Abstract
NHS patients referred for group analytic psychotherapy often have limited capacity to manage their own or others’ emotions and therefore struggle to use analytic group psychotherapy because its unstructured format can feel too anxiety provoking. This research looked into members’ experiences of group analytic therapy, using a qualitative approach, to examine the experiences of group processes for members and their therapists. Phenomenological Interpretive Analysis was used to analyse the interview transcripts and develop over-arching themes.
Findings revealed shared themes between members and therapists, describing strong feelings: ‘anger; competition with members and disappointment with therapists’ and ‘fears of emotional damage’. A super-ordinate theme of ‘weathering’ emerged, which connected to members being able to stay and understand these strong feelings and which led to themes of ‘sharing leading to new learning’ and ‘change’.
Differences in themes were also found: ‘anger could be destructive’ and ‘feeling attacked’ were identified by members only, whilst therapists identified ‘re-enactment: repair or re-traumatization’. Members emphasized; ‘therapists as parents providing safety’ and ‘support from other members’ as crucial in helping them to stay to ‘weather’ the group process.
The theme of ‘weathering’ was important because it related to all themes and provided an explanation for personal change in members. Clinical implications are discussed.
Keywords
Introduction
Severe emotional disturbance in NHS patients referred to group analytic psychotherapy lessens the capacity for groups to use ‘processes based on verbal communication and empathic resonance’ (Nitsun, 2015). The unstructured nature of group analysis, which facilitates interpersonal learning through the development of mutual analysis (Foulkes, 1964) can be very anxiety provoking. Especially as prospective group members have usually spent their lives trying to avoid overwhelming feelings, linked to early or ongoing trauma.
The question is whether analytic groups are sufficiently adapted to contain and treat NHS patients, who have limited capacity to self-regulate emotions (Karterud, 2011) and are often referred when other treatments have been exhausted (Nitsun, 2015). Karterud (2011) concluded from his research, that replacing a classic group analytic approach with a more directive, Mentalization Based Therapy approach (MBT), led to better outcomes for patients less able to tolerate their own or others’ emotions.
Nitsun (2003) has described the need for active intervention by conductors to address anti-group processes, which if left unchecked, fragment a group.
Therapists’ passivity has been cited as unhelpful by members in group therapy studies (Johansson and Werbart, 2009; Pipon-Young and Cole, 2012; Hummelen et al., 2007). It appears that the need for support, whilst strongly identified by patients in these studies, was not prominent in their therapists’ minds. This may have been understood by therapists in the context of transference, to be experienced and worked with, rather than a ‘legitimate’ need to be met.
This is consistent with Foulkes’ suggestion that conductors should not collaborate with members’ wishes for an archaic leader, rather weaning them off, to enable development of their own authority (Foulkes, 1964). Whether the expressed need for safety is based on members’ realistic recognition of their own limits, or a form of avoidance, seems to be a dilemma facing therapists. Therapists may perceive dangers in colluding with members’ avoidance of feelings (Pothoff and Moini-Afchari, 2014). However, feeling safe enough has been seen as a key condition for mentalizing and remaining in therapy (Allen et al., 2008).
Structured group approaches, such as schema therapy, focussing on identifying and understanding the switches between modes or different states of mind in members, has shown excellent results in a randomized control trial (Farrell et al., 2009). In this context, group analytic psychotherapy is under pressure to justify its unstructured, slower long term, process approach, as being appropriate to patients and resources in the NHS (Lorentzen, 2016).
Whilst there is an ongoing debate about the need for structure and active leadership amongst researchers and therapists (Karterud, 2015), less is known about services users’ experiences in analytic groups (Blackmore et al., 2009). Given this, it seemed important to examine members’ experiences and compare it with therapists’ experiences—of salient processes in analytic group therapy. The present study aimed to generate an in-depth picture of the experience of change processes and to identify what helps members stay and use therapy from the perspectives of both members and therapists, in NHS based analytic groups.
