Process Groups

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The Process Group is a process-led facilitated group experience. Members will have the opportunity to explore at first hand relationships in the group as they grow and develop. Personal development or process group work is seen as core to effective counsellor and helper training. On writing the process group account: You can't describe everything that happened in the group so you might want to focus on one or two central themes. The aim is to develop a narrative style of writing, to tell a story of the process group. This idea of narrative is tethered to the challenge of getting to grips with the clients story; in other words if you can demonstrate that you are able to hold a story in mind (of the process group) and then recall it, you will show your capacity for working with case accounts and narratives of therapeutic endeavour . There are 2 aims; on the one hand you are tasked to account for your part in the group; your subjective engagement, your own emotional response, your own dynamic engagement, and on the other hand you need to demonstrate that you have been able to sit on your own shoulder and reflect on what you've observed in the process of the group; ie your subject-objective response to others. In some ways it is an exercise in object-subjectivity we might say.

Introduction to Groups:

A History of Group Therapy

The following extract is from: Winship, G (2009) Gruppeterapeutiske tilange i sygeplejen (Group Therapy). Chapter in: Psykiatrisk Sygepleje. Edited by Buus, N. Dansk Sygeplejerard, Nyt Nordisk Forlag Arnold Busck A/S.

BACKGROUND

Practitioner group skills coalesced in the foundations of group analysis where the work of Micheal Foulkes (1948) and Wilfred Bion (1961) among others offered a bedrock for advances in group theory and research. Foulkes was a psychiatrist and psychoanalyst who began to develop his idea about group approaches at the University Frankfurt in Germany. The psychoanalytic institute where Foulkes worked from the late 1920s shared the same site as the School of Social Research headed by Max Horkheimer and the sociology department led by Karl Mannheim. Other young academics and practitioners like Herbert Marcuse, Eric Fromm, Theodor Adorno, and Norbert Elias, also converged around this time at Frankfurt University forming what became known collectively as the Frankfurt School of Social Research. The main strands of theory that linked the group were Freud, sociology, politics and Marx. Foulkes in particular was influenced by Mannheim and his young sociologist protégé Elias (Winship, 2008). It is notable that all three men fled to England in 1933 in order to escape the rise of Nazism. Fromm, Marcuse, Horkheimer and Adorno likewise fled, though in their case to America where they became most influential.

Although Foulkes was a psychoanalyst he was keen to unfold the individual focus of the psychoanalytic dyad in order to embrace the social and group dimensions The term 'Group Analysis' (as it became known) was actually coined by coined by Mannheim, and was envisioned to be a sort of clinical sociology. It was not so much that the theory of psychoanalysis was felt to be limited, rather Foulkes felt that dynamics such as transference could be potently be multiplied, and therefore amplified in a group setting. Working with about eight patients in a group, Foulkes and his early collaborators found their group approach encouraged a new degree of therapeutic openness and sharing among patients. Foulkes described the network of relations in the group as a 'matrix', deriving the term from the Greek word for womb. The matrix became the focus of studying and reflecting on relationships in the group, both present and past. The group became an equalising space, with Foulkes adopting the role of conductor or facilitator which sought to modify the authority of the psychoanalyst. This inclination towards horizontality and equality in the group seems to have been influenced by the essence of the Frankfurt School approach and its Marxist inspired agenda. Foulkes maintained an optimistic view of the group as constituting a healthy wholeness. In other words, group members were seen as having the capacity to help each other along on the path to well-being, where the sum of the groups healthiness was greater than the individual parts.

Bion's (1961) approach to groups, by contrast, was far less optimistic. Bion did not begin with the assumption of the group's healthiness, rather his starting premise was that a group tended towards what he called; basic assumption (ba) functioning. Based on his observations of groups in the army, where he had experimented with leaderless groups in the appointment of army officers, Bion noted that there were three basic assumptions which were characterised by a regressive or immature level of functioning. The first of these was ba leader dependence. Bion noted that a group had a tendency to look to a leader to solve problems, provide answers. The leader was imagined to be powerful with answers and the task of the facilitator was to help the group members realize their own potential and find mutual solutions to their problems. The second basic assumption was ba pairing. Bion noted that often the group would allow two members to dominate the proceedings, thus a pair was left to do the difficult work of the group. In ba pairing group the pairing might be derived from feelings of either love or hostility. Again, the facilitator needed to try and raise awareness of the pairing process and what this meant for the whole group in terms of a defence manoeuvre. Finally, Bion noted how often the group would take to directing its aggressive feelings towards events, people or objects outside of the group. This process of vilifying an external agent served to create a false feeling that inside the group everything was ideal. This process of projecting outwards from the group Bion called basic assumption fight/flight.

