempts either to "feel better" orto "change". In the first, "to feel better"may he accepted through ego-strengtheningmeasures and the total utilization of all thecreativity and constructiveness of the healthyself with reduction of the force of the paralyz­ing super-ego. The second, "to change", isto develop insight through an analysis of thetransference relationship and so bring abouta modification of personality and an altera­tion in adaptive mechanisms as the individ­ual's affect-charged conflicts subside. Statedslightly differently, through reality-testing thepatient comes to develop less archaic behaviorand ways of relating to peers and authority.

With this preliminary statement hy wayof setting forth our orientation, we shall pro­ceed to some specifics.

First, we define psychotherapy in groups asthat process of psychiatric treatment whichis carried out with a numher of patients­8 to 10 most frequently-in which an attemptis made through reaction and interaction he­tween the memhers themselves and with thetherapist, to shed light on the nature of thetransference which, more or less, shapes thepatient's feelings and behavior, including hisacts as well as his ideation.

Group therapy, therefore, is that methodof help (or treatment) heing offered to in­dividuals who have come together in a ther­apeutic organization for the purpose of look­ing into and taking responsibility for theiracts, thoughts and emotions. Group therapymay be analytic, suggestive, directive and/orsupportive with a therapist and/or co­therapists depending upon the orientationof the leader. Group therapy, as defined inthis paper, is psychoanalytic in orientationwith four relationships occurring; Patient­Doctor, Patient-Patient, Group-Doctor andGroup-Patient.

January-February, 1964

SCHEMA-LINES OF INTERACTION

/DOCTOR~

Patient 0( • Patient

~~Interpersonal Life

+Intrapsychic Life of the Individual

+SELF+

(healthy core )

of the individual

{

Group andPatient

Interaction

PSYCHOSOMATICS

orientation, be it directive, supportive or an­alytic, becomes of less importance. In effect,a combination of all three, varying at differenttimes in degree as the resources of the patientpermit, emerges in the therapy setting. Stateddifferently, the leads are provided by the pa­tients and in the display of their acts, reac­tions and interactions; the group then is pro­vided with that material, which may beworked on or through. This will depend onthe severity, intensity, importance or affect­charged character of the experience. This ac­tivity tends to encourage the unfolding of thepatients in their varying and variable aspects.The individual Self thus emerges.

In the emerging personality, there will ap­pear, inevitably, elements not only of path­ology but also of health and strength. In theensuing experience of self-identification andself-realization, growth occurs.

Psychosomatic medicine, also called "psy­chotherapeutic medicine" by Lidz," is a holis­tic approach and represents the influence ofemotions and personality maladjustments inproducing physiologic dysfunction and dis­ease. Emotional factors affect the onset, thecourse and the termination of any disease.Thus the interrelationship between illness, be­havior, patient-doctor relationships, intrapsy­chic conflicts, and emotional responses to con­flicting therapeutic goals and treatment plan­ning, will all affect the course of one diseaseand its complications.

Flanders Dunbar" stressed the holisticcharacter and the interrelationships of psycheand soma in 1947.

Podolsky' further defined this as "medicaldisturbances in which situational and emo­tional factors play a significant role in eitherthe precipitation or the exacerbation of symp­toms."

Weiss and English" defined "psychosomatic"as a method of approach to general medicalproblems, that is, one simultaneous applicationof physiological and psychological techniquesto the study of the patient in an effort to makea definitive diagnosis and in preparation forcomprehensive medical care. Its aim is to dis­cover the precise nature of the relationship ofthe emotions and the body structure. We donot believe that there is a special kind of ill­ness called "psychosomatic"-it is merely thatemphasis is being placed on relationships.

16

With respect to the concept of psychoso­matic disorder itself, the following is offeredless as an attempt to formalize that which isessentially fluid but simply to provide a frameof reference. The psyche functions throughthe physiological and is not something apartfrom the body. GrinkerG has offered a schemabased on the broad and fundamental investi­gations of Alexander:

1. All healthy and sick human functions arepsychosomatic.

2. Emotions are always associated withconcomitant patterns expressed through theautonomic nervous system.

3. For specific emotions there are appro­priate concomitant vegetative patterns.

4. Emotions repressed from overt expres­sion lead to chronic tensions, thus intensify­ing in degree and prolonging in time the con­comitant vegetative innervation.