A qualitative approach focussing on the meanings and understandings of participants was considered ideally suited to meet the research aims (Smith, et al., 2009). Interpretive phenomenological analysis (IPA) was chosen as it captures the quality and nature of individual experience, whilst acknowledging the researcher’s role in interpreting the data (Burck, 2005).
Method
Participants
This study involved six members and four therapists recruited from two co-facilitated weekly therapy groups following Foulkes’ analytic model (1964). They were out-patient groups, taking place within an inner London NHS Trust psychology department. Participants were approached by a general letter, which facilitators placed in the group room. All participants had been in the groups for at least four months and were self-selecting. Three male and three female members aged between 41 and 60 years and two male and two female therapists aged between 31 and 40 participated, a reasonable sample size for IPA analysis (Smith, et al., 2009). Most members had received previous therapy and presented with relationship difficulties linked to personality disorder co-morbid with anxiety and depression. The therapists were clinical psychologists and both therapist couples received an hour’s fortnightly supervision with a group analyst and worked within a psychodynamic framework. The groups were co-conducted for mutual support (Farrell et al., 2009).
The interviews
Group members and therapists were asked to meet individually with the author, who was not known to participants.
Four open ended questions linked to personal experiences of group therapy were explored with participants: what brought members to group therapy? What had their experiences been? What had been most and least helpful about group therapy? Was there a difference between how they thought the group might help when they joined and how it was helping them now? Two general questions were examined: how would they describe how the group worked to a friend? Were there similarities and differences in the roles therapists and members took in the therapy process? The same questions were asked of members and therapists, to allow participants to raise what was important to them, to guard against, as far as possible, being guided by author preconceptions.
Outcome was explored by asking participants about perceived changes in psychological functioning and whether it was linked to valued behavioural change (Donabedian, 1980). Members were not questioned about their difficulties. Interview questions were not rigidly adhered to, but used to prompt participants in describing their experiences. Interviews took up to an hour, were audio recorded and transcribed.
Analysis
Interview data was analysed by the author following IPA protocol (Smith, et al., 2009). The analysis stayed close to participants’ expressed experiences. This follows IPA, where the process of interpretation is anchored in participants’ accounts, guarding against preconceived concepts structuring the analysis. The analysis moved from initial comments on the transcript by the author, to the clustering of ideas, into final themes. These themes could be linked back to original commentary attached to transcript extracts. Data extracts and commentary about emergent themes are given in the results section. Supervision was used to develop coherence and plausibility of themes and reflect on when the author’s prior conceptions influenced analysis. The author kept a reflective log throughout the data analysis in order to be mindful of potential bias due to her professional background and interest in group analysis 1 .
Results
The analysis generated seven themes for group members and five for the therapists. See Figure 1.
Overview of themes for group members (GM) and therapists (TH).
Summary
Participants reported powerful feelings of ‘anger: disappointment with therapists and competition with members’; and ‘fears of emotional damage’. A process named ‘weathering’ was found to be an overarching theme by both members and therapists and seemed to connect with all other themes: If powerful feelings could be weathered and stayed with, understanding and working through, could occur, giving rise to positive processes of ‘sharing, leading to new learning’ and ‘change’. However, ‘weathering’ was seen as a challenging process and ‘support from other members’; and ‘therapists providing safety and care’ were essential ingredients in enabling members to endure the very strong feelings stirred up during group therapy.
The key theme of ‘weathering’ will be explored first, followed by an exploration of other themes generated by members, which will be compared with therapists’ themes.
‘Weathering’
Both members and therapists identified that it was frequently hard for members to stay with the process of therapy due to fears of damage, caused by overwhelming feelings, emerging in the group. This fear was linked to a shared theme: ‘fears of being emotionally damaged’ and group members’ themes: ‘anger could be destructive’ and ‘feeling attacked’. ‘Weathering’, as a super-ordinate theme, described the shared process of staying with these painful and overwhelming emotions, enduring, as opposed to avoiding them.