In comparing and contrasting Foulkes and Bion, it is worth noting that they both worked on the war time group experiments at Northfield Hospital in Birmingham (1942), treating shell shocked soldiers where ideas about therapeutic community (TC) practice were germinating (Harrison, 2002). Both therefore contributed to the development of group based theory and practice that emerged in the 1940s, influencing the climate of psychiatry. Where Bion and Foulkes converge is in their concern to facilitate patient's in taking charge of their own destiny. Both were interested in the emotional oscillations between reliance, autonomy and mature dependence and how these dynamics were manifest in the group. Bion and Foulkes therefore posited group therapy as an opportunity to grapple with micro-politics of democracy (peer relations) and hierarchy (leadership) as they were refracted through the interpersonal affiliations in the group. But Bion and Foulkes also depart on some fundamental issues. Whereas Foulkes' approach seems more friendly Bion's approach, was more inclined towards criticality, observing the negative states of the group from outset questioning and scrutinising social conventions. There is a notable anecdote from Bion's (1960) where, upon noting that a new group wanted to introduce themselves to each other by name, Bion interceded to ask why they thought that their depression would be helped by knowing each other's name. In the anecdote Bion tells us that the group was plunged into a stony silence by his intervention and that he felt that he had somehow made a 'terrible gaff'. What we deduce, I think, is that Bion was genuinely interested in the question of naming self and other and how the group process would be effected by the event of naming. We see also that he felt bad about asking the question, though he was genuinely curious. We see also that the group felt him to be either rude or disapproving. I think it was the negative response of the patients that provided the most potential for learning. This was characteristic tone of Bion, and much has been made of his approach akin to throwing beams of darkness onto things (Pines, 1985).

Nonetheless, in spite of difference between Foulkes and Bion, a body of linked psychoanalytic theory emerged as a firm base for the development of group approaches in the UK. Because both were psychiatrists, Foulkes working at the Maudsley and Bion at the Tavistock, it is likely that group therapy was more readily embraced by NHS psychiatry. Group theory, in concert with other social constructionist models of mental illness, were ascendant from the 1960s challenging the orthodoxy of biological psychiatry. Indeed, group therapy occupied a prominent position in psychiatry during the 1960s and early 1970s where a considerable body of literature about groups emerged in a number of specialised journals. Yalom's (1970) articulation of the methods of group psychotherapy that become best known and perhaps best received. Yalom condensed theory and developed a manual of practice that was accessible and persuasive. In particular Yalom developed an outline of the curative factors that could be potentiated in group therapy: i) Instillation of hope -the importance of instilling a belief that the process of the group could improve well-being. ii) Universality - the sharing of difficulties in the group that could help members see that their problems were not isolated and therefore one they were not alone in having difficulties. iii) Imparting of information - where the facilitator (or patient members) might be able to give didactic instruction about mental health, mental illness, or whatever else might be the focal problem of the group. iv) Altruism - the group provided an opportunity for members to help other members of the group. v) Corrective recapitulation of primary family group - the group offered a transference experience of primary family experiences that could be understood and worked through as a basis of a new synthesis of family. vi) Development of socializing techniques - social learning and the development of interpersonal skills. vii) Imitative behaviour - Taking inspiration from other members and copying their modes of healthy being to function more adequately. viii) Catharsis - the process of expressing feelings and affect in a way that permits a working through of difficult emotional states. ix) Existential factors - recognition of the rudimentary reality of life and death, ultimate aloneness, ultimate death, ultimate responsibility for our own actions. x) Direct Advice - receiving and giving suggestions for strategies for handling problems. xi) Interpersonal learning - receiving feedback from others and experimenting with new ways of relating.

Other notable texts that contributed to the development of a discourse of group psychotherapy include; Whitely & Gordon's (1979) Group Approaches in Psychiatry, Dorothy Stock-Whitaker's (1985) Using Groups to Help People and RD Hinshelwood's (1987) What Happens in Groups a cluster of theoretical benchmarks emerged for the practice of group psychotherapy. Harry Wright's (1989) Group Work: Perspective's and Practice gathered together much of this foregoing work and distilled an impressive manual of group theory and practice for mental health nurses. However, during the 1980s there was a steady drift in psychiatry away from social constructivism towards the insular tendency of bio-cognitive-behavioural models of suffering. Many psychiatric nurses aspired to become community based practitioners working more individually with patients. The decade of the brain promised much, as did some tentative advances in genetic medicine, however, by the later 1990s there seemed to be a change of course again where a social determined agenda for psychiatry was rejuvenated. Greater emphasis returned to notions of neighbourhood, peer relations and models of recovery through social inclusion (Social Exclusion Unit, 2004). It was against the backdrop of this drift that the case for group approaches seemed to again be returned to a point of valued utility in the array of therapeutic acumen for mental health nurses. The evolution of community care and the decantation of patients into the community, not only caused a dispersal of the social density that was once a backbone of psychiatry, but also diminished the group relating skills of staff. That is to say, where patients and practitioners were gathered together in the large asylum, out of necessity, nurses learned lessons in group practice. Whereas, in the community, away from the hospital, no longer under the same pressure to work with groups of patients, group skills preparation for nurses had gone out of the frame.

