Section 1 Group Therapy

## **Chapter 1**

## Perspective Chapter: Therapeutic Alliance, Rupture and Repair in Group Therapy

*Esther Lynch, Jeremy Lynch, Kiana McClintick, Bradford Pippen, Kayla Womack and Kiela Hinson*

## **Abstract**

This chapter contains an overview of the therapeutic alliance including the purpose and importance of therapeutic alliance as well as recent research that provides knowledge on therapeutic alliance within the group therapy context. This chapter will also take a deep dive into understanding the rupture-repair model, its' connections with therapeutic alliance, and provide clinical examples of what a rupture and repair may look like in group therapy. Finally, this chapter discusses cultural considerations and includes clinical examples on rupture and repairs where individual and cultural differences are important. In conclusion, therapeutic alliance has been identified as a key contributor to positive outcomes for group therapy clients. While ruptures are expected to occur during therapy, It is important to note that both the rupture and the repair equally effect the therapeutic alliance as well as the outcome of treatment. Outcomes to therapy that align with a strong therapeutic alliance include reduced symptoms, client retention, improved outlook on life, and an improved occupational and interpersonal functioning. Outcomes of therapy associated with a successful repair involve a decrease in anxiety and depressive symptoms, increase in daily living activities, an increase in empathy for their group members, and stronger therapeutic alliance among the group.

**Keywords:** therapeutic alliance, repair, rupture, group therapy, cultural competence

## **1. Introduction**

Many professionals consider therapeutic alliance to be a key hallmark of successful therapy. The quality of the working relationship or therapeutic alliance between the therapist and client is most beneficial when a strong bond is present, and the goals and tasks of therapy align. The core of exploring and understanding the therapeutic alliance is examining the client's attitude towards the therapist and the therapist's ability to engage and relate to the client. The two must mutually agree and collaborate on the goals and tasks of therapy, which takes understanding on both parts. Cultural competence plays an important role in the understanding process. Information must constantly be reviewed and evaluated for accuracy due to differences as well as similarities and how those experiences may or may not affect understanding.

This chapter explores the dynamics of therapeutic alliance in a therapeutic group setting. In a group setting the relationship or alliance exists within the whole group and the therapist leads the group through the therapeutic process.

In a group setting, there are many personalities to manage and to attempt to bring cohesion to the environment. When there is a breakdown in the alliance process, this is known as a rupture. Ruptures are a part of the process for both individual and group therapies. In a successful therapeutic alliance, the therapist and client, or group members can successfully resolve any tension or breakdowns in communication And successfully navigate difficulties in the collaboration of goals and tasks. If the rupture is not repaired correctly then it can lead to poor outcomes in therapy. We explore the types of ruptures that can occur as well as strategies to repair those ruptures correctly. Clinical examples are used to illustrate interventions used to manage ruptures and repairs to create a strong therapeutic alliance with group members.

## **2. Therapeutic alliance**

There is a breadth of research about the benefits of alliance within therapy [1, 2]; Therapeutic alliance refers to the connection a therapist has with their clients and encapsulates a degree of trust and collaboration that sets the stage for future sessions [3]. More specifically, therapeutic alliance refers to the genuinely developed connection between therapist and client, and the degree of agreement and commitment to treatment goals used in treatment [4, 5]. A strong alliance exists when there is a strong foundational relationship that identifies each person's role in the relationship, and both agree on the goals and tools to be used.

Therapeutic alliance has emerged as one of the central contributors to positive outcomes for clients in therapy [3, 6]. The term therapeutic alliance was first mentioned by noted psychoanalyst Sigmund Freud and has since come to reflect Bordin's model, which emphasizes the need for clarity and collaboration [5]. A strong therapeutic relationship reflects the degree of agreement to working towards the mutually agreed upon treatment goals and clarifies the roles and expectations for both client and therapist [7].

Mental health professionals establish alliances with clients by providing space for vulnerability, conveying empathy, and remaining adaptable [8, 9]. Developing good therapeutic relationships requires working with the client to determine their goals while providing a judgment-free space. Additionally, studies have shown that a strong therapeutic alliance includes mutual agreement on the goals and tasks, and a willingness to make changes for the client's benefit [5, 8, 9].

