Groups went out of fashion in the world of UK mental health for more than twenty years. Now they are re-emerging in a looser form, often as part of wider social networks - an inevitable, if unacknowledged recognition of their role as basic units of society. The new form they take is a reaction against their perceived over prescriptive character in the past, particularly in psychodynamic psychotherapy. However, although the need for group work has become explicit again, those who construct them remain largely ignorant, as in other areas of mental health practice, of progress made in the life sciences, on understanding natural human groups and the ‘social brain’.
My first taste of group work was in 1988, a year after my first admission to a psychiatric hospital. The clinic was a converted country house several miles from the city centre. It was traditional group therapy, in a relatively controlled environment. A large living room, in which 10 easy chairs placed in a circle fitted easily, in a quiet and remote location. It was thought a virtue that we were away from a normal environment, but actually it was so untypical that I soon came to question its relevance to our real world problems.
I realised almost immediately I’d need time, both before and after the weekly one and a half hour sessions, to adjust to the difference with the outside world - sometimes up to half an hour to get my head together. It began as a closed group of 8 clients with 2 nurse therapists as facilitators (smaller groups were thought too intimate, larger increased the likelihood of two conversations developing). When someone failed to turn-up the empty chair was left as it was. The facilitators were there when we arrived and stayed seated until we left. They sat across from each other - an obvious way to ‘cover’ the room and cue each other! (It was easy to start thinking like that because they were so ‘non-directive’, many of the clients in contrast were actively looking for advice and direction). They rarely intervening, but most members wanted explanation, insight and leadership. The group didn’t remain closed for long however because people steadily dropped-out. For newcomers it was more difficult to join an established group. I remained for eighteen months.
The idea of a Group as presented to us was that in such controlled circumstances, the masks we presented to the world, or screens we hid behind, would be removed; problems we hid from ourselves and others would be revealed, the unconscious forces that led us to replicate mistakes exposed. We would be encouraged to express both positive and negative feelings as they occurred, and have those thoughts and feelings accepted by the group. We would be helped in learning how to express emotion.
I discovered later that the therapists had been trained in a psychodynamic approach, although there were no explicit references to transference relationships (let alone counter-transference), defence mechanisms or indeed a group dynamic. We were however gently reminded of how we might be bringing past and present relationships ‘into the room’ replaying them or acting them out. We all found it difficult to articulate problems in front of the group and cope with the reaction of others, but the desire to ‘do archaeology’ (dig-up the past) was strong, in preference to confronting what was happening between us in the ‘here and now’. But it always remained the assumption of the therapists that what we were doing was seeking insight, and that that in itself would provoke behavioural change.
Pre- and post-group meetings between members were not allowed, but they took place nonetheless. Indeed these encounters led in time to my being a guest at the family home of one of the older male clients on several occasions, and to my meeting outside the group with one of the younger female clients. Also, with a third member, I had one of those moments of disbelief upon meeting someone you have heard talked about incessantly, in this case the person’s partner, and immediately concluded they’re not a bit like you’ve been led to believe!
I found the therapy sessions often quite exciting but emotionally draining, a tension between what I was observing and feeling. People would try to sit in the same seat every week, and become quite disconcerted when I didn’t. The ninety minute sessions were not at all egalitarian, clients competed for time for themselves, some tried to ‘hog the limelight’; others more subtly, would seek to shift the conversation in the directions they wanted to go, some sought alliances, some to mediate, some seemed to just want to belong, others to be accepted as they were. Within a session there were short periods of half an hour or so when real work seemed to be done in a mutually supportive way. But the events within the group were much less dramatic than those recalled by the members from their lives outside it.
My sense of mental wellbeing certainly improved whilst I was in that first group and for almost a year after. Since then I’ve been part of dozens of groups intended to have some sort of therapeutic effect, and structured and managed to varying degrees. I’ve come to prefer the more informal groups one can contrive for oneself with ones peers. The first thing to emphasise is that it is the activity, or the making of relationships themselves, which is important rather than some imagined product or outcome.
