Group formation and dynamics in group therapy
A multi professional approach1
Flavia Righi – Directing psychologist and psychotherapist (COIRAG apg)
Francesca Zordan – TNPEE (child neuro psychomotor therapist) UONPIA (local public child psychiatric services) in Rozzano, under the direction of Ospedale di Circolo di Melegnano (Hospital located in Vizzolo Predabissi in the province of Milan)
This article offers a detailed description on how a therapy group is formed, the participants’ characteristics, and the analysis of a significant therapy session where special attention is given to dynamics within the peer group and between the adult and the child. The conclusion, drawn from various points of view, illustrates how therapeutic roles are complementary between the co-conductors.
Our article describes a therapeutic experience with a group of children. We planned and realized this project in a public Child Psychiatric Territorial Service in a city on the outskirts of Milan. We will analyse the necessary steps for group formation, consider the therapeutic “couple”, and present a detailed description of one of the more significant therapy sessions. The description of the therapy session allows for observing both the development of horizontal dynamics between peers and the dynamics between the children and the adult therapists.
The conclusion focuses attention on the functions and roles of the two group leaders and how they were complementary in therapeutic action. These aspects are considered essential for “good” care taking when there are two different professionals conducting a group.
The same authors wrote another article, containing theoretical references on therapy groups, on group conduction, on recent debate in the field, and the reasons that gave origin to this group. It can be consulted in this journal’s preceding issue2.
We would like to borrow Velia Bianchi Ranci’s words, quoted below, as a metaphor that might be useful in bringing readers closer to the contents of our experience in conducting group therapy. In particular, we think her words might be helpful in understanding all that happens in the health professional’s mind during the diagnostic procedure that precedes group formation:
Gestation could be the metaphor used in describing the anxiety, desires, and fears of the therapist when thinking about group formation. Such emotions are to some extent similar to those of an expectant mother because the nine months of pregnancy, just as the weeks or months spent in preparing the group, are fundamental to the “extra uterine life” both of the baby and of the group. (Sacchi, 2001, p.117)
A pre-defined procedure determined the selection of the children. It was intended to evaluate if the choice of group therapy was appropriate for the future participants’ psychic functioning. The psychotherapist began with an anamnesis followed by unstructured play observations, and then the administration of an I.Q. test. The children were then observed by the TNPEE (psychomotor therapist) for three sessions in the psychomotor therapy room. None of the children had ever been in psychomotor therapy and the observations were useful for evaluation.
The psychotherapist, who had a previous history with the parents, informed them about the methods and the schedules for evaluation. Both professionals were present when the evaluation results, along with the group therapy proposal, were offered to the parents.
We would like to underline the fact that all of the families both shared and accepted intervention for their children. They also made a commitment to attend monthly group parental meetings organized at the service by the child psychiatrist and having the aim of supporting parenthood. We would also like to make it evident that a different kind of intervention was offered to the parents than that offered to the children, in so much as we presumed that the parents had accepted therapy for their children and not for themselves.
Given the age of the children, the parent’s compliance to group intervention was essential, in the same way that their actively sharing the group’s premises contributed to the group’s constitution. The parent-child relation is significantly relevant; it influences a child’s perception of the therapy group to the extent that if the parent’s trust in the group project isn’t perceived, the child will seriously limit his/her investment.
Four children, two males and two females, between seven and eight years of age, began the group in May 2013. All of them were residents in the city of Rozzano, but didn’t attend the same classes at school. We want to emphasize this aspect because it was necessary to guarantee freedom from any external social life interference.
The group had a semi open structure; the first four participants were to begin together and each member could conclude according to his/her personal evolution in time.
It would then be possible to add new members to the group up until a limit of 6 participants.
All participants manifested emotional and behavioral problems and were at the age of latency.
A brief description of each group member follows:
- K. is a second grader. She appears to be inhibited, isolated and obviously immature in interpersonal interaction. She always speaks quietly just as she always gazes downwards. She tends to have a childish attitude when acting and interacting. Her mother reports K.’s difficulty in making balanced relationships on an equal level and how her classmates often make fun of her calling her the “sleeper in the woods”. K.is aware of the situation but hasn’t succeeded in finding a way to establish contact with the others, so she tends to isolate herself and entertains herself drawing. Drawing is certainly an area where K. has potentiality.
- C. is also in second grade. She came to our service for language problems, but inhibition in the emotional and social area emerged during observation. C. still sleeps in her mother’s bed and has a hard time initiating any kind of extracurricular activity. Her mother admits her own difficulty in separating from her daughter and signals her daughter’s difficulty in making friends with peers.
- E. is in third grade and is the oldest child. He comes to our service for speech therapy because of learning disabilities. He has an older brother affected with tuberous sclerosis whose acting out complicates family dynamics. E.’s problems emerge when he doesn’t manage finding a place suitable to him in his peer group. He often finds it hard managing aggressiveness in play.