#### **2.1 Working towards alliance**

Psychotherapists build strong therapeutic or working alliances with clients by establishing a sense of mutual respect, trust, and safety through social interactions [10]. Establishing and maintaining this connection requires the therapist to engage in an authentic working relationship geared towards helping the client reach specific, pre-identified goals for psychotherapy [11]. A strong therapeutic alliance exists between therapist and client when the client can express vulnerability openly [11].

The following example interaction illustrates how Joe, the therapist leading a group with the goal of developing effective communication builds alliance with the group by discussing individual goals during the first session [5].

*Perspective Chapter: Therapeutic Alliance, Rupture and Repair in Group Therapy DOI: http://dx.doi.org/10.5772/intechopen.110700*

**Joe:** Hello everyone and welcome to our first group session on developing effective communication skills. I'd like to start with everyone introducing themselves and giving a brief description of why you are here and what is your goal for becoming a part of this group.

**Chris:** Hello, my name is Chris and I'm here to improve my communication skills with the goal of communicating more effectively with my wife.

**Kathy:** Hi everyone. My name is Kathy and I decided to join the group so I could work to communicate more efficiently in my workplace.

**Alice:** Hi! My name is Alice, and I am here to work on my communication skills with the goal of repairing and improving my relationship with my adult daughter.

Although this interaction seems inconsequential, Joe knows how important it is and the impact it can make on therapeutic outcomes to develop therapeutic alliance with each individual in the group. Agreeing on the goals of treatment is one of the three essential elements that make up the therapeutic alliance [5].

#### *2.1.1 Therapeutic alliance interventions*

Interventions for establishing and maintaining therapeutic alliance in group psychotherapy include creating gender-specific groups, encouraging the formation of working relationships among members, treatment type, providing treatment options, words of encouragement from the psychotherapist-leader, and introducing mindfulness-based interventions [12–14].

In a systematic review of articles addressing therapeutic alliance, group cohesion, empathy, and goal consensus/collaboration in psychotherapeutic interventions, researchers found significant independent relationships between cohesion and rapport with positive treatment outcomes [13]. They also found studies that reported slightly increased collaboration was related to successful outcomes [13, 15]. However, a review of studies about collaboration in group psychotherapy found that this element may have an impact on treatment outcomes distinct from therapeutic alliance. The most notable impact on treatment outcomes were for those who were identified as being at risk for the likelihood of negative outcomes early on in treatment. The formal feedback during the collaboration helped to change the client's perception of change, motivation for treatment, the therapeutic relationship, and increase social support system [16].

#### **2.2 Factors that affect therapeutic alliance**

The climate of the relationship may have more impact on alliance building in group therapy than individual therapy [1, 14]. A meta-analysis of studies examining therapeutic alliance in group therapy and outcomes found a strong correlation specifically between the group leader-therapist and group members [1]. In other words, they found that the therapist's alliance with each group member was connected to their positive treatment outcomes [1]. However, when comparing the effects of alliance in group therapy compared to alliance in an individual therapy setting, results showed a slightly weaker for outcomes in group therapy. Though group therapy was found to have a slightly weaker effect on outcome than individual therapy, difference in the effect could be explained by the complex relationships that exist in group settings [1].

Another study found that individuals in group therapy pay more attention to the overall quality of their relationships with others in the group rather than everyone's

assigned roles as member or leader [17]. Additionally, researchers found that the other versus self-focus factor present within group psychotherapy also influences therapeutic alliance building [18]. Meaning, the more members are interacting and focusing on the presenting concerns of their fellow group member, the stronger the group alliance will become.