The term ‘weathering’ emerged from participants’ words. A group member described managing to stay and share her rejected feelings with another member, which ultimately helped her to feel more understood and connected:
‘I didn’t mean to hurt you (she said) and I said but you did . . . we made friends and so yes we weathered it’ (GM2b, 274). 2
A group member encapsulated the bitter sweet nature of weathering:
‘Even the bad times have been enlightening’. The therapy is ‘very beneficial . . . (although) been terribly bad times’ (GM1b 208).
The term ‘weathering’ was used by a therapist to describe the new emotional learning occurring when members realized they could ‘survive’ strong disagreements and ‘stormy’ emotions in the group. This therapist explained it was important for members to:
‘Know that it (the group) can weather storms . . . that’s an experience for a lot of people maybe that has been missing (in their families)’ (TH2b, 78).
Therapists described how members had to stay with angry and frustrated feelings before being helped by the group. They would:
‘Go away pissed off and not helped (TH1b 331)’, initially, longer term ‘nearly everyone who stuck with the group has, seems to have benefited’ (TH1b 423).
Group members’ perspectives
Group members gave many examples where they managed to stay with very difficult situations and feelings, which proved ultimately helpful.
‘Anger—competition with members and disappointment with therapists’
This theme captured strong feelings emerging, in themselves and others. The following sub-themes were generated.
‘Anger with other members’
A member described getting so angry with another member that he threatened physical violence: He ‘put me down and I, I threatened to knock him down’ (GM2a 449).
A member described becoming angry in the group, something she had previously avoided. She reported saying of another member:
‘I wanted to crush him like a . . . beetle’ (GM1a, 129). The therapist said ‘he (the group member) was like my relative and I said no . . . It was rubbish’ (GMa,131). GM1 said expressing anger ‘unblocked quite a bit’ (GM1a, 144) and helped her improve the relationship with a relative outside the therapy as: ‘it was like releasing a lot of anger about her (relative)’ (GM1a, 141), ‘because I managed to, I rang (her and) . . . we’ve started a new relationship’ (GM1a, 162).
‘Anger: disappointment with therapists’
Members expressed disappointment with their therapists for ‘not doing more’, describing hopes being dashed over the amount of help they received, and being furious at times because they felt their therapists were actively withholding help due to being lazy and neglectful:
‘They’re expert and they don’t feed anything back’ (GM1a, 342). One member said he remembered another member had: ‘shouted . . . why didn’t you . . . you have to look after me’ (GM1b 584). One member recalled another’s fury with their therapist for not giving enough help, saying he: ‘attacked him (the therapist) at first because he hadn’t been more helpful’ (GM1a 218). Another stated: ‘I wanted much more of them than I was able to get’ (GM1b 662).
‘Anger linked to pain of sharing’
Anger seemed to be expressed through conflict and competition between members over having to share space and attention in the group, a finite resource which was fought over, as described by one member: ‘I’m trying to get some feedback, listen can I get in?’ (GM2c 654).
‘Fears of emotional damage’
This theme captured concerns that being exposed to strong feelings could be damaging, rather than a therapeutic process, as described in the following sub themes:
‘Anger could be destructive’
Group members worried about the damaging effect of their anger on others and feared that others might not survive their anger, including the therapists:
I ‘feel sorry for the therapists . . . rough time . . . people are really getting at them’ (GM1b 612). Concern that expressing anger could cause fear in other members was illustrated by one participant reporting he had made: a ‘threat, physical (one)’ to another member. He complained that a third ‘said that he didn’t like this display of alpha male behaviour and he’s about to run out of the group’ (GM2a 449) and was worried about ‘damage’ that could be caused (GM2a 327).