- D. is in second grade. He comes to our service for speech therapy because of learning disabilities. He appears to be adequate in respecting rules, but has a hard time modulating or regulating actions both within his peer group and with adults. He manifests clumsiness, evasive eye contact and intolerance to body contact. His maternal grandmother, affected by Huntington’s Disease, an autosomal dominant disorder, died when he was born. His life began in a mourning family where death and abandonment feelings permeated the environment. Themes related to death and abandonment are often present in his play.
All of the children admitted to the group have difficulty involving themselves in a relationship using age and context appropriate behavior. The common denominator of their discomfort is social, or how to create good relationships in life’s various groups (scholastic, recreational, family).
Our main objective in intervention is to give these children the possibility of experimenting new behaviors in a secure and protected environment. Therapy proceeds through the construction of relationships in shared play. As a consequence, this experiential space will allow for representing, recognizing and sharing emotions, in addition to facing deep conflicts, in a less menacing and distressful way. At the same time, the group experience allows the children to observe the reactions of their peers, without requiring them to do introspection individually.
The choice of a group (…) offers the possibility of facing situations that individual therapy can’t easily approach or that don’t evolve as easily. The group can be considered a place for contrast, support, competition among equals, reciprocity, and communication modes typical of children, and as a transitional space from a family to a social dimension. (Miglietta, 2007, p.13)
THE GROUP EXPERIENCE
To bring our readers closer to the real experience of the group, we thought it important to report some passages from a therapy session and comment them in order illustrate the different approaches that were used.
We chose to present the first session in which a fixed video camera was introduced since this “new entry” immediately activated the memory of intrusive experiences in the children. Examining this aspect is interesting and draws attention to how each child searched for individual strategies to be employed when facing mental strain.
It’s the beginning of the session, and even if everyone should be seated, there is a lot of turmoil. While jumping around, D.yells, “Silence!”. He also turns off the lights. Francesca takes advantage of the situation and explains to everyone why we decided to introduce the video camera, but her explanation isn’t enough. Flavia comments on how this object seems to have excited D., K., and C. but has made E. sad. Flavia asks E. to share his thoughts and he very clearly replies, “My secrets are inside this room”. Flavia replies, “Certainly. Are you afraid that they might leave this room?” Francesca explains all that we do for protecting their secrets, how the camera is useful to us in reviewing their play and in exchanging our views for finding new ways to spend our time with them together.
Flavia asks if the other children too have secrets that they don’t want to get out of the room. Each child says something, while D. has a harder time until even he finds a fear that he can share with the others. After having expressed the distress aroused by the video camera, they begin playing.
Introducing a destabilizing object helped inexplicit fears until then to emerge. The children’s mental anguish, personified as spiders, insects, sorcerers and witches, evil princesses, and the dark were deposited in the group space, experienced as a place of protection. The children could now “play with them”.
Later we’ll see how identifying a scapegoat, in this case, the group leaders, can gradually attenuate the children’s experience of aggressiveness:
The game starts with D.’s explicit remark. “I’m afraid of K.. K.is the monster!” D., K., and C. begin chasing each other all around the room. Movement is fast with a generally intense emotional and body tone. Everyone yells, laughs, trips and falls, and throws foam rubber objects on the ground. They seem to be actions more related to sensoriality and to the pure pleasure of movement. E. doesn’t follow the group’s movements and comments, “But this isn’t the game!” He hides in a huge foam rubber cylinder where he assumes a foetal position. Francesca helps him create a hiding place and a “safe place” so that he is protected from the others’ confusion. In the meantime, Flavia tries to create a symbolic container by asking each child what role he/she is playing. D. is the princess, K. is the monster and C. is the sorceress. Francesca keeps her place near to E. to demonstrate her physical closeness. Flavia watches detachedly and verbally comments the action and the scenario that has been created, “It looks like two separate worlds to me, three (children) are in the middle of chaos and one is trying to build…” At that point, D. increases the volume of his voice, screams and destroys E.’s construction.
Let’s underline the complementary positions of the two therapists in this passage. Francesca uses more action and movement; she tries to piece together the action segments and create a “real” and safe container, or hideout, using objects and space. In addition, staying close to E. allows her to protect him from the other children’s possible uncontrolled or undirected movements and ensure a safe environment for all of the group participants. Flavia functions as an external narrator maintaining a standing position. She is immobile and solid while she describes what she sees and gives symbolic meaning to action, to emotions and to communicative expressiveness.
The game continues. The children try building a safe house for D., C., and K., and it’s there that we (Francesca and Flavia) are given the role of “servants”.