Yet, community care in the UK has been characterised by fragmentation, poor communications between staff and a lack of peer support among patients (Cox, 1998). Perhaps it is timely again to ask if the delivery of community psychiatry, and in particular primary care, might benefit from a re-invigorated valuation of therapeutic group approaches? Without a robust frame for understanding about the process and art of facilitating healthy group relations, community and neighbourhood psychiatry may continue to flounder and fracture in the way that has become characteristic of care in the community.

WHAT DO WE MEAN BY GROUP THERAPY?

Although there have serious concerns with the progress of community based psychiatry and the absence of therapeutic intent under the dictate of patient management, I begin here with the on-going problem of acute in-patient psychiatric care. It is now well understood that there has been an absence of therapeutic engagement of patients on psychiatric in-patient wards with milieus characterised by boredom and inactivity among patients, leading to frustration, violence and chronic low morale among nurses (Rask & Lavender, 2002; Bennett Inquiry, 2003; SCMH2004). At present acute psychiatric in-patient units are particularly difficult environments that stretch the resources of even the most capable nurses. The UK Audit of Violence (RCP, 2005) drew attention to the wide array of problems encountered by staff including the unsafe atmosphere of acute wards compounded by inadequate staffing with high vacancies and inexperienced leadership. The report characterised treatments as coercive and chronic staff demoralisation with 78% of nurses, 41% of clinical staff and 36% of service users reporting that they had been personally attacked, threatened or made to feel unsafe. The significance of user involvement as an indicator of a progressive therapeutic milieu remains largely an aspiration, though there is some emerging evidence that democratic administration and collective rule-setting in the milieu might have a positive impact on reducing levels of aggression, violence, seclusion and staff sickness and increasing staff morale (Mistral et al, 2002). That is to say, running a range of ward based group activities, with a combination of business and therapeutic focus, leads to an improved ward atmosphere. It has been one of the problematic legacies of the shift towards individualised therapies in mental health, that we have lost sight of the health transformative potential of group relations.

So what do we mean by 'group based interventions' and how might these be applied to in-patient units? The following diagram highlights the range of group settings:

LARGE/COMMUNITY GROUPS 20+ participants

MEDIAN GROUPS 12-20 participants

EXTENDED SMALL GROUPS 7-12 Participants

NUCLEAR SMALL GROUPS 3-7 Participants

Large group interventions of upwards of 20 participants (staff and patients included) are sometimes referred to as 'community groups'. Whiteley (1975) describes a time n when large groups of upwards of 50 patients were reasonably common place in large psychiatric hospitals, where the therapeutic inclination of such events might be more thought of as 'sociotherapy' rather than the more honed experience of psychoanalytic psychotherapy. Although these large group experiences have largely been eroded with the downsizing of institutions they nonetheless remain a potential source for therapeutic management, ward administration and patient involvement. Large groups can feel unwieldy and sometimes alienating without structure, so have more lately (where they have been deployed) tended towards operating along the lines of a business meeting with an agenda. Large groups tend to be held less frequently than smaller groups, perhaps on a once a week or once a month basis. Some institutions, might hold an annual large group where ex-patients and ex-patient staff return for an event such as a Christmas or Summer party. For instance, on the drug unit at the Bethlem Royal Hospital we used to have an annual Christmas party where ex-patients (known to be drug free), would come back to the unit. Ex-staff were also invited and with current staff and patients, between 70 and 100 people would be at the event. Although the party mostly involved food, dancing and socialising, we also had a half hour space each year where there was an opportunity for people to share (a technique derived from the self-help group traditions of Narcotics Anonymous and Alcoholics Anonymous.

Patients and staff alike necessarily find it is difficult to find the courage to speak in such a large group forum. Even so, a large group experience seems to have a positive impact on the sense of belonging in bringing all members of the community together (Kreeger, 1975). And even if the large group is a difficult experience, and it is likely to be particularly so for patients who have difficulty managing crowds or other intensive meta-social situations, reminiscent of a classroom or local community setting, it might well be the case that participants (including staff) find the confidence later to speak more freely in the small group situations. In other words by learning to manage the experience of being in the large group forum, patients and staff achieve a sense of capacity through mastering or surviving the anxiety provoking situation. In behavioural terms the experience may be close to that of feeling flooded by an experience. However, because of the increased numbers of participants, participants also find it easy to hide by remaining silent in the large group. In this sense the large group setting permits a gradual exposure to the anxiety of finding a voice in the large group. The gradualism may be cultivated if the facilitator avoids building an expectation that participants should speak. Participation may still be possible where there are business items to be discussed and opinions can be articulated by a show of hands. In terms of patient or user-involvement, I have conducted some research examining democracy in practice where I have found that large groups can represent the most potent event of user involvement when the potential of the large group can be harnessed to deploy referenda democracy in ward administration (Winship, 2004).

