When thinking of starting a Psychotherapy Group, the first question is:
* What type of psychotherapy are we talking about?
There are many types, forms and different styles of Psychotherapy Groups from
Psychoanalytical Groups, Psychodynamic Groups, Behavioural Groups, Humanistic
Groups, through to Cognitive Behavioural Therapy Groups and the myriad of
Psychoeducational groups as well Relational Psychotherapy Groups.
My own experience of a personal growth group started in the early 1980s when I was a
participant in a so-called Encounter Group. These groups were focussed on self-
awareness and personal growth through inter-personal interactions. There were often
large numbers of participants; the one I attended was 30 in number, however they could
go up to 50. The groups could last from anything from 1 day to 1 week in length.
These groups, in my experience, often lacked any real focus or psychological healing.
They often lacked pre-defined structure or professional facilitation.
There were no forms of contracts or any real pre-determined topics. Shame was not
accounted for or rarely talked about, and in my experience these groups often fostered
a Shame culture.
The opposite of this type of group in many ways was the Transactional Analysis
Psychotherapy group that I later joined. Transactional Analysis was a Psychotherapy
model/approach created by Eric Berne in 1960. Transactional Analysis itself was first
practiced by Eric Berne in groups and he ran a therapeutic group in Carmel Hospital in
the early 1960s.
Transactional Analysis groups come from Psychodynamic and Humanistic traditions.
The Transactional Analysis group that I attended in the 1980s was an ongoing
Psychotherapy Group which met weekly at the same time and the duration was 2 hours
in length at the same venue. It was led by a senior trained Psychotherapist which
provided a safe and secure setting for the Psychotherapy Group. In this group there
was an agreed leader who, as I said, was an experienced Psychotherapist, who was a
constant and reliable person for me throughout my attendance in the group. The
environment put a focus on Protection, Safety and Security at the heart of the group
experience.
Contractual Method was an important and vital aspect of this type of group. Each
participant in the group made an individual contract with the leader of the group before
they entered into the group. This treatment contract was the individual’s focus of
therapy in the group. The participant would also make a business contract around fees,
attendance and norms of the group.
The psychotherapy contract was always for positive change and growth. It was
Bilateral, Specific and Explicit.-2-
The Transactional Analysis group was, by definition, informed by Transactional Analysis
theory and method. The group was made up of 8 people, it was an “ongoing” group,
not time-limited. However, it was a “closed” group which meant that people committed
to their attendance and duration in the group.
Each person, as said above, had their own therapeutic contract made with the leader
which was their individual focus within the group. Once they’d achieved the resolution
of their contract they might leave the group or indeed recontract for other aspects of
change which they might want to address with regards to their emotional wellbeing.
In Transactional Analysis groups, the client is the “Star” of the group, and they would
negotiate to take individual time in the group with the leader of the group to do
therapeutic work with regards to their agreed contract.
This style and form of running a Psychotherapy group was that it could be seen as
“Individual Therapy in the Group”.
Within this structure there would also be time given to the group as a whole for
constructive feedback with regards to the “Personal Work” that the individual achieved.
This group feedback, however, would be limited as the focus in the group was primarily
on a singular experience rather than multiple experiences.
This type of group described above in Transactional parlours at this time was often
called a “Hybrid Model of Therapy”.
RELATIONAL GROUP PSYCHOTHERAPY
Relational Group Psychotherapy is a form of group Psychotherapy grounded in
Relational Psychoanalysis and Interpersonal Theories where the focus is not on the
Individual, it is fundamentally concerned on the Multiple interactions and connections
with the therapy group.
It is concentrated on the “Here and Now” experiences within the group and the “Here
and Now” interactions between the group members as a means to understanding and
changing Relational patterns.
The “Here and Now” process between the members of the group becomes a
microcosm of the outside world.
The interactions and personal connections or disconnections of the members of the
group will mirror their Relational patterns in every day life.-3-
KEY IDEAS AND CORE PRACTICES OF A RELATIONAL GROUP
PSYCHOTHERAPY (Erskine 2023)
1. Security, Protection and Safety
Security, Protection and Safety are paramount and an essential template of a
Relational Group Psychotherapy. At the beginning of any Relational Group
Psychotherapy, and in fact throughout the whole continuity of the group,
Security, Protection and Safety is at a high premium.
Of course the attention to Security and Safety will be paramount and should be
attended to by the therapist in the forming of the group, mainly because no “real”
healing will take place in a climate of insecurity and lack of protection.
2. Intersubjectivity and the Intersubjective Field
The Intersubjective Field is the Relational space created by the mutual presence,
perceptions, thinking, emotions, behaviours, and unconscious processes of the
members of the group and the therapist.
It is a collective shared space created in the “Here and Now” from moment to
moment
From this field, Relational patterns will occur and get played out within the
psychotherapy group.
3. Co-Creation
In the context of a Relational Psychotherapy Group, Co-creation refers to the
collaborative processes through which the group members and the therapist
jointly shape the therapeutic experiences that will emerge from the
Intersubjective field.