Francesca suggests building a hideout together, but the group of three doesn’t want to share E.’s hideout. E., in return, claims that a password is required to enter his hideout. Each child in turn exclaims his “no” and E. intensifies his isolation claiming that not one, but “five passwords are necessary”. D. summons us loudly and continues to exaggerate by beating his hands on the cushions and then ordering us to get to work for him and the other two. Francesca asks him if we are by chance their servants. D. affirms enthusiastically, and wanting to emphasize our role, says that we have to maintain it “even at night”. Suddenly the light is turned off and Flavia answers in a tone that implies a little fear, “even at night?” All three children scream at her and she pretends to be afraid.
The psychotherapist’s position is sufficiently static and her role as a servant is finalized in supporting the house’s main wall. It is the psychomotor therapist who gives her the role of mattress holder, the main wall support, while she helps the children plan, construct and secure their “house”. Once again Francesca acts and helps the children in co-constructing a space that is shared and protective, while Flavia renders explicit what is happening and puts it into words using an intrapsychic interpretation of the action and the emotions related to it.
The following sequence shows how the group attack aims at evaluating whether or not the group leaders are able to tolerate the worry, the fear and the fragmentation anguish introduced by the video camera.
Finding themselves close to each other, the two group leaders exchange their thoughts out loud, and comment on what’s happening. “It looks like the video camera roused a lots of things, from the fear that some thoughts might leave the room to their anger toward us,” says Flavia to Francesca. Francesca replies, “I think so…that’s the way it looks”. They continue their dialogue adding, “It’s as if the children are saying, ‘You put the video camera in the room and now we’ll get back at you!’” At that precise moment, C. looks at E., who is hidden under a blanket inside the cylinder, and says, “I think he might be crying”. D. joins in, “Let’s go see!” All of the children go towards E.
The children find immediate relief in directing their attention toward E. who has remained rolled up like a cocoon in the cylinder. We can observe how the body and the mental state find integration here, allowing for emotions to become explicit and transferring the focus of attention. The child designated as scapegoat is now liberated from his role and aggressiveness can be directed towards the adult.
As Bianchi Ranci wrote, “the peers that have taken turns in being attacked by the group function as a “lightening rod” so that the therapist isn’t destroyed by their aggressiveness […] through interpretation, the therapist gives meaning to the children’s experience by taking on the role of scapegoat and demonstrating how their aggressiveness can be tolerated. (Bianchi Ranci, 1998, p.34).
The initial risk that the group might be destroyed in general unhappiness recedes in a different way and allows for seeing the other’s sad and fragile or undefended parts, that were previously too frightening.
D., K., and C., after having gone close to E.,, continue running, yelling and laughing. E. cries and says, “Quit it!” Francesca reminds the children of the game setting by asking, “Are you sure E. is playing?” She goes closer to him in the meantime, kneels down, and begins reassuring him by rubbing his back. At the same time Flavia adds, “Maybe he hasn’t understood what’s happening. Can’t we do the same things more delicately? Maybe it’s harder to see someone’s sad side instead of his happy side?” The rest of the group replies, “ Well, yeah”. K. takes a wooden massager from the toy box and exclaims, “A nice massage!” She gets nearer to him and then starts massaging. He refuses body contact so K. then suggests, “Maybe he needs a gift!” Flavia says, “…or someone to talk to” and Francesca adds “…or someone to play with him, and E., himself, might have some ideas”. D. suggests, “Come on, let’s stop…let’s calm down and listen to him.” C. begins pretending to immobilize everyone with a plastic hammer and nail while saying, “You’re a house”.
Everyone starts telling E. about the game they were playing and E. slowly comes out of hiding, stands up and begins interacting with the group.
After having come out of his place, E. finally decides to impersonate a pirate that repairs everything while the others create a massage center. E. decides he has to go on a journey to find his constructions made of gold left behind in another country. D. immediately screams, “Me too! I have to go to France where I was born!” Francesca asks him if he’ll be travelling with the pirate and D. and E. begin preparing a boat that will take them to their destination together with the relatives that will participate in the trip. C and K. are D.’s sisters who decide to close the massage shop. C. takes a doll as a daughter. In the beginning, E. doesn’t want to share the boat, but it doesn’t take much to convince him that they can all leave together.
At this point, both of the group leaders move together in the room accompanying what happens with words and supporting the group’s movements with actions that aim at reinforcing what the children are doing. In this simple and brief passage it becomes obvious how the group acts as a container where fear can be expressed and at the same time a place where it’s possible to face fear by identifying strategies potentially exportable in less structured and less protected settings.
The psychotherapist’s and neuropsychomotor therapist’s attitude is such that the children can communicate spontaneously and the solidity of the relationship helps them tolerate occasional frustration when excluded from activity.
This suspension of action is useful to the group and to the group leaders because it permits observing at a distance. While the group leaders trustfully wait, the children find their own solutions for playing together. Although they are silent, the psychotherapist’s and the neuropsychomotor therapist’s presence is the determining factor in group formation because they are the ones who maintain the setting and determine the structure.