There is necessarily limited intimacy in the large group forum and therefore some patients will find themselves more able to participate in smaller groups. There may be a range of median sized group activities like watching a film, doing a creative therapy activity in groups of less than 20 participants. More formal therapy groups are generally recommended to have a lower membership of between 8-12. The rationale behind this number being seen as optimal for small group is, however, not that clear from the literature. My own research into the ideal conditions for therapy has led me compare and contrast the dynamics of the jury (of 12 members) as a template for creating a milieu where therapy and social justice can be best enacted (Winship, 1997; 2001). It seems to me that a group dynamic of between 7-12 members provides both an experience of intimacy and anonymity in equal measure. That is to say, for inhibited and anxious patients, the group is both a place whereby it is possible to listen, hide and wait, while the group also offers a forum whereby issues can be talked about and heard by others. I have often thought of the dynamic created by a small group of 7-12 participants as mirroring something of an extended family system for patients, hence the term extended small group which I contrast with the dynamics of a small group with 3-7 participants which I refer to as a nuclear small group. That is to say in a group of 7-12 participants the group might recapitulate an extended family experience (I'm borrowing Yalom's terminology here). The transference in this case would be an experience of parents and siblings perhaps, as well other family members more removed like like aunts, uncles, cousins, grandparents. In the smaller group of 3-6 participants the transference re-capitulation may more closely resemble the greater intimacy of a nuclear family, with parents and siblings.

In both the extended and nuclear small groups, different constitutions of family come in out of focus in a variety of ways. As Yalom argues, the group offers a potential system to explore these dynamics. An in-patient unit (or a day hospital unit) may divide its total community up into one, two or three small therapy groups in order to create small therapeutic group spaces. However, even though 8-12 members is usually seen as the orthodox size for small group therapy, in my opinion there is no reason to think that groups of less than this number are sub-optimal. Indeed, I have often found working with a small group of patients, for instance between 3-7, enables valuable in fostering helpful inter-relations. A group of 3 patients may exert more exacting parental transferences and sibling rivalries than that which is aroused in the groups of 7 upwards. In small groups of six upwards, transferences are less immediately discernible and often seemed to be more inclined to incorporate wider family transferences; uncles, aunts, grandparents and so forth. I have surmised that in smaller groups of between 3-5 members, it is more likely that nuclear family dynamics come to the fore in a way that was not apparent in the larger smaller groups (n=6-12) where, as I have suggested, more extended family dynamics emerge. I suggest delineating between nuclear small groups (n=3-5) and extended small groups (n=6-12) and apply this definition to the range of group activities that might be implemented in a ward community. A nuclear group of 3 patients might be entirely suitable in offering an intimacy that is an interim space between individual therapy (dyadic) and the traditional experience of group therapy, for instance working intensively with a small group of psychotic patients as one of my mentors explained (Rey, 1994, personal communication). At the Arbours Crisis Centre in North London 'team-patient meetings' as they are called, may involve 2 or 3 staff to one patient, thereby creating a nuclear size group dynamic. Equally so, a nuclear size group may be ideal for an informal group activity such as cooking or other recreational pursuit such as a board game or game of cards. My experience is that there is much to be gained from re-considering the standard size of 8 as pre-requisite of small group therapy.

AUTHORITY & SAFETY - HOW DO GROUPS WORK?

Through all of these range of group sizes, the absence of overt disturbance and violence within group therapy encounters has always struck me as notable. The safety rent from group therapy situations is often under emphasised. Colleagues (myself, Beatrice Stevens, Sally Hardy & Kay Longworth) carried out a retrospective analysis of approximately 40,000 hours of formal group therapy on acute and intensive care in-patient wards (from 1970-2000) and noted only one violent incident during this time span during (Winship & Hardy, 2007). This statistic: 1 violent incident per 40,000 (1:40,000) hours of therapy is based on naturalistic career memoir and purposive sampling and of course there a number of methodological questions that might be mounted regarding the generalisability of the findings. However, the low level of violence in group therapy sessions does at least allow us to advance a hypothesis that groups may be an effective way of safely managing disturbed patients.