5. The resulting excessive organ innerva­tion leads to disturbance of function whichmay eventually end in morphological changes.

Perhaps of more specific interest is a con­tribution by Ruesch7 who derives his conceptof human nature from the theory of com­munication which considers that events link­ing parts, whole individuals, groups and so­ciety are explicable by one conceptual modelas follows:

1. There is unsatisfactory self-expression ininterpersonal relations in one or more areas ofpersonality.

2. Perceptive processes related to socialevents are distorted by preponderence of pro­prioceptive systems.

3. Perceptive messages are interpreted ascoercive.

4. Value judgments are based on inner ac­tions.

5. There is lack of integration and goal.6. There is poor observation of action in

others with little self-corrective process.7. There is more dependence on others

than exchange of information and cooperativeinteraction.

8. The weight of information comes fromchemical and mechanical sense organs andlittle from mature visual and auditory senses.

9. Bodily signs are more important thansymbolism.

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GROUP PSYCHOTHERAPY-DEUTSCH AND LIPPMAN

10. The delineation of psychological-physi­ological boundaries is incomplete.

11. There is a magical identity of self withothers and there are no corrective measures.

In Slim, this describes the victim of psycho­somatic disturbances as suffering from afailure in communication based upon early de­fects in interactions with his first human en­vironment. In its broadest terms, the func­tioning of every part of the organism is mold­ed hy the culture within which the individualhas developed. In another sense, the utiliza­tion of several cross sections of transactionalactivity among somatic, psychic and environ­mental systems at various times could give usa better idea of the longitudinal processes.

In the past years, the theoretical considera­tions hy various writers in their attempts todescrihe, define, and elucidate the characterof psychosomatic illness have not, unfortunate­ly, when used for the patient, been productiveof results which could be confirmed by con­trolled studies. The earlier notions regardingcorrelation hetween body type and illness arerarcly mentioned. Attempts to link specificdisease with psychiatric formulations in termsof dynamic or descriptive states have heenequally harren in laying the groundwork fora thcrapeutic approach. The stress upon psy­choanalytic orientation with its oedipal pre­occupation has tended to ignore the many sig­nificant factors arising from pregenital phases.To understand these, verbal screens must hepenetrated and pre-verhal affective behaviorunderstood.

Stated somewhat differently, the affectiverelationships which are developed in infancyand early childhood will determine the futureemotional state of oneself and the characterof one's emotional relationship with others.Therefore this becomes a serious retardingforce in terms of the development of the indi­vidual and his ohject relationships and effec­tively prevents self-realization as the indi­vidual acts out his self-actualization. Thegroup process with its opportunity for the ex­pression and demonstration of these conflict­ing and conflictual processes permits a re­evaluation of the primitive disabling concepts;it provides a release of the stored-up tension­anxiety state and a subsidence of its physi­ological concomitants. It is understood that

January-Febmary, 1964

prior to instituting any form of therapy a seri­ous attempt to diagnose and evaluate the or­ganic state present must be made. Duringpsychotherapy, if some organic condition hasbeen found, it is highly desirable to review itsprogress at regular intervals with close co­operation at all times between the severalmedical disciplines concerned. The total per­son remains our primary consideration.

Having attempted to put the problem oftherapy of psychosomatic illness in this frameof reference, we may now proceed to a moreprecise consideration of the process itself. Inthe course of the regression of the patient car­ried out in the midst of the transference rela­tionship, insight may be developed. Since thisis carried out in an atmosphere, one of theessential elements of which is anxiety, onemay predict a correspondingly temporary in­crease in the severity of the symptoms. Theillness is considered to be an extension, pro­jection or construct of one's self-image." Themaintenance of this construct therefore is seenas a defense serving to shield the patient fromthe oppressive burden of self-awareness. Insomewhat more meaningful fashion-"It issometimes better to lose the sight than to en­danger the soul. ... It is sometimes better toBee from life by means of a serious illness, yesperhaps hy death itself, than to live groaningunder the burden of repressed guilt."9