The therapeutic alliance between group leaders, or psychotherapists, and group members, or clients, was found to be related to treatment outcomes in a Swedish study by Von Greiff and Skogens [19]. They examined positive changes in clients attending a group therapy program for alcohol and substance use. Clients' responses about acceptance, trust, confidence, and partnership revealed two themes identified as: 'treatment staff' and 'treatment group' [19, 20]. These themes align with the principles and goals of therapeutic alliance where the leader and its group members have an influence on treatment outcomes. A follow-up study by Von Greiff and Skogens [20] exploring the individual differences underlying clients' descriptions of alliance in a substance use psychotherapy group found that the social roles of clients impacted the group's cohesion. This study also found that race/ethnicity, social class, and particularly gender, can play a role in the psychotherapist-leader and client-group member relationship.

#### **2.3 Treatment outcomes**

Numerous studies have found a consistent link between therapeutic alliance and positive treatment outcomes for individuals in psychotherapy [21–23]. Specifically, the quality of the working alliance between therapist and client has been linked to successful treatment for a diverse array of clients, presenting problems, and treatment modalities [6, 21]. Four meta-analyses on therapeutic alliance conducted over two decades revealed a significant correlation between a strong working alliance between client and therapist and successful outcomes [21, 24, 25]. Although these studies examined alliances within the context of individual psychotherapy, a strong therapeutic relationship is similarly necessary for couples and group psychotherapy.

Successful outcomes connected to therapeutic alliance in psychotherapy include improved client retention, reduced symptoms, improved occupational and interpersonal functioning, and an improved outlook on life [22]. Researchers have examined the relationship between the working alliance of psychiatrists and patients and treatment outcomes [26]. Successful outcomes were evidenced by reported increased patient happiness with treatment, adherence to medication and keeping set appointments [22, 26]. Another study on therapeutic alliance between psychiatrists and patients with bipolar disorder resulted in fewer negative beliefs towards medication, diminished stigma towards bipolar disorder, and fewer manic symptoms [27]. These improved treatment outcomes are also connected to therapeutic alliance with psychotherapists.

Research focused on therapeutic alliance within group psychotherapy, or cohesion, has focused on various types of group relationships. One focus has been on the connection one member has with another member [1, 20, 28]. Findings show that individual relationships or working alliances between group members and the group leader play a significant role in group success [20, 28]. The relationship has more importance than the roles in the group.

#### **2.4 Recent developments and future research**

Though providing therapy online has existed for over 20 years, many mental health professionals first experience with teletherapy began during COVID-19.

#### *Perspective Chapter: Therapeutic Alliance, Rupture and Repair in Group Therapy DOI: http://dx.doi.org/10.5772/intechopen.110700*

Major reasons contributing to the resistance on doing therapy online include lack of experience, lack of training, unsuitable equipment, and difficulty managing ethical challenges. A recent study was conducted to understand the perception therapists had on building group therapy alliance online. Results showed that group therapeutic process, therapist comfort, and challenges predicted outcomes [29]. More specifically, the higher amount of therapeutic processes as well as therapist comfort level with online therapy, and the lower number of therapeutic challenges, the better the outcome. Another discovery was that group therapists reported lower satisfaction and comfort towards online therapy when comparted to in-person groups. Finally, this study reported that working through conflict and avoidance was more complicated for online groups. Even with complications, therapist continue to utilize technology to provide group therapy as even with these complications, it is evident the therapeutic processes found in face-to-face groups is also present in online groups.

Even with the breadth of research that exist on the topic of therapeutic alliance, large gaps in literature remain. Future research in this area could continue to the work of obtaining individual responses on clients and therapist to better understand how the alliance is being built, the nature of the alliance, and the overall outcomes of the therapeutic process in a qualitative nature. Future research could also lean towards a deeper investigation on the relationship between the therapeutic alliance and outcomes for specific diagnosis. Lastly, there is a lack of research focusing the culturally appropriate therapeutic alliance interventions.

## **3. Rupture and repair**

Sometimes the communication and goals of the therapeutic approach are not aligned, and a rupture may occur in the therapeutic alliance. Any moments or period of times where breakdowns in the therapeutic alliance occur is considered to be a rupture. A rupture can be anything from a client disliking or disagreeing with something said, to a client not feeling that they are in a safe space where their deepest feelings and thoughts are free of judgment. A rupture can also include moments where a client withdraws when something is not said or addressed appropriately.