The notion that groups are safe havens for psychiatric patients' contravenes the long held belief (particularly during the 1970s and 1980s) that acutely disturbed patients should be spared the high expressed emotion of a group crucible. Clinical experience however, tells us that the most likely time for violence on an acute ward is during medication or meal time. Formal group time, if it can be embedded into the schedule of a treatment milieu (whether this is in an in-patient unit, day hospital context or a specialist Therapeutic Community (TC) appear to create the safest possible space for patients and staff in the turmoil of the day. The need for safe cohesion in the treatment milieu has been continually re-cycled by the necessity of group intervention appealing to the inherent urges for social density and collective experience.

So how does the group work? The rubric for the approach the approach derives from the idea of talking therapy where the aim is replace actions with words. Although this idea is the basis of dyadic psychotherapy, a group has a number of value added efficiencies: firstly it is possible to maximise the use of time by treating several or more patients simultaneously thus increasing therapeutic contact for patients and secondly many heads make lighter work either where more than one staff can offer second opinions on issues and also where patients are confident to feedback to other patients. Indeed, the efficacy of enhancing peer patient intervention in a group was apparent in a day hospital programme that ran a range of therapeutic group activities. The day hospital programme, over a period of twelve years, had a zero suicide rate with a population of patients that were often admitted because they were considered high suicide risk and who would ordinarily have been admitted as in-patients before the old asylum had been closed. The impressive clinical outcome seemed to testimony to the fact that collectively, it appeared that peer patients seemed to be more able to assess the risk of self harm than either the staff or objective measures of suicide risk such as questionnaires. The user involvement system of the day programme ran to an extended contingency of out-of hours support between members. An example of how this peer group support system operated is illustrated in the following vignette:

A patient newly admitted to the day hospital phoned a fellow member for support around 11pm one evening. She told her fellow member that she felt like setting fire to herself and talked in a bizarre way about self-immolation on the grounds of religious conviction (it was shortly after September 11th when the Twin Towers had been subject to what has become known as 'suicide bombing'. The patient who received the call was worried by the call and phoned another member of the group (as per the procedure for dealing with a difficult support call). By 1am a third member had been recruited to form a 'physical support group' (as PSG or Possee) which needed to consist of 3 members to be active and together they visited the disturbed patient in her house. They talked with her and wondered whether or not to take her to accident and emergency, whether they could leave her or who else could support and so on. In the end they stayed with her until the morning and brought her into the community.

It should be said that the system of operation in the day hospital had a very precise set of 'house rules' which had been negotiated between staff and patients. The rules were only altered across time with careful re-negotiation between staff and patients. In other words, there were dimensions of bureaucracy derived from deliberative democratic process that served as an important adjunct in the process of therapy. The result was a group relation ethos in the day hospital that facilitated a safe, reliable and workable system of crisis management. This is not to say that the programme was entirely without flaw. For example, even though the day hospital had a zero suicide rate during treatment with a population of patients that might have otherwise been admitted to in-patients units if the resources had been available, there were two suicides of patients who were on the waiting list for treatment and one suicide 18 months after treatment. These shortfalls in the system were addressed with the establishment of a waiting list follow-up group which proved to be effective.

Given the potential efficacy of group based approaches in managing harm and self harm, it is therefore to welcomed that the UK Department of Health (2002) recommended structuring in-patient treatments with recourse to group involvement from patients:

"4.49 The therapeutic value of effective ward community groups involving experienced staff (from all disciplines) should be considered as part of any therapeutic milieu. These groups have the potential to contain and anticipate disturbance, use the resource of other users and offer opportunities for reflection and insight." from: The Mental Health Policy Implementation Guide for Adult In-Patient Care Provision [DoH, 2002:X]

My understanding of the group's capacity to contain destructive and violent urges is gleaned from practice situations where I have observed, what appears to be social justice occurring as an inherent facet of group dynamic (Winship, 1998). I have, through the course of other research studies of group process, attempted to examine the potential of democracy as a therapeutic agent (Winship, 1997; Winship, 2000; Winship, 2003; Winship, 2004; Winship, 2006; Winship & Hardy, 2007). This idea of a 'healthy wholeness' in the group is derived from Foulkes (1948) as discussed earlier. The therapist's role in fostering a climate conducive to social justice in the group is not entirely straightforward. It does begin with an attempt to offer an inclusive milieu whereby patients are able to find words to describe feelings, but this is not achieved necessarily through a friendly process of creating a premature sense of intimacy and equality. Rather, intimacy, equality and ultimately democracy are to be achieved. This would seem to be Bion's perspective (as I described earlier in the anecdote from Bion's book Experiences in Groups where a new group wanted to introduce themselves to each other). Bion also begins by stating the hierarchical differences in the group, he draws attention to leadership and the reliance on the facilitator. Bion's approach does not bow to false friendliness and instead offers a hard place for the patient to run up against. The perceived authority of the group therapist can be taken to task by the patient. The group can be critical, playful and sometimes spiteful, but as the group therapist remains committed and interested in the process, the patient develops a new synthesis of benign authority. Authority is eventually perceived as less authoritarian, and eventually the group can emerge as a training ground for experiencing enfranchisement and a democratic axis of engagement. I concur that it is through the process of drawing attention to the authority differentials, that true empowerment begins. In this way, the question of instantiated authority, convention and so forth becomes the source of exploration. It is, after all, the terror of malignant authority that haunts many patients, the sound of persecutory voices often perceived to be authoritarian (command hallucinations) and so forth. Malignant authority that has been internalised, deal crushing blows to self esteem; the disabling anxiety of the social phobic likewise seems to be a crushing sense of authority where the throng of others is felt as belittling.