‘Fears of being emotionally damaged’
Members expressed concern about being emotionally damaged, through witnessing other peoples’ distress and emotional outpouring, leaving them feeling overwhelmed. A member described feeling:
‘Emotionally shattered with it (the group)’ (GM1b 57) and having to listen to members: ‘bringing their problems and it’s very . . . upsetting things’ (GM1b 298). ‘It’s upsetting me too much’ (GM1b 330). You ‘come out and you feel dreadful’ (GM1b 155).
‘Feeling attacked’
Doubts were expressed as to whether it was therapeutic to feel attacked in the group, especially when this experience mirrored past traumas. Members described wanting to leave the group, but also described the benefits of staying. One member said being attacked by another member was:
‘Incredibly negative at the time, but turned out to be hugely liberating’ (GM2c 755). ‘She was very rude . . . did me a lot of good because standing up to women is not something I’m good at’ (GM2c 347). After the attack he felt: ‘huge emotion and tension . . . really felt ill, good God, it was the most incredibly positive thing . . . look what’s happened’ (GM2c 766).
Another member described persevering to communicate her point despite feeling fearful, which was a breakthrough as she had never done this before:
He ‘really started attacking me, (it reminded me of) the past . . . I remember always being very frightened’ (GM2c 740). ‘I thought oh God he just doesn’t understand . . . everything to him is anger. He listened to me and I say I think I got through to him’ (GM2b 296).
Experiencing feeling attacked in the group seemed helpful when members ‘weathered’ the experience by staying with their feelings and in dialogue with others, even when they felt threatened.
‘The dilemma of weathering: staying to understand versus avoiding frightening feelings’
Group members described a struggle with tendencies to avoid overwhelming feelings, through excluding them collectively from the group:
‘We don’t get angry in the group, ‘cos it’s quite frightening’ (GM1a 161) or removing themselves. A member said he had to: ‘leave the room, ‘cos I was emotionally (upset)’ (GM1b 49) and had ‘been at point of stopping (group therapy) I think three times’ (GM1b 214).
One member explained that the group ‘does take over emotionally, completely . . . (then I) kind of think, no, this isn’t my family’ (GM2b 345). This member seemed to find a space to think and to separate the original traumatic experience from her experience of the group.
Being able to withstand the impulse to leave the group because of a disagreement with another group member was highlighted: I am ‘So glad I didn’t (leave) because it was resolved’ (GM2b 262). One member talked about someone who had dropped out: ‘The reasons they’re leaving is, are quite patently the wrong ones’ (GM1c 214).
What is needed to weather strong feelings?
In order to ‘weather’ frightening and distressing feelings, members made it clear that ‘support from other members’ and the therapists ‘providing care and safety’ helped them stay and endure the group experience.
‘Support from other members’
Members described wanting to leave the group, but being helped to persevere:
‘Five of us who kept going, some of us wanting to withdraw, but keeping going encouraged by others’ (GM1a, 73).
Support from others helped members bear feeling attacked in the group. A member described feeling supported to stay and confront his attacker (another member), through putting his feelings into words, rather than avoiding the situation which he had always done in the past:
‘I was able to open up . . . say what horror this is’ (GM2c 48) and ‘was backed up’ (GM2c 749) by other members.
‘Therapists as parents providing safety and care’
Clients conveyed that they needed their therapists to make the group safe and provide a containing function. One participant described his therapists as:
‘Extended parents’ (GM2c 136) and that his male therapist ‘provided a paternal role for me in a way a strong guardian’ (GM2c 183).
This parental role extended to providing individual attention and support to members, helping them stay in the group. After missing some sessions, one client explained the therapists had written to her to:
‘Encourage me to come back, so I thought oh they do care, they do miss me’ (GM2b 591).
Members felt they needed their therapists to provide a safe setting in order for them to explore and take risks in relating to each other more closely:
‘People think they’re there to keep order, to make sure that we don’t end up killing each other’ (GM1c, 358). One participant encapsulated this theme saying: ‘As long as they (the therapists) keep the bus on the rails . . . and take care that that we’re not going over the cliff, that we can party on in the back’ (GM2c, 161).