Ruptures and repairs are very common in sessions and can occur more than once during a session. Eubanks et al. [30] describes the process in which a rupture is repaired as a resolution process. This process allows the clients and therapist to work together to create therapy goals. The rupture should be addressed directly once it has been identified. Therapy cannot continue successfully if the therapeutic alliance is poor for long periods of time. The therapist may choose strategies like revealing their experience of the rift in the group or starting a new task [30]. Rupture resolution has been found to repair the harmful impact the experience may have brought on and repair the working alliance [31]. If a rupture and repair event is handled correctly, it helps to strengthen the relationship create a deeper bond. The rupture and repair event also gives insight into the client's interpersonal style, areas of defensiveness, and ability to handle conflict.

In a study conducted on clients with post-traumatic stress disorder, the researchers identified that ruptures in alliance were quite common (46%) [32]. As stated earlier, the therapeutic alliance can be a key factor in therapeutic outcomes for clients. As we understand what a rupture is in the context of a therapeutic relationship, we must also consider how our clients may feel if there is a rupture that is not repaired between the client and therapist [32], suggesting that the experience of an unrepaired rupture relates to poorer PTSD treatment outcome. Gersh et al., [33] identified a significant relationship between the time of the rupture in the therapy process. This study identified, in clients with borderline personality disorder, early treatment ruptures were associated with poor outcome whereas greater late treatment resolution was associated with better outcomes.

In this clinical example, Joe, Chris, Kathy, and Alice to show a rupture in a communication skills group setting evidenced by the client becoming defensive and rejecting the intervention [30].

*Joe and Alice are discussing her fractured relationship with her adult daughter. Joe asks Alice if she was able to use the new communication skills they had discussed last week to attempt to resolve an argument she had with her daughter. Alice answers that she has not talked to her daughter this week. Joe asks, "Isn't one of your major goals for attending this group to repair your relationship with your daughter? Is there a reason why you chose not to reach out to your daughter this week?" Alice becomes visibly agitated and says, "I don't see how the new skill will help anyway. I'm not really sure why I'm here anymore. I don't appreciate you judging me, and I am not even the one who should be trying to repair the relationship. She is the one who ruined our relationship to begin with!"*

### **3.1 Repair interventions**

There have been a few interventions that therapists can use to repair alliance ruptures which center around the rupture and resolution model created by Safran and Muran [34]. Safran and Muran [34] stated that the interventions depend on metacommunication of the current situation. They referred to metacommunication as the act in which the therapist is constantly mindful of the client-therapist action. Safran and Muran [34] contributed to resolving therapeutic ruptures by creating direct and indirect interventions therapists can use. Direct interventions are considered as interventions where the client is actively engaged and aware of the intervention. Conversely, an indirect intervention are interventions that affect therapeutics alliance and covert in nature. Safran and Muran [34] suggested the following rupture resolution strategy model (see **Figure 1**).

A1a. Therapeutic Rationale and Tasks: This intervention consists of outlining or repeating the rationale of treatment [34]. If there is a rupture, therapists can check with clients to ensure they understand the goals and rationale of treatment and render explanations for clarity. Therapists can do this by employing therapeutic tasks/exercises that can help clients process therapeutic change.

A1b. Interpersonal Themes, Disagreements, and Tasks: Related to the goals and tasks of therapy, a client may disagree with the therapist, and it causes them to unintentionally process and explore interpersonal matters that may be affecting their treatment.

A2a. Clearing Misunderstandings: The therapist can clarify any misunderstanding a client may experience from therapy. This can look like the therapist helping the client resolve why they may feel a sense of discomfort.

A2b. Interpersonal Themes: Similar to A1b., this relates to how internal processes related to interpersonal matters can affect the bond between therapist and client.

B1a. Changing Goals and Tasks: The therapist works to change goals and tasks that are more relatable to the client(s) that that carry the possibility of increasing their willingness to participate in other tasks that more closely align with the therapist's goals for the group.