Captain Pirate advises everyone that a storm is on the way. K. takes a cloth and covers the three family members when Flavia says, “Take cover, everyone under the blanket!” Since K. can’t quite manage to cover everyone, Flavia and Francesca help her so that she, too, can take cover.
The integrated interaction between the two professionals gave the children a dual experiential register, and the dialogue became such a catalyser of change that K. can feel authorized in assuming a protective role with the others by conducting them to a safe place and covering them with a blanket.
We’ll try to explain the many reasons for positively evaluating multi-professional intervention after this experiment in group co-conduction, especially when it comes to the enormous potentiality inherent in this kind of work arrangement, in the following conclusions.
Both professionals had already experimented working with groups, but in different contexts. The TNPEE had worked with psychomotor support and educational groups referring to Bernard Aucouturier’s methodology. She had conducted a group both as a single leader as well as a co-leader. The psychologist, who had group analysis training, had already experimented co-leadership in group therapy with another psychotherapist. These previous experiences in group methodology made it all the more obvious that not only experience was essential but also training in group dynamics and counter transfer management for group leaders.
We also want to underline how an extended period of mutual acquaintance was important in order to make us feel “integrated” in therapeutic action. Working together helped us mature an authentic and consolidated understanding of each other and recognize each other’s personal and professional qualities.
In order to work as a therapeutic couple in mutual harmony, and not just a mere combination of one professional plus another one, work has to be dedicated to understanding each one’s role in a complementary relationship with the other’s role. Listening to oneself and, at the same time, listening to the other is necessary for discovering how objectives can combine. In order to achieve modulation in alternating roles and reciprocity, we had to constantly think about our experience and develop awareness about the passages we used for arriving at an agreement. Our exchange was sometimes tormenting and challenging but we always managed to resolve the contrasts.
Reciprocally observing different professional methods gave each therapist the chance to recognize herself in the couple and alternate with the other in a balanced and harmonious way.
The neuropsychomotor therapist is an expert in action and she privileges the ways that make action happen. Her objective is recomposing the children’s various action fragments and helping them find a common meaning through interaction in play. The neuropsychomotor therapist “speaks to the body, from the body and with the body” (Berti and Comunello, 2011, p.86).
The psychological function is determined by the presence of the psychotherapist as a witness to play. Her intervention facilitates the passage from kinetic movement to scenic movement where actions, sounds and scenery are transformed into a language with specific meanings. It is in this way that play becomes a symbolic form of communication. Play is therefore a unifying element that structures itself as a means for expressing sensoriality and for tolerating strong emotions. Once this happens, the child is able to act on them, to project them, to experience them and share them.
The joint construction of the therapeutic setting and its well-defined rules, created an environment where the children felt protected, contained and able to positively invest in the group thus giving each one a chance of feeling the “group” as a common creation.
Daniel Stern (1987) is a worthwhile reference when speaking of integrated therapeutic action and how the Self develops and evolves through different stages, when we’re referring to the process that allows for a child to move from one level to another, from an emerging self to a narrated self. Ferruccio Cartacci also reaffirms how the “unifying element [or that which unifies the Self] proceeds from the whole of body sensations, to how they are subjectively experienced, to a verbal code, and then to narration. All of these factors become stratified and render the child’s unity more complex and consolidated.”(Cartacci, 2002, p. 56)
Therapeutic complementarity, allows for intervention to be more global and effective, and thought and action to be continuously connected as we saw in this example of joint leadership. The psychomotor therapist’s actions and body expression that integrate motor, expressive and communicative skills were interwoven with the psychotherapist’s prevalent use of words and the interpretation of actions. In such a way, the therapist’s intervention allows for the group’s multiplicity of actions to become a multiplicity of expressions and their representations to become meaningful representations
A double matrix leadership in their group experience helped them transform sensations, actions and motor discharges into scenes and stories. Giving form and voice to emotions allowed them to achieve affective literacy because the playing, the scenes and the stories make for thinkable thoughts about events. Finally, we find it important to underline how an adult must know how to work with what happens, while it is happening, and, at the same time support group movement without deciding its ways, its themes or its sequences.
In the end, our group therapy experience with children can be considered a space where different therapeutic models meet, where words give way to play, at times purely sensorial, but then return through the narration offered by the leaders, to a language with an affectively invested meaning.
1 This second contribution by the authors (Righi and Zordan) on the conduction of psychomotor therapy groups completes the first article (published in N.50 of this journal ) which was more theoretical. This article focuses on a specific methodology and an accurate clinical report.
2 See F. Righi and F. Zordan, Un modello di intervento multidisciplinare: terapia di gruppo in un servizio publico (A multidisciplinary intervention model: group therapy in a public health service), <Psicomotrictà>, vol. 18. 1 (50), March 2014, pp.14-19.