An old, but illustrative example from inpatient wards is what might be called, The Art Room Versus The Smoking Room; it is common for the outsider to view The Art Room as an area of calm, purposeful activity with a definite outcome. They may express surprise when after an hour’s absorption in making a painting, a client simply walks away discarding their individual effort. They may seek to praise the client’s work, suggest it be kept, or put on the wall. The client shows no interest in this - it is the hour away from his or her intrusive thoughts that is important. In contrast The Smoking Room is viewed by the outsider as the antitheses of healthy activity; dark, poorly ventilated, clients indulging their habits for nicotine and caffeine, sitting around in unfocused, purposeless conversation. Yet flow, the loss of self-consciousness first experienced in childhood, often occurs in one-to-one conversation (occasionally with more). From the client’s point of view here is the opportunity to talk to each other about the very things that they are unable to express to staff, and which other clients are better able to understand. (It’s worth noting in passing that clients will often ‘protect’ staff psychologically, by not discussing issues and behaviour they have come to know will disturb them).
Secondly real facilitators do not teach. The term has been much abused. It does not refer to someone who arrives in a group with an agenda, with things they will teach or seek to demonstrate. (They would certainly not stand-up, use a flip-chart and lecture to a group!) A proper facilitator is a member of the group, and is unlikely to intervene until they have come to know the group. They seek first and foremost to be fully in the room, sensitive to the feelings of both the group and the individuals within it. Interventions occur when they seek to redirect conversation or activity towards areas which their experience suggests are useful. Thirdly, groups always have a ‘star’, but they are not leaders appointed or accepted by the group, but the person who appears to be get most from the group, changing or benefiting the most. Other members often respond positively to that person as an example or role model, but sometimes negatively as yet another example of how they are failing!
Fourthly, since the activity of the group is all - and the ‘here and now’ a group’s proper concern - it is important to what extent someone is in the room, living in the present moment, able to let go of thoughts and feelings about the past and future and fully participate. For example, one person sits alone in a corner of the room; are they agitated and their thoughts miles away, or are they calm, quite and possibly acutely observant? Alternatively, is the person calmly absorbed in an individual task, or agitated by their observance of what is happening in the room? The person who is not participating remains an outsider. Often clients are forced to remain outsiders despite being in groups. Staff are usually part of a fixed group outside of the activities they devise for clients. They have their own professional competencies and ‘codes’ of behaviour. In so far as they bring such ‘values’ to the group, they prescribe/ pre-determine group activities and relationships before it even starts, and so always exclude clients. But staff of course then remain outsiders to the shared concerns of clients. Clients have informal codes of behaviour too, and confidences which they share only with each other - not just because they may feel misunderstood, or wish to protect, but because of the practical consequences of giving information to the mental health services which may be passed on, recorded and acted upon. Clients often form self-help groups of ‘like’ people - they gain the emotional bond of shared experience, but they also share the same strengths and weaknesses.
Fifthly, as in any social encounter what the participant remembers or ‘takes away’ from a group is rarely a precise memory of what was said. What is remembered is the atmosphere or mood, whether it was a good experience; relaxed and friendly; or anxious, hostile or perhaps aggressive - a general feeling of like or dislike for the other participants. Finally, practice has taught me that the more mobile, less routine and predictable a group’s activities can be the better; but all change, good or bad, is stressful.
However, even the very basic level of interpretation I’ve given to group activities is often frowned upon these days within the mental health industry - giving choice to the client and upholding ethical and sometimes political values, means not seeking to understand social processes. (The very antithesis of what this blog is about). Social networks are thought okay and their voluntary nature emphasised, but at times even encouragement to join is thought too prescriptive. If only mental health professionals were more aware of the content of genuinely peer organised activity, or indeed online activity! But the basic drive to belong is recognised, and loose open groups with no fixed location guard against dependency and institutionalisation. Changing your environment and finding new people to motivate you, are the only elements that will break old habits by replacing them with new more useful ones - the brain is just like that.