As a further extension of this process, fan­tasy hecomes a most useful method for creat­ing and maintaining an acceptahle ima~e ofone's self. Anxiety may thus be reduced, butsince the factors creating it in the first placeare still active, the relief can be hut temporaryat best. The external reality and the actualinterpersonal relationships are relatively minorfactors in the creation of anxiety. The moresignificant source remains in the nature of theself concept, and its internalization, which he­comes the method for maintaining the selfconcept or image. In the group there is re­vealed in the action and interaction, the sev­eral aspects of this self concept and the relatedinternalization. Thus, with ever-changing pat­terns of the group members' behavior, the op­portunity is presented to define the characterof the act and interaction. It can thus beassessed in terms of the reality situationpresent, rather than to remain bound in thetransference situation which has been mis-

17

PSYCHOSOMATICS

taken for reality with the consequent preser­vation of the anachronistic behavior andfeeling state.

The group members have less tolerance forillness and more vigorously demand and fre­quently receive more prompt healthy re­sponses. The reverse also occurs in that de­fenses and resistances may be re-inforced asthe individual sees himself being threatened.Thus we see that the members of the groupmay relinquish for a time their own egocen­tricity in order to support the sickest memberwhen such assistance is required.'"

This leads to a diminution in the projectiveand acting out procedures, for in the courseof such reassessment the patient begins torealize and appreciate how situations havebeen set up in which the several activ­ities of exploitation, aggression and justifica­tion may he carried out either against anothergroup member or against oneself, or as is mostfrequent in a combination of both. In a de­rived sense an increase in insight associatedas it initially may be with an increase in ten­sion, not infrequently leads to further selfpunishment which in this context implies anexacerhation of the symptoms of the physi­ologic state present. It may here he pointedout that the advantage of the relief gainedthrough the internal or external projection de­scrihed above in terms of the hody image liesprimarily in the fact that the patient has ef­fectively sealed off the interconnection he­tween that which he painfully suffers and thepleasure achieved from the symholic act. 1J

To clarify further, headache has become aninternalized self image, the major feature ofwhich is guilt and self punishment. ( selfha tred ). This occurs in response to the unac­ceptable hate of the significant parent whomthe patient is attempting to destroy throughincorporation (overeating). Or perhaps theeating represents the security of an originalinfantile state which the patient has not beenencouraged to give up. The conflict betweenthe real self and the image results in a void,an emptiness, which the patient attempts tofill in a variety of unrealistic ways, such asovereating.l~ Put, perhaps, more concretely:the pain and anguish of the otherwise attrac­tive young woman who finds herself gainingweight immoderately and yet who seems un­able to stop eating excessively, states that not

18

to eat gives her an unbearable headache, andthat the weight gain while deplorable is lessdistressing, becomes more understandable.

The basis of the psychotherapy itself is es­sentially two fold. It rests upon the develop­ment of greater ego strength and insight. Toachieve these, not as ends in themselves, butrather to aid the patient in the creation of newand more gratifying solutions to conflicts andinterrelationships, the group process must beclearly understood.

The group meets not only as participantsfor the conduct and justification of its trans­ference attitudes and distorted object rela­tionships hut also as observers of the be­havior and attitudes of others. They act, re­act and interact, all in a varying balance offantasy and reality. It is to be emphasizedthat all which occurs in the group is not path­ological. As the peers and the authoritiesemerge and vary and as the behavior andfeelings are revealed, each has an opportunityto check the archaic against the realistic.Since these values are never fixed but are con­stantly undergoing change, the immutabilityof one's attitudes is challenged. The realityof the situation in terms of this immediate on­going relationship is measured against the in­dividual's behavior (act, feeling, thought).The degree of balance between the two maythen he determined. In this sense the healthymay he reinforced, the unhealthy revealed.The patient is now confronted not by the im­passivity of the therapist but hy the thoughts,acts and feelings of others and his own, andis able to evaluate his own healthv andneurotic motivations. In the process, se'lf con­frontation is encouraged, since he is bothchallenged and supported, in the give andtake of the group's activity, to face his resis­tance and self deception, experience his anx­iety, and return to the awareness of his Selfand his healthy motivation. Guided by theillusion that contact with others is a threat inwhich demands must be met, hostility pro­duced, and "shoulds" fulfilled, the individualavoids this contact with consequent fantasyconstruction (self actualization). Through theagency of the group process, he now experi­ences all facets, degrees and qualities of in­teraction and comes to see the illusory char­acter of his behavior as he engages in themore gratifying experience of self realization

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GROUP PSYCHOTHERAPY-DEUTSCH AND LIPPMAN

and interpersonal fulfillment. The anxietywith its motivation is replaced by pleasurewith its motivation. The value of the second­ary gains, avoidance of conflicts and anxietyand creation of fantasy states is replaced bythe values of self realization and healthierinterpersonal relationships. More specifically,the secondary gains achieved through illnessno longer retain their over riding value andthe patient achieves more realistic motivation.His inner life and his interpersonal relation­ships stand before him in the group inter­action.