*Perspective Chapter: Therapeutic Alliance, Rupture and Repair in Group Therapy DOI: http://dx.doi.org/10.5772/intechopen.110700*

#### **Figure 1.** *Therapeutic alliance intervention strategies [32].*

B1b. Reframing Goals and Tasks: This intervention involves reframing the goals and tasks to increase meaning and purpose for the client and increase the client's motivation to engage in the interventions.

B2a. Empathy: The therapist can take an empathetic approach and reframe the rupture in a positive outlook.

B2b. Emotional Experiences: The therapist can implicitly address the connection element of an alliance in a way that offers a different, beneficial interpersonal experience for the client.

Their goal in creating these strategies were to clear any misunderstandings among the group members and therapist, to adjust any goals and tasks of the group if deemed necessary, and to justify an intervention.

### **3.2 Treatment outcomes**

Effective rupture resolution can impact the group, and other positive outcomes can be found [35]. Such positive outcomes include lessened anxiety and depressive symptoms, increase in daily living activities, and can lead to a stronger therapeutic alliance among the group. The group is provided with the tools necessary to move forward in the therapeutic process by sympathizing with other clients' issues and can lead the individual to see their negative self-appraisal of their internal beliefs [36].

In this repair example, Joe links Alice's defensiveness to the larger interpersonal communication patterns that have caused her problems in her past relationships [30] and works with Alice so she can recognize these patterns and develop alternative communication.

*Joe takes a moment and nods. Joe says, "I assure you that my intention was not to judge you. I am curious, though, do you think that becoming defensive in the past has impacted your relationship with your daughter in a negative way?" Alice thinks about this carefully and says, "our last argument ended with me feeling judged and getting defensive with my daughter." Joe nods again and asks, "why do you feel the need to defend yourself in these situations? Are there other ways you can communicate what you need from the conversation without becoming defensive?"*

#### **3.3 Recent development and future research**

Although there have been developments in psychotherapy research and practice with individuals, research in alliance ruptures and repairs regarding group psychotherapy is behind [35]. The challenge of research in groups is that the group structure is more complex than individual therapy. Group therapy offers a complicated set of interactions between members of the group, members to members, and group member to the therapist unlike individual therapy [36]. Unique to group therapy, interpersonal relationships and how they learn from one another is a factor to consider [18, 37]. It has been suggested that group psychotherapists can create a safe therapeutic environment by encouraging members who have experienced ruptures due to their interpersonal disregards (bitterness, intrusiveness, etc.) to bring the issue to the group, reflect on the ruptures impact on themselves and the rest of the group, and to learn positive ways to interact with the group members and therapist [18, 37]. A limited number of studies have investigated alliance in group therapy and no studies have explored the rupture and repair processes in real-time but instead have focused on alliance ratings within the group [35]. One current study by Garceau et al. [38], evaluated the usefulness and practicability of the Rupture Resolution Rating System (3RS) within a group psychotherapy context. This scale was used to explore whether and how the 3RS could apply to group therapy with a specific goal of assessing the interactions that occur in group therapy. Other goals included helping group therapists to better identify and repair rupture, informing research on the usefulness of managing ruptures and repair as they happen. Lastly, this study sought to identify possible modifications needed to make the 3RS compatible for the use of group therapy [38].

The 3RS is an observer-rated instrument system that is used to code ruptures and repairs in the individual psychotherapy context through videos or transcripts. The 3RS system counts the frequency in which there are withdrawal ruptures or confrontation ruptures. Withdrawal ruptures can look like the client "shutting down" or disengaging. Confrontation ruptures can look like the client challenging or controlling the therapist, or by confronting their frustrations. Once the codes are counted and rated, the session is then given an overall rating regarding the ruptures impact, how the ruptures were repaired, and the impact the therapist made on the ruptures [30, 39]. The instrument does not code every disagreement between the therapist and client as a rupture if the therapist and client acknowledge and discuss the rupture together [38]. As of this study, no other research has been conducted on the efficacy of using the 3RS system in a group psychotherapy setting.