The benefits of weathering
‘Weathering’ was experienced as therapeutic because it provided new emotional learning for members, enabling therapeutic processes of ‘sharing’ and ‘change’.
‘Sharing leading to new learning’
Sharing helped members to realize the universality of problems, as one member described:
You can ‘see a similarity . . . (in other members, it) gives you a bearing’ (GM1b 123).
Noticing differences also underpinned new learning. One client said:
‘I didn’t realize that people could be that sensitive (she) taught me something which, because I suppose my life’s taught me not to be sensitive’ (GM2a 283).
Being offered a fresh perspective on oneself was described by one participant, when another said to him:
‘You’ve done all that yourself, and I hadn’t realized that. That’s a pat on the back’ (GM1c, 254).
‘Change’
The process of change was directly linked to managing to stay in the group, as one member commented about another:
‘He’s calmer, he’s not so agitated’ (GM1a 439).
Members described the group helping them reduce destructive and self-harming behaviours:
I ‘did feel suicidal, but it got less and less’ (GM2b, 576). Another said it was the:
‘First time I’ve not been dependent on either drugs or alcohol for 31 years’ (GM2c, 779). This change was attributed to ‘learning to manage your emotions’ (GM2b, 624) rather than self-medicating or dealing with them in destructive ways via alcohol or drugs.
‘Change’ meant members felt less overwhelmed by symptoms of anxiety and able to assert their needs in more productive ways. One explained:
‘I don’t think many people have panic attacks, we’ve tackled that . . . (We are) stronger, more confident, better able to deal with things’ (GM1 451). Another remarked: ‘I never used to have this confidence’ (GM2b, 498).
Comparison: group members and therapists
The majority of themes were shared between group members and therapists (figure 1). Both members and therapists identified the painful nature of therapy linked to overwhelming emotions, through the shared themes of: ‘anger linked to competition with members and disappointment with therapists’ and ‘fear of emotional damage’. There were however differences in emphasis and perspective, indicated by differing sub-themes. Members emphasized aggression in the group by adding an additional sub-theme of ‘anger with other members’. This conveyed a more direct and interpersonal quality to the anger expressed in the group, that therapists did not describe.
Although both members and therapists worried about ‘Fears of emotional damage’, members expanded this through sub-themes of ‘anger being destructive’ and ‘feeling attacked’. They emphasized anxieties of being made worse by the group, by venting anger but also being the victim of others’ anger, hence the sub-theme of ‘anger with other members’ which only members identified.
Therapists however generated a different sub-theme: ‘re-enactment: repair or re-traumatizing?’ referring to the potential benefits of repeating past trauma in the group, but it also posing a risk, if the experience was not worked through and understood. One therapist said it can be:
‘Helpful for them (members) to have the experience of feeling deprived and to reflect on it and what it means to them’ (127), in the context of ‘sharing in a (group) family which is more healthy’ (TH1b, 591).
However therapists were also concerned this experience could be extremely painful and possibly damaging:
A ‘repeat of, of not feeling heard and not feeling that important or taken seriously’ in the group, is ‘horrible’ (TH2b 335), stated one therapist.
A therapist worried about the repetition of feeling neglected, enacted for members, by having to share a therapist and often feeling they were:
‘Not getting enough’ (TH1b 107). He worried it was ‘almost cruel to put somebody into a family (group) situation who’s had an unhappy family background’ (TH1b 564).
In order to weather the group experience, members emphasized that they needed ‘therapists as parents providing safety and control’ and ‘support from other members’. Therapists on the other hand only briefly mentioned ‘Therapists as parents providing safety and control’ (a minor theme) and they did not link it to the powerful and encompassing parental role, providing caring attention and physical and emotional safety, that members emphasized. Nor did the therapists mention ‘support from other members’. However therapists included themselves in the weathering process, something which members omitted to mention. One therapist explained it was important for the therapists to model their own weathering of the group process, showing:
‘We can bear that and survive it’ (TH1b, 727).