Throughout recorded history there can be found observations by the socially curious on what might be the natural or optimal size of a human group. At the lower end groups begin at around 5 - the basic family unit. More than that and two ‘conversations’ emerge, at around 8 to10 a group begins to have divided loyalties. At the upper end it has long been noted that where people live, work and play together then at between 100 and 130 they will split into two new groups. Doomsday Book gives you an average size for a village of 130, recent archaeology offers a similar figure for earlier Anglo-Saxon settlements. The necessity for battalions, the imposition of a chain of command to control numbers larger than the basic unit of a ‘company’, emerged in Roman times. Today, some isolated religious communities with long traditions will anticipate a split, and plan for the division of resources, as their numbers approach 100 - one of the new groups will relocate locally, but separately. Promising small businesses which expand rapidly are notorious for failing when the number of employees exceeds about 130 if they don’t radically devolve away from the ‘hands-on’ day-to-day personal control of one individual or family. (The late Wilbert Gore, he of Gore-Tex fame, allegedly built factories with only 150 parking spaces - when people started parking on the grass he knew it was time to add a new small plant elsewhere rather than expand on the same site). Whilst for ‘bandits’, or other family-controlled outlawed groups, then holding the group together may become their principal preoccupation!
The key recent insight has come from Robin Dunbar (Dunbar 1992, 1996) in his study of grooming behaviour in primate groups. Having observed the stable group sizes of other primates - the number that any one individual can effectively groom - he made the intuitive leap that the natural size of social groups is directly proportional to brain size (more specifically the neocortex, the cognitive processing bit!) What followed was a complicated statistical exercise, including making allowance for brain size relative to body size, which hypothesised an upper limit for a human group holding together of around 150 (mean group size 147.8). (Indeed amongst the 21 modern hunter-gatherer groups Dunbar considered, the average size was 148.4).
One shouldn’t underestimate the implications of ‘Dunbar‘s number’. We are social animals and whilst we can recognise thousands of faces, our brains have a limited memory and processing capacity - there are only so many people we can truly ‘know’; both in the sense of cognitively knowing enough to understand and therefore have a relationship with, but more fundamentally, the capacity to feel for, care about and be emotionally attached to. The ‘bands’ in which our distant ancestors lived were of course comprised of their closest genetic relatives. There was no distinction between those with whom they lived and worked (shared a culture with) and those with whom they had a strong genetic attachment or attraction to. In our world we are very unlikely ever to meet those closest 150 relatives for whom our brains are forever searching.
However, it remains the case that our loyalties are limited; to be cautious or even hostile to outsiders or strangers is normal, so is discrimination and exclusion. As you get to know too many people it is common to ‘become a stranger to’ someone you once knew well. Equally, we should be wary of those who claim to be entirely ‘open’ people and a friend to all the world. There are some things we cannot succeed at, we are severely weakened if we are not either fully participating in our own groups or are over ambitious (compromising our chances of survival) and try to embrace beyond the capacity of our own brains for emotional attachment. The benefits of training, education and the ‘collective brain’ offered by computer technology cannot override the social brain. We do better when we recognise fundamentally different or opposing interests and negotiate with other groups with different interests and loyalties, rather than pretend we can embrace the whole of humanity. We should suspect delusion in those who espouse selflessness and claim self-sacrificing devotion to too many. We may well have a primal drive to belong, but only to our own group.
(Note - I’m only implying ‘group selection’ in cultural and not biological evolution, none of the above contradicts neo-Darwinism which I take as a given in everything written on this blog).
Dunbar R (1992) ‘Neocortex size as a constraint on group size in primates’ in Journal of Human Evolution vol. 20 pp. 469-493
Dunbar R (1996) Grooming, Gossip and the Evolution of Language Faber & Faber: London