At this point the specifics of the group psy­chotherapeutic approach will be defined.Eight patients constitute a workable group.The organic diagnosis appears to have littlesignificance. However, what one must con­sider is the over-all character, personality andcultural structure. 1\'0 group should be over-

. hurdened hy too many aggressive patients;'nor an excessive numher of detached patients.'Compliant patients' may he a hlock to thegroup's progress, if in excess.

In general, utilizing the already describedfeatures for selection we believe that hetero­geneity of group make-up in its broadestsense constitutes a valuable guiding principle.Such factors as sex, age, educational and cul­tural hackgrounds, religious and racial ele­ments, type of somatic disease, and others arcto he considered. In other words, a groupmight hest he considered, in microcosm, as across section of one's experiences. Perhaps onemay say that the only element of homo­geneity hy which one is guided is that eachmemher is a part of the human race with allits strengths and weaknesses.

In the course of conducting group therapywith patients with psychophysiologic illness,certain factors common to group therapy it­self may be emphasized.

With regard to "acting out" this may bestated: This appears as does all acting Ollt,primarily resistive in character and to be dealtwith promptly. The more precise form seen inour experience is either in the development ofincreased severity of symptomatology or thecreation of different symptomatology. Other­wise one must always be on the alert to dealpromptly with such expressions in view of,not only their anti-therapeutic value, but alsothe serious complication of a worsened condi-

January-February, 1964

tion. It is of some importance to distinguishfurther between acting out and abreaction.This may provide considerable difficulty attimes. However, if one can identify the trans­ference factor present, it is probably actingout. If one can recognize the feeling experi­ence without the transference factor, this maybe abreaction.

Communication within the group may takethe non-verbal form. Physiologic response,blushing, pallor, squeamishness, movements,may be detected and evaluated. These mayhave their origin in intra-psychic or inter­personal experiences. It is of value to con­sider these reactions promptly since much ofassociative significance may be thus elicited.

The use of dreams undergoes a modificationin the group. This generally follows the lineof incomplete association. However, the de­velopment of multiple associations may result.In any event such use is determined by thetherapist's individual orientation and the pa­tient's facility. This varies naturally not onlyfrom therapist to therapist, hut from groupto group and from time to time.

In regard to the problem of "workingthrough": In the midst of the great varietyof experience presented in the group, thenecessity inevitably arises for the process ofworking through if healthy alternatives are tohe achieved. Having provided for the firstsetting and the climate in which movement isencouraged in the process of interaction andreaction, this movement must now be exam­ined or worked through. The patient beginsto appreciate the repetitive character of hishehavior, its compulsive and remorseless qual­ity and its unreality in the present. His asso­ciations, when brought out, act further to re­veal to him the archaic character of this be­havior, and its basic transferential quality.This permits a meaningful or insightful ex­perience rather than the perpetuation of anacting out process of which the individual isat first unaware. Further, the realignment ofintra-psychic forces makes for more realisticobje(:' relations and self realization. The psy­chosomatic symptom is no longer an essentialpart of the new equilibrium. The hithertoweak and fragmented egos have beenstrengthened through this support and ex­perience; new ego boundaries have beenestablished and hence object relationships as-

19

PSYCHOSOMATICS

sume reality proportions.1:l In a concurrent

process, there is a greater movement to healthby thus reducing the faulty self image and re­placing it with a constructive, creative self.More specifically, the individual's neuroticpatterns and solutions, manifested in psycho­somatic symptoms, will be less required. Inthe changing patterns of group interactionand individual patient's psychic movement,no one formula may be utilized. The thera­peutic technique will be varied as the circum­stances of each seem to require. Therefore,the timing of such techniques must take theircue from the ongoing actions and interactions.