For both members and therapists, the key theme of ‘weathering’ heralded positive processes of ‘sharing leading to new learning’ and ‘change’. However the therapists described change more as developing relationships with others, whereas members highlighted improvement in symptoms. In the theme ‘sharing leading to new learning, ‘therapists described members discovering that they had ‘something to give others’ which was of value, by finding:
‘Another aspect of themselves, a helping part’ (TH1b, 179).
The theme of ‘change’, for the therapists, was about relating to others, for instance a group member being:
‘More assertive in personal relationships’ (TH2b, 121) and ‘allowing maybe more other things to happen . . . the risk of trying to be in a different relationship’ (128).
Therapists also touched on the idea that change may encompass painful realizations or insights. One therapist described a member becoming:
‘More in touch with what’s missing in her life . . . (which) could lead to very constructive things’ (TH1a, 226).
Discussion
The emerging themes in this study reflected experiences and observations familiar to group therapists. However, examining members’ experiences as their realities, rather than through the filter of analytic interpretation, highlighted dilemmas facing both members and therapists. This stimulated reflection upon commonly held principles.
A process named ‘weathering’ emerged as a key theme. If members were able to stay with strong feelings stirred up in the group, rather than acting on their discomfort by leaving or withdrawing, there was an opportunity for new learning and change.
The situations that needed to be ‘weathered’ were described by members as emotionally charged interpersonal encounters with other members. These interactions illustrated a key therapeutic process which Foulkes called ‘ego training in action’ (1964) and Brown (1994) renamed ‘self-development through subjective interaction’—a process of maturation that happens specifically in groups through interaction.
Whilst participants in this study regarded ‘weathering’ as ultimately helpful, the findings pointed to quite how difficult the therapeutic process was and how at times it stretched members’ capacity for endurance, to the limit. There seemed to be moments when it was on a knife’s edge, as to whether someone stayed or dropped out. It is important to remember that those who participated in the study were able to ‘weather’ these relational storms and had stayed in the group. But members spoke of others who had not and had left. Being exposed to the input of others who openly expressed strong feelings such as anger, makes a group less protected than individual therapy. But also more exposing than everyday life, where social constraints can limit confrontation with raw emotions.
Hummelen et al., (2007) in their qualitative study on patients who dropped out of group therapy, showed that exposure to strong negative emotions was one reason given by participants. Contrastingly, the patients who volunteered to participate in the present study had managed to ‘weather’ similar challenges and felt helped by group therapy. Support from members and therapists was needed in this process, as expressed through the themes of ‘support from other members’ and ‘therapists as parents providing safety and control’. This echoes the widely documented links between cohesiveness (at group level) and therapeutic alliance (relation to the therapist) and outcome (Burlingame et al., 2001; Bruce et al., 2013).
‘Weathering’ shares common features with the concept of mentalization (Allen et al., 2008), but is not identical. Mentalization is defined as a mental activity through which one’s own and others’ behaviour is perceived and understood in terms of intentional mental states, such as needs, feelings, reasons and purposes. Thus, ‘weathering’ fleshes out the first step needed in mentalization. This is persevering in the mental activity, despite distress, needed to translate pressing internal impulses into bearable experiences, as opposed to acting upon them (Allen et al., 2008). It adds to the concept, by describing participants’ perspectives of how they ‘get to mentalize’, highlighting the emotional work involved. It captures the subjective quality of the dynamic journey, from feeling overwhelmed by fear, discomfort and anger, to attaining new learning and change. Vividly elaborating the attacks and barriers to ‘thinking about painful states of mind’ (Bion, 1959) along the way.
Differences between members and therapists, emerged in the significance attributed to the therapists’ role, in helping members ‘weather’ overwhelming feelings.
The findings raise the question of whether therapists underestimated the extent to which members struggled with the emotional challenges of being in a group and overestimated their mentalization capacity (Pothoff and Moini-Afchari, 2014). Hummelen et al., (2007) found similar differences between therapists and members: the therapists’ accounts of why patients dropped out of therapy did not include strong negative feelings, particularly aggression and rage, which patients named as important factors.