## **4. Cultural considerations**

To enhance group alliance, members and the group leader need to understand one another. Cultural differences play a role in the dynamics of understanding and

#### *Perspective Chapter: Therapeutic Alliance, Rupture and Repair in Group Therapy DOI: http://dx.doi.org/10.5772/intechopen.110700*

building mutually agreed upon goals and tasks. Cultural competence was a term first introduced in 1989 by Dr. Terry Cross titled A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed [40]. This piece of literature influenced the next generation of studies that investigated the impact of culture in systems of care. Since Cross [40], the integration of cultural competence into theoretical orientations, interventions, research approaches and methodologies has been expanded to more accurately address the impact of culture on outcomes [41–45].

The multicultural movement has been explained as the fourth major force in psychology behind psychoanalysis, behaviorism, and humanism [46]. The multicultural movement was developed in response to research that demonstrated mental health disparities among racial and ethnic minority groups [47]. In recent years, the exploration and investigation from the multicultural movement has required additional development and growth from clinicians. This growth requires a shift in the language of cultural competence into what is now understood as the framework of multicultural orientation [48]. The multicultural orientation framework centers three core concepts: Cultural Humility, Cultural Comfort and Cultural opportunities. Cultural humility includes recognizing that power differences exist between therapist and client on multiple levels, recognizing that these power differences include the power to define what is important and salient for others. The cultural humility framework also emphasizes the importance of understanding cultural differences influence assessment, diagnosis, treatment, and research [49].

Cultural comfort and cultural opportunities, the second and third core concept, are considered to be the behavioral representation of cultural humility. Cultural opportunities are indicators during therapy that provide an opportunity for the client's cultural identity to be explored [48]. These moments are usually initiated by the client and can involve their values and beliefs. Only when appropriate the therapist can also initiates a cultural explorative conversation. It is these conversations that lean into the concept of cultural comfort. Cultural comfort is defined as the mental and emotional experience therapist experience before, during, and after engaging in a cultural opportunity with their client. More specifically, cultural comfort is regarded as feeling open, calm, and present while also noting and accepting discomfort during culturally sensitive exchanges [48].

Hal et al., 2016 in their review of meta-analysis on cultural adaptations of psychological interventions found that, "culturally adapted interventions would produce greater reductions in psychopathology than another intervention or no intervention was supported" [50]. Hal et al., demonstrates the relationship between adapting or shifting interventions improves client psychopathology [50]. For example, a client may curse, or use swear words while responding during a group therapy session. Cursing can be an expression of the client's culture, experience and cursing can be an expression of culture [51]. The cultural responsiveness and humility of the counselor can provide an open stance to allow the client to communicate in the way that feels most comfortable to them [48]. This openness to allow the client to communicate in their own voice provides opportunity for deeper connection and improves the therapeutic alliance [52, 53].

The following clinical example illustrates a rupture where individual and cultural difference were important to attend to in a group setting as evidenced by a group member withdrawing from the group and from the work of therapy [30]. *Joe is a Black male therapist and is the leader of the group. The group is focused on developing effective communication skills. The group members include Chris, Kathy, and Alice. Chris is a 42-year-old White male. He joined the group with the goal to communicate more* 

*effectively with his wife. Kathy is a 37-year-old Black female. She became a part of the group to learn to communicate more efficiently in her workplace. Alice is a 53-year-old White female. Alice joined this group with the goal of developing her communication skills to assist in improving her relationship with her adult daughter.*

*In this session, Joe, Chris, and Kathy are engaged in a group discussion. Kathy brings up an interaction she had at the airport earlier in the week. She expresses frustration because a security guard put his hands in her hair with no warning when she was going through airport security. Kathy expresses that this practice is discriminatory, dehumanizing, and disrespectful. The group can see that Kathy is visibly frustrated by this interaction.*