This will lead to the creating of a safe, secure and supportive environment where
an individual member’s experiences and emotions can be shared in a culture of
Trust and Safety.
A Co-creative group that emerges from the Intersubjective field will be a
collective “Us” process rather than an “I” experience.
Clinical Example: At the beginning of the Relational Psychotherapy Group,
Joan states that she does not feel safe in the group. After accounting for her not
feeling safe in the group I gently inquire “what needs to happen in the group for
you to feel safe?”
She responds that she needs to hear from other people about whether they feel
safe in the group.- 4 –
This leads to a group discussion about Psychological Safety and Security.
Members individually share with Joan whether they feel psychologically safe in
the group. Which then leads to a further discussion by different members of the
group around Safety and Security. They also discuss as a collective group what
needs to happen in the group for people to feel psychologically safe in the
group?
Whilst accounting for Joan’s feelings of not feeling safe in the group, several
members also share their vulnerabilities and fear of being exposed in the group.
After the members of the group have finished sharing their responses and
sharing their internal experiences on the subject of Psychological Safety and
Security, I turned to Joan and gently inquire with her how is she feeling now? Is
she still feeling unsafe in the group?
To which she replies she felt much better now and safer in the group.
I inquired with her what had happened to make her feel more psychologically
safe in the group.
She answers that with members sharing their vulnerability and personal
experiences she felt safer and had a sense of belonging in the group.
This clinical example illustrates that when members of the group collectively
share their own experiences and vulnerabilities, Joan felt accounted for and a
sense of belonging in the group which led her feeling internally safe and secure
in the group.
In this co-creative space, the therapist’s task is to not dominate the group but to
facilitate all the participants to actively contribute to a co-creative, collective
experience.
4. Validation
Validation in the therapy group process is an essential concept to understand
and use in the clinical setting.
Validation plays a fundamental role in creating Safety and Security as well as
healthy connection and encourages emotional healing at an individual level and
a group level.
Validation is the process of recognising, acknowledging and accepting the
thoughts and feelings of the other persons in the therapy group as
understandable and legitimate, even if you don’t agree with them.
Effective Validation requires active listening, empathy, and a non-judgemental
attitude with regards to the individual person and group members as a whole.-5-
Finally, Validation in the above sense means that the therapist has to use
reflective listening to the client’s narrative and often mirrors back their emotions
and experiences to show understanding and empathy.
Clinical Example of using Validation: The members of the group are
discussing Shame and its impact for themselves at a personal level. Mary turns
to me and states that she finds other people’s empathy towards her
uncomfortable and she finds deep shame at expressing her vulnerability in the
group.
I make eye contact with her and say “I am sorry to hear this and I really hear how
uncomfortable it is for you expressing your vulnerability in this group.”
This example shows me showing interest in her, making contact with her, and
reflecting back to her what she has said about her vulnerabilities.
This shows active listening and reflection which showed that I understood what
she was saying and that she was important to me. In my reply I demonstrated
an empathic and caring attitude to Mary.
5. Normalisation
In the service of Normalisation the therapist will help the person make sense of
what is “normal” when they feel something or an event is not normal.
In Psychotherapy, Normalisation is a Psychotherapy technique in which a
therapist helps a person understand that their thoughts, feelings, reactions or
behaviours are understandable and common responses to a particular situation
experienced or stage of life.
For example, a Psychotherapist might say “Many people experience difficulty
concentrating and intense emotional ups and downs after a significant loss”.
This does not mean the therapist is saying the person’s distress is unimportant
or that everybody experiences it in exactly the same way. Rather, it places the
experience in a broader human context and can help the person feel less alone.
Normalisation is often balanced with Validation acknowledging the person’s
unique experience while also recognising that their reaction makes sense given
their specific circumstance.
6. Empathy
Empathy is the capacity to understand another person’s internal experience as
they experience it, while maintaining awareness that it is the other person’s
experience, not yours.- 6 –
It is important to note here that Empathy is not the same as Sympathy, which is
often a mistake a beginning therapist falls into.
Empathy involves specific attention and contact with the client. It means that the
therapist attempts to get into the frame of reference and internal world of the
client. In other words, to try and understand a client’s emotions, beliefs and
perspective. The therapist will then reflect that understanding back to the client
with genuine interest and caringness.
Clinical Example of Empathy: “It sounds as though you are very angry at this
moment and also have a lot of self-criticism and that’s particularly painful to you.”
Empathy is pivotal in the Relational world as it’s one of the key conditions that
underpins and helps therapeutic change.
7. Positive Permissions
Permissions are vital for the therapist within their therapeutic relationship with
their client. It is important that the therapist thinks of using Permissions for many
reasons. Firstly, the therapist may give Permissions as an antidote to the
negative internal parent of the client. Secondly, to be able to voice what the
client may not be actually be aware of is vital for them. Thirdly, positive
Permissions are like oxygen for the client in the promotion of their emotional
wellbeing. I think of Permissions as vital in the process of helping the client
develop a robust sense of self and defeating or desensitising their internal
negative voice.