To my mind, Bion's hierarchical stance offers an environment that favours the emergence of a sense of authority among patient group members. In this sense it is based ultimately on an optimistic notion of a healthy and just group mentality. This can be contrasted with Gustav le Bon's original observation of the mindlessness of crowd mentality which led him to be depressed and fearful of the group, much like William Golding's novel Lord of Flies suggested that a group (of children in his novel) left to their own devices, would self-destruct. There can be little doubt that we see anti-group tendencies in a group of suicide bombers or a suicidal cult (like the Branch Davidians), or a criminal gang. But these destructive groups (gangs or cults more like) are more rare than common. My clinical experience has led me more often than not to the conclusion that groups do indeed have propensity towards well-being and fair-play. I will mention one vignette which illustrates what I believe to be the inherent tendency towards social justice, even in a group where it might be least expected.

Vignette:

In the course of working in a young offender's institute in a recently opened treatment wing, I ran some small group psychotherapy sessions with the in-mates. There were eight young offenders on the wing who brought with them a range of index offences including homicide, serial homicide, rape and burglary. The new programme was not entirely smooth running and it was rather ad-hoc who was co-facilitating the group with me. In one session I found myself running a group with a female staff member who was being inducted to the wing. I was anxious and slightly off balance with yet another co-facilitator, but was nonetheless pleased that the group was up and running after several months of preparation. In the early part of the group two of the in-mates talked about their offences, having determined to do so in a previous group. All seemed to going well. Then there was a lull and a short silence, which inevitably felt awkward for such a new group. During the silence one of the young men, a seventeen year old with a violent past, stood up, and proceeded to wedge his chair against the door. He turned back towards the group and said with some degree of menace; "lets have a riot". Neither I nor my co-facilitator found any words; a combination of the ineloquence of fear and curiosity albeit rather frozen. I was thinking about setting off the security alarm off when two other in-mates intervened and coolly told their fellow in-mate to sit back down. The agitator didn't seem impressed. One of his peers seemed inclined to join him for a moment, but then other voices rallied and after, what must have been less than a minute or so, the in-mate removed his chair and re-joined the circle.

The vignette might seem an exemplar of extremity. However, I have often recalled the incident to mind when a sense of dangerousness comes to the fore in other groups I've been in. The case vignette suggests that even in the most arid and hostile of emotional climes, where cruelty seems more pervasive than kindness, a group can still muster some degree of sensibility. In the above case, it is apparent that democracy exerted a life preserving potential and showed that a group of particularly damaged young men might muster enough collective healthiness to restore faith in human relations.

STRUGGLE - HOW TO ORGANISE A GROUP

In therapy we are concerned with the way in which the patient is able to take charge of their own destiny and the emotional oscillations between reliance, autonomy and mature dependence. Groups offer an opportunity to grapple with these dynamics as they are refracted through the micro-politics of social relation with peers as they interact with hierarchy (leadership) and anarchy (chaos). The task of the group is to explore the roles and relationships within the group as the dynamics of hierarchy and equality come in out of focus. The therapy group as a learning experience becomes a type of psychosocial mental circuit training that prepares participants for exploring the immediacy of contact with clients.