*Chris asserts, "Airport security searches everyone. I don't see how this practice is evidence of discrimination. They are just trying to keep us safe while flying." Chris then changes the topic to discuss an experience that he encountered this week that he was wanting to discuss with the group. Joe does not address this change in topic nor how Kathy's concerns are dismissed in this interaction. Kathy visibly withdraws from interactions with the group as the group continues to discuss how they used different communication skills throughout the week. This goes on for the rest of the session and this rupture is not addressed by Joe. Thus, Kathy feels unheard and invalidated both by other group members and by Joe, the facilitator of the group.*

### **4.1 Repair**

Though the research on repair within black, indigenous, and people of color (BIPOC) is scarce, the existing research does confirm engaging in the repair resolution process is integral to the rupture process within BIPOC population. A study completed by Yeo and Torress-Harding, found that microaggressions have a significantly negative effect on the therapeutic alliance [54]. Yeo and Torress-Harding also found that when therapist recognized, acknowledged, and invited a discussion of a rupture, where the therapist committed a microaggression towards the client, the therapeutic relationship was positively impacted [54]. Additionally, the participants emphasized a need for therapist to be more flexible in their approach, empathetic, and to increase their cultural sensitivity as well as knowledge.

The communication skills group that we observed in our earlier clinical example is meeting for their next session. In this example, Joe works to repair the rupture by acknowledging his contribution to the rupture [30] and apologizing for his role in the rupture. Joe also uses appropriate self-disclosure to bring discriminatory and uncomfortable search practices to the forefront of the conversation. Chris follows suit and also apologizes for causing the rupture by invalidating Kathy's experience. *Kathy is still actively withdrawn from the group, giving short answers only when necessary. Joe notices this and addresses his observations to the group, letting Kathy know that he has noticed her withdrawing from the group. It is clear that Kathy is visibly hesitant to answer, but after some time she says, "I was discussing what happened at airport security last session and my experience was dismissed by Chris." Joe says, "I'm sorry that your experience was overlooked last session and I apologize for not helping to maintain focus on your encounter." Joe looks at the group and asks, "has anyone here experienced discriminatory or even uncomfortable practices during a security procedure at an airport or elsewhere?" Chris and Alice shake their heads. Joe discloses, "I get 'randomly' searched frequently when I fly. I've never had anyone touch my hair in security, though. These experiences are not the same, but my experience does help me to be more empathetic regarding your incident. It is important to acknowledge that the intersection of your identity as a Black female isn't one that is shared by anyone in this group, and it is important for us to remember that when we*  *Perspective Chapter: Therapeutic Alliance, Rupture and Repair in Group Therapy DOI: http://dx.doi.org/10.5772/intechopen.110700*

*are discussing different experiences. Chris, do you have any thoughts on the matter?" Chris takes some time to consider and then apologizes for dismissing Kathy's experience. Chris says, "I'm sorry that I didn't stop to think about how that experience made you feel. I also brushed off your assertion that the practice is discriminatory. Like Joe, I have never had my hair searched at airport security or anywhere else. Unlike Joe, I have never been randomly searched at airport security either."*

A key role in the therapeutic relationship is modeling the behavior that helps our clients tune in to and grow from the rupture and repair model [55, 56]. The relationship we have with our clients is both a reflection of their interactions with the outer world and a model for the type of behavior we wish to see our clients represent during and after the therapeutic process. The rupture-repair process in therapy better equips our clients with the ability to learn how to react, structure and respond to ruptures in other areas of their life. As helping professionals, clinicians have a responsibility to continue to develop our ability to understand various presentations of symptoms, diagnosis, and interventions accurately and critically.

## **5. Conclusion**

The focus of this chapter is on understanding the role therapeutic alliance plays in group therapy. When a breakdown in the therapeutic alliance occurs, it must be addressed appropriately. This process is known as rupture and repair. The following are key areas to take away from this chapter.


## **Conflict of interest**

The authors declare no conflict of interest.

## **Notes/thanks/other declarations**

Many thanks to our loved ones and mentors for bringing us to this point of our journey.