Clinical example of using Permissions: Often it may be important to give the
client the Permission to Exist. This is a vitally important permission which needs
to be said explicitly to the client. It needs to be a directive and highly contactful
transaction which is given to the client as a Permission transaction to allow
themselves to take on board that they Exist and that they have the right to Exist.
Permission around experience is also important when working therapeutically.
The therapist may give permissions for the client to experience their own
sensations, to think one’s own thoughts, and to feel one’s own feelings as
opposed to what others may believe one should think or feel.
The permission to Be Themselves as an individual of appropriate age and sex
with potential for growth and development is also vital.
Another permission which is often used therapeutically is the permission for the
client to be emotionally close to others. This again is very important in the sense
of validating someone’s sense of self and challenging often the injunction that
people carry around which is not to show feelings or nor to be close to others.- 7 –
PREPARING FOR THE START OF THE GROUP
1. Business Contract
The establishment of a business contract with each individual is important before
the start and formation of the group.
Aspects that will be covered in the business contract will be:
(a) Fees
(b) Time and duration of the group
(c) Attendance and non-attendance
(d) How much notice to give when you leave the group
(e) When a person attends the group they are not under the influence of
alcohol of drugs
(f) Whether the group is time limited or ongoing
(g) Number of participants in the group
(h) That the group is open or closed and a description of both
(i) That it’s a membership group
2. Defining the Group’s Purpose
It is important with each individual before the starting and forming of the group
that you will define the group’s purpose of the group and the person commits to
that purpose.
3. Assessment and Screening of the Individual
This is an important part of any forming of a Psychotherapy Group. Each
individual needs to be assessed in terms of their mental health challenges and
suitability for the Psychotherapy Group. For example, in Transactional Analysis
terms how much access they have to their Adult Ego State and detailed attention
to “Risk Assessment”. For example, have they got a commit to “live” and
whether they are “an active Suicide risk” and their level of suicidal ideation needs
to be considered.
4. Determination of Group Size, Frequency, Duration, Open or Closed,
Whether it is a Membership Model that the group follows.
In preparing for the starting and forming of the group, the confidentiality will be
discussed individually and collectively in the group. Each of the members of the
group need to explicitly agree about the principle of confidentiality.
5. The First Sessions of a Psychotherapy Group and What to Consider when
the Group Meets for First Time
I am assuming that the Business Contract assessments of the participants have
been done by this stage. The first sessions of the beginning of a group are vital-8-
and provide the scaffolding for any effective group psychotherapy. The major
issues for a Psychotherapist to consider are firstly, and most importantly, the
fostering of “Trust, Safety and Security” in the group. In the service of
establishing Trust and Safey in the group, I would suggest at least the first
session of the group would be involving “ice breaking exercises”, and each
participant sharing with the group their therapy contracts, what they want to
achieve in the group and what their motivation was for coming in the group.
The Forming of the group is the prime purpose of these initial sessions, not
doing individual therapy with people in the group.
The style and method of the group and the attention to Trust, Protection and
Safety will determine the effectiveness and continuity of the group.
Regardless of the style of the group, the leader of the group will look for:
(a) How people contact and don’t contact other people in the group
(b) How contactful are they internally with themselves
(c) The emergence of blocks or sub-groups evolving in the group
(d) The different or similar Attachment styles of the participants in the group
(e) How Silence is dealt with or not within the group.
(f) The therapist needs to be aware of Transferences and Counter
Transference moment by moment within the therapeutic group.
(g) The therapist needs to be aware of any power plays or any leadership
roles within the group.
(h) The therapist needs to be aware of the concept of Resistance and
Defences in the psychotherapy group.
(i) The therapist needs to be aware of the concept of Competition either for
time or space within the psychotherapy group.
(j) If it is a Relational Psychotherapy Group, it must be noted that there will
be a specific focus on Group Relational Patterns and a “We” experience
rather than an “I” experience.
6. Composition of the Group
1. Composition of the group might be by diagnosis or symptom. For
example, eating disorders, personality disorders etc.
2. By common experience, for example adult survivors of child abuse.
3. By gender.
4. By sexuality
7. Norms of a Psychotherapy Group
(a) Attendance or lack of attendance.
(b) Confidential agreements
(c) Group agreements such as no social contact outside the group.- 9 –
8. Common Challenges within Groups
1. Dominating members
2. Withdrawing members
3. Resistance
4. Conflict between members
5. Establishing of Sub-Groups and what you do about it.
9. General Therapists Tasks throughout the duration of the Psychotherapy
Group
1. To provide time structure
2. To maintain and manage the group
3. To be aware and manage transference and counter transference
4. The maintenance of confidentiality
5. To be aware of ethical issues
6. Reviews of ongoing contracts
7. To facilitate arrivals and departures of members of the group
10. Ethical Issues to consider
1. Confidentiality breaches
2. Safeguarding concerns
3. Dual Relationships
11. Stages of Group Levels
1. Forming
2. Storming
3. Norming
4. Performing
5. Ending