Organising a group might seem fairly straightforward, but finding a suitable room space and a suitable time where other staff can participate on a regular basis, can be a logistical headache. I have had the experience of establishing new groups in a range of settings, for staff and for patients. Setting up a staff group is usually a good way to begin to expose staff to the experience of being a group; learning to be with each other in the first place, before then contemplating running a group with patients. I have commonly found that people are reluctant to attend, and on some occasions I have sat alone waiting for people to turn up. The same resistance to engagement is apparent with patient therapy groups. When I set up a group (twice weekly) on the nine bedded intensive care unit at the Maudsley, for several weeks the patients did not really attend, rather they wandered in and out of the group, perhaps sitting down for a few minutes before moving on. The group was held in the middle of the ward day area and became a focal point for the hour that it was held if only in as much as patients wandered through the group on their way to the office or the bedroom. I took a very flexible approach, I did not try and stop patients, but offered invitations to join. When one or two other staff, perhaps feeling sympathetic to my struggle, started to attend regularly, so too the patients began to remain seated. The group never really flourished, but it was eventually accommodated in the time table. The group continued to meet after I left the unit, which seemed some measure of success. I wrote an essay afterwards called the 'broken circle' and reflected on the perpetual task of the group to merely get to the point where patients and staff could sit down together. Being an intensive care unit the group was always prone to fracture and disarray. However, in some ways, the group became a useful barometer for the chaos on the ward and to some extent a moment of trying to counter the chaos. The group did not have the benefit of longitudinal attendance by patients who were getting better because when a patient showed the capacity of being able to attend the group and sit through it, it usually indicated that they were ready to leave the ICU. Instead of the group having a number of senior patients who would be able model how to use the group, instead the group operated at a level of being mostly broken, with only occasional glimpses of coherency.

This sense of always 'getting there' in groups is probably relative to all groups from ICUs to out patient psychotherapy groups. There can be no doubting that they are difficult spaces to inhabit and I understand the reluctance of staff and patients to attend. It is an overarching caveat of group therapy, that the work is demanding and requires some special level of preparation and supervision for staff. But there are dividends. The endurance of group therapy as a treatment of choice in the field of personality disorders (PD) in particular, stands as a testimony to the worth of investing time and resources in establishing group therapy preparation for staff. Group therapy emerges from the orbit of dynamic psychotherapy, where the clinical procedure seeks to explore life events that might have led to a damaged personality development. There is persuasive data about the value of this exploratory psychotherapeutic approach with acutely ill patients from a randomised controlled trial (RCT) carried out at the Halliwick Unit, St Anne's Hospital in North London (Bateman & Fonagy, 1999; Mishan & Bateman, 1994;). The Halliwick programme of partial hospitalisation (i.e. day time only) which included milieu psychotherapy, combined with formal psychodynamic group intervention, was found to be effective in reducing hospitalisation and self harm, bringing about significant health gains in the treated cohort, compared to a control group who received general psychiatric intervention as usual. The health gains in the treated group were sustained over a follow-up period of eighteen months. The researchers were unable to explain whether it was the milieu experience (in the day hospital) or the formal psychotherapy that was most efficacious, although it appears likely that a combination of the two approaches (psychodynamic psychotherapy and social interaction) proved most beneficial when compared to the control group.

Group therapy, with the visibility of the therapist or facilitator, offers a base for exerting hierarchical authority, drawing on the instinct of group members to gather together under the guide of a higher authority; basic assumption leader dependency as Bion (1961) calls it. The status quo can be maintained in this way, as a gregarious atmosphere of social homeostasis pervades, where safety and compliance are ascendant, where the possibility of disruption and chaos can be expressed and contained. The collective of the group can exercise its urge towards empowerment and agency; even the weakest (or more unwell) members of the group can be drawn along by this urge, and we may even see this as an inherent propensity towards enfranchisement and social justice as I mentioned earlier. Oppression is superseded by a concerted sense of fair play, as the group exercises its voice and will to righteousness. These social democratic principles have been embedded in the predominant arc of group psychotherapy in the UK as it emerged from the Frankfurt School tradition as I described earlier.

RECOVERY AND & THE SKILLS OF FACILITATION

The range of skills required for establishing a therapeutic group intervention falls broadly under the rubric of the talking therapies. The task of establishing a space for the group involves the creation of rudimentary circular forum which permits maximal auditory and visual contact between group members. Visualisation of each other member is important, but probably less so than the fact that in a group therapy session, voice is often directed towards the centre of group where most people have the best chance of hearing utterances. The therapist facilitator establish the group in a circle of chairs which facilitates members seeing each other. This sense of seeing and being seen is the essential ingredient of belonging and therefore social inclusion. The facilitator draws attention to the nuances of social interaction. The facilitator avoids directing individuals to speak, instead waiting for an apposite time to include the more silent members. Contrary to popular belief, I think the facilitator does not directly aim to get patient to talk about themselves; more seemingly mundane and every day matters can be subject to useful discussion. Fundamentally, the group space becomes a dwelling for member voices where free discussion (or free association) can offer access to more intimate emotional issues. This is illustrated in the vignette below:

An out-patient group of patients compared their experiences of driving. One woman said she was quite "phobic" (her word) about driving on a particular section of road in her home town. She had tried many ways to overcome her fear but without success. She had resigned herself to using alternative routes rather than travelling down the feared section of road even though this meant adding time to her journey. One of the men said that he was very attached to his car, and though inside it he felt isolated and cut off, he liked the idea that he was in control and in a secure place all of his own. Another woman said that she was continually concerned when driving that she would bump into something, even though she rationally knew that she was quite safe and had never had an accident. She nonetheless suffered much tiresome anxiety. One of the group said that they thought that cars represented a 'phallic object'. The facilitator wondered if cars were not more like mothers. The group pondered this. The male patient who had said he felt in his car did think he was isolated from his mother. The woman who was concerned about crashing said that indeed her mother used to be very clumsy and often bumped into things.