Fear of annihilation, linked to fears of provoking aggression and a fragile sense of self, are exacerbated by the dangers the group situation evokes (Nitsun, 2015). According to Nitsun (2015) these factors are under-estimated in the literature and practice, yet can account for group fragmentation and member drop-outs.
However, therapists in this study did express concerns through the theme: ‘Re-enactment: repair or re-traumatizing’. Rather than lacking awareness of their group members’ struggle, they may have used a different, theoretically based, language. But in contrast to group members, therapists did not emphasize the role of support from others and barely mentioned their own role in helping members to feel safe enough to stay.
The need to acquire behavioural skills, to manage their emotional responses in close relationships is crucial for borderline clients (Harvey, Black and Blum, 2010) because intimate relationships are often the context of early trauma. Initial stabilization of emotional affect using a structured and often didactic approach to reduce arousal is a necessary precursor for mentalization, according to Bateman and Fonagy (2013) and therefore useful in analytic groups (Nitsun, 2015).
Hummelen et al., (2007) interviewed patients with Borderline Personality Disorder, who had dropped out of group psychotherapy and their therapists. Finding group therapy too distressing and not feeling contained by the weekly sessions, emerged as important factors in patients’ accounts of their reasons for leaving. The authors observed a discrepancy between patients and their therapists, as therapists seemed to underestimate the significance of aggressive emotions on patients’ dropping-out.
Interestingly a qualitative study by Johansson and Werbart (2009), found group members attributed positive group experiences of increased self-knowledge and improved handling of emotions, to themselves and their ‘own activity’. Whilst negative outcomes were attributed to a ‘lack of therapist activity’ and other members.
However, processing emotions that have ‘been allowed to emerge’ through decreasing facilitator interventions (Foulkes, 1964), is key to therapeutic change in group analysis (Foulkes, 1964; Yalom, 2005; Bion, 1967). Focus on group process is often omitted from structured groups, reducing opportunities for positive change (Pipon-Young and Cole, 2012; Burlingame et al., 2003).
Potthoff and Moini-Afchari (2014) demonstrated how directive interventions could be incorporated into group analysis, whilst maintaining a climate in which unconscious dynamics could be explored. This shows how an open group analytic format can be compatible with MBT interventions. They suggested keeping an eye on unconscious group dynamics, whilst concurrently monitoring the level of emotional challenge, which could be regulated.
Group members in this study appeared to have benefitted from an opportunity to explore their feelings and relationships within the unstructured format of an analytic group. This was despite finding the process very challenging and needing the support from other members, whilst wanting more protection from their therapists. Weighing up the benefits of allowing free expression, to maximise opportunities for ‘ego training in action’, with the need to provide limits, before it is experienced as overwhelming or destructive, is an important consideration for therapists in their task of balancing analysing and supportive functions (Foulkes, 1964). This requires a complex judgement of the group’s and individual members’ capacity to ‘weather’ and how far members can be relied upon to initiate support in helping the weathering process.
When free-floating emotional expression is in danger of becoming unproductive and destructive, directive therapist intervention is needed (Nitsun, 2003). Intervening to lower the emotional intensity of an exchange seems crucial in creating optimal conditions for mentalizing, since overwhelming emotional arousal can trigger fight or flight (Allen et al., 2008).
This seems particularly pertinent to psychotherapy groups run in the NHS, where members’ psychological resources may be limited. External storms may also need to be weathered by groups, through providing a refuge from benefit cuts, inner-city poverty and isolation, according to Nitsun (2015). Thus weathering maybe an essential process in the development of insight and change in therapy.
Many group analysts working in the NHS are aware of the need to adapt their practice to their patients’ capacity to ‘weather’ the challenges of group therapy, but this research contributes to a more substantiated rationale for this stance.