In this connection, the role of the leader isof the utmost significance. He must be con­stantly aware of and sensitive to the manyactivities and nuances of the individuals' be­havior and state (both verbal and non­verbal). His emphasis and orientation mustalways he derivative of his concern with thelatent rather than the manifest. In this con­nection, guided by the above consideration,the therapist will intervene or remain quietas his evaluation indicates. Such interventiontakes a variety of forms, and includes the di­rection of attention to dreams, free associa­tion, encouragement of interaction, interpre­tation or shifts in emphasis when the indi­vidual tends to remain fixed in his action, andreality testing. This activity on the part of thetherapist is obviously as varied as the activityof the group. In fact, this very shift in tech­nique, emphasis and activity makes for one ofthe most productive and constructive aspectsof group therapy. In the very heterogeneityof experience and the opportunity for its ex­amination lies the great values of the process.The attempt to construct a unity out of theheterogeneity would he both anti-therapeuticand also destructive of this value. \Ve do nothelieve, in our frame of reference, that the"group" has a life or "self" of its own, butrather that it exists as a number of individualswith all their health and sickness, functioningfrom different motives for the basic achieve­ment of self realization.

The alternate sessions, and combined indi­vidual and group therapy remain techniquesused as the therapist's philosophy and per­sonal orientation indicate. We do helieve,however, that when they are used, theirtiming will depend upon the resource and re-

20

quirements of the individual patient. It is ourbelief that no blanket formula is at presentvalidated by the available evidence. We dobelieve that should alternate sessions be util­ized, they await a degree of integration of thegroup members in order to reduce the degreeand quality of acting out. Our groups havebeen characteristically open ended. In thisarrangement the maximum opportunity is fur­ther provided for optimum interaction with asbroad a spectrum of personality, as is pos­sible, in as many different and differing phasesof human activity. This inevitably includesthe widest range of medical conditions. In amanner of recapitulation, heterogeneity in itsbroadest sense, including personality, position,education, social aspect, organic or symptom­atological condition is the arrangement ofchoice. Fundamentally, in our orientation, weuse psychoanalytic principles.

REFERENCES

1. Horney, Karen: Neurosis and Human Groteth.New York: Norton & Co., 1950.

2. Lidz, Theodore: General concepts of psycho­somatic medicine. In American Handbook ofPsychiatry by Arieta, Vol. 1, Chap. 32, Page647. New York: Basic Books, 1951.

3. Dunbar, Flanders: Mind and Body: Psychoso­matic Medicine. New York: Random House,1947.

4. Podolsky, Edward: The psychosomatics of lowback pain. Psychosom., 1:141 (May-June) 1960.

5. Weiss, Edward and English, C. S.: Psychoso­matic Medicine. 3rd Edition. Philadelphia: W.B. Saunders Co., 1957.

6. Grinker, Roy R.: Psychosomatic Research. NewYork: Grove Press, 1961.

7. Ruesch, J.: The infantile personality-The corcproblems of psychosomatic medicine. Psychosom.Meel., 10:134, 1948.

8. Rubins, J. L.: Psychodynamics and psychoso­matic symptoms. Amer. ]. Psychoanalysis,19: 165 (Nov.) 1959.

9. G~~ddeck, Georg: The Unknoten Self. London:VISion Press, Ltd., 1951.

10. Dcutsch, Albcrt L.: Human relationship (Men­schlichkeit) in ~roup therapy. PsycllOsom.,2:267 (July-Aug.) 1961.

11. Wolf, Alexander and Schwartz, E. K.: Psycho­analysis in Groups. New York: Grune & Strat­ton, 1961.

12. Horney, Karen: Neurosis and Human Groteth.Nt>w York: Norton & Co., 1950.

13. Federn, Paul: Ego Psychology and The Psy­c1lOsis. New York: Basic Books, 1952.

14. Alexander, Franz: Scope of Psychoanalysis,1921-1961. New York: Basic Books, 1961.

15. Balint, M.: Training for psychosomatic medicine.In Adwnces in Psyc1lOsomatic Medicine. Editedby Arthur Jores and Hellmuth Freyberger. NewYork: Robert Brunner, 1961.

16. Holt, Herbert and Winnick, Chas.: Group psy­chotherapy with obese women. Gen. Psychiat.,5: 156 (Aug.) 1961.

Volume V