The following week there was another discussion about cars. The woman who had been "phobic" about driving on a particular road announced that she had at last driven successfully along that section. She thought this was a good sign and that she had moment when she felt confident and in charge of her life for a change, in a way that her mother had never allowed her to do. The man who had spoken about his isolation and attachment to his car spoke about his mothers death. It became clear that he had felt out of control in relation to the loss of his mother and he said he understood that his attachment to his car as it represented something which he could control.

The idea that a group space accomplishes and even liberates 'voice', is a rather utopian vision. It is often the case that therapy groups are far from harmonious places, quite often they can be truculent, agitated and fractious and simply difficult to bear for both patients and staff. The types of realisations in the vignette are usually the end point of much churning over. I thin it is always helpful to begin with recourse to the human struggle that seems inherent in the process of a group, that life is not easy, freedom is not a given and that harmony is distilled from chaos. The collective experience of the patient group participants may well amount to a matrix of disenfranchisement, oppression, loss and abuse. The rise of the talking therapies in the twentieth century derives from a notion that the route to health and well-being is won through the process of dialogue where voicing ones mind is transformative. Deriving from the liberating principles of psychoanalytic free association, it is still the most radical behest of talking therapy that talk remains the best hope we have for resolving conflicts. This is an idea expressed among social theorists and philosophers like Jurgen Habermas and Anthony Giddens who see that dialogical exchange is not only the ideal explanatory level, but also the route to political enfranchisement and a better world. Consciousness raising and emotional well-being in this sense are determined by voice. It is where voice fails, that war starts.

It is towards the emotionality of the voices in the group, that the group therapist attends. That is to say, the therapist gauges the collective interweave of feelings as they are presented in the group, before attempting to find words to describe the free floating emotions. Once feelings are put into words they are less likely to be acted upon. The task for the group therapist is to be emotionally alert, to listen out for orientating utterances, before drawing attention to echoes and resonances. The therapist facilitates an auditorium for voices, in the first place setting out the chairs and establishing a space where distractions are limited, ensuring a room is booked is exclusively for the time: from one hour to one and half hours duration. The facilitator ensures that there are no other commitments scheduled at this set time, as far as possible, and keeps this space clear for the life span of the group which may be limited to weeks and months, or opened ended in some cases over a period of years. In the first place the therapist may need to more active, rousing the silence with thoughts about what group members may be thinking, while demonstrating a capacity to wait for members to find words in their own time. The therapist might reflect upon matters of concern for the group, relevant issues for the group both inside and outside of the group. Some therapists recommend that there should be intense focus within the group, based on Bion's (1960) basic assumption theory that by talking about outside matters the group is collectively defending against talking matters inside the group. I remain more sanguine about basic assumption level of communication and feel that free floating discussion, wherever it located, may be functional in establishing a core of shared experiences. That is to say, the group's manoeuvre to talk about external affairs or the remains of the day, whether this is current local, national or international, may not only be legitimate, but also necessary.

There are less common occasions when enthusiasm for dialogue among group members may be difficult to curb for the facilitator to cub. It is quite common for therapists to encourage group members to speak one-at-a-time. Again I am unsure of this requisite for monologue. More lately, I have taken it to be axiomatic never to tell a talkative group to speak one at a time. Indeed, I have come to see that cacophony in a group might be taken as a sign of progress. I think it is a common mistake to see problems emerging from inside the individual and it is in the noise of the group that one gets a clear picture of the interweave of lives inside and out.

The dynamics of social inclusion and exclusion require practitioners to be more socially and culturally attuned. Mental illness as an outward-in type of process, interpersonally derived and socially constructed is hardly a new idea; self-esteem is political when it emerges from racism, eating disorders are complicated by cultural icons and fashion. Our theories of mental illness have been erroneously honed by the inward search, to the substrate of genes, for solutions. Even Freud, with his unfolded family model of the determinants of illness, was taken to task by Herbert Marcuse in Eros & Civilisation where Marcuse argued that Freud was too narrow in his view and that psychotherapy unnecessarily pathologised individuals when causal pathways were political, social and cultural. Group therapy is an important counterpoise to the egocentricity of most biological, cognitive and psychological approaches. Group therapy doesn't quite amount to a clinical sociology with its own meta-theory, but it does offer an important stand for social construction and social solution, where individual problems are unfolded in a micro public sphere.

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