*Perspective Chapter: Therapeutic Alliance, Rupture and Repair in Group Therapy DOI: http://dx.doi.org/10.5772/intechopen.110700*

## **Author details**

Esther Lynch1 \*, Jeremy Lynch<sup>2</sup> , Kiana McClintick1 , Bradford Pippen1 , Kayla Womack1 and Kiela Hinson1

1 Tennessee State University, Nashville, United States of America

2 Fisk University, Nashville, United States of America

\*Address all correspondence to: emendez@tnstate.edu

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] Alldredge CT, Burlingame GM, Yang C, Rosendahl J. Alliance in group therapy: A meta-analysis. Group Dynamics: Theory, Research, and Practice. 2021;**25**(1):13. DOI: 10.1037/ gdn0000135

[2] Ryu J, Banthin DC, Gu X. Modeling therapeutic alliance in the age of telepsychiatry. Trends in Cognitive Sciences. 2021;**25**(1):5-8. DOI: 10.1016/j. tics.2020.10.001

[3] Norcross JC, Lambert MJ. Psychotherapy Relationships That Work II. Psychotherapy. 2011;**48**(1):4-8. DOI: 10.1037/a0022180

[4] Ardito RB, Rabellino D. Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology. 2011;**2**:270. DOI: 10.3389/ fpsyg.2011.00270

[5] Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice. 1979;**16**(3):252

[6] Stubbe DE. The therapeutic alliance: The fundamental element of psychotherapy. Focus. 2018;**16**(4):402- 403. DOI: 10.11176/appi.focus.20180022

[7] McParlin Z, Cerritelli F, Friston KJ, Esteves JE. Therapeutic alliance as active inference: The role of therapeutic touch and synchrony. Frontiers in Psychology. 2022;**13**:329. DOI: 10.3389/ fpsyg.2022.783694

[8] Cameron SK, Rodgers J, Dagnan D. The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults

with depression: A meta-analytic review. Clinical Psychology & Psychotherapy. 2018;**25**(3):446-456. DOI: 10.1002/ cpp.2180

[9] Cameron SK, Rodgers J, Dagnan D. The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta-analytic review. Clinical Psychology & Psychotherapy. 2018;**25**(3):446-456. DOI: 10.1002/ cpp.2180

[10] Burke A. Four lessons in building therapeutic relationships. Counseling Today. 2021.Retrieved from https://ct.counseling.org/2021/11/ four-lessons-in-building

[11] Pashak TJ, Heron MR. Build rapport and collect data: A teaching resource on the clinical interviewing intake. Discover. Psychology. 2022;**2**(1):20. DOI: 10.1007/ s44202-022-00019-5

[12] von Greiff N, Skogens L. Positive processes of change among male and female clients treated for alcohol and/or drug problems. Journal of Social Work. 2017;**17**(2):186-206. DOI: 10.1177/1468017316638576

[13] Schnur JB, Montgomery GH. A systematic review of therapeutic alliance, group cohesion, empathy, and goal consensus/collaboration in psychotherapeutic interventions in cancer: Uncommon factors? Clinical Psychology Review. 2010;**30**(2):238-247. DOI: 10.1016/j.cpr.2009.11.005

[14] Wesson N. Center for the Study of Group Psychotherapy. Individual vs. Group Psychotherapy: how is the therapeutic process different? [Internet] Available from: https://csgp.org/blog/

*Perspective Chapter: Therapeutic Alliance, Rupture and Repair in Group Therapy DOI: http://dx.doi.org/10.5772/intechopen.110700*

individual-vs-group-psychotherapyhow-is-the-therapeutic-processdifferent/ [Accessed: December 1, 2023]

[15] Horvath AO. The alliance. Psychotherapy: Theory, Research, Practice, Training. 2001;**38**(4):365. DOI: 10.1037/0033-3204.38.4.365

[16] Tryon GS, Winograd G. Goal consensus and collaboration. 10.1037/ a0022061

[17] Johnson JE, Burlingame GM, Olsen JA, Davies DR, Gleave RL. Group climate, cohesion, alliance, and empathy in group psychotherapy: Multilevel structural equation models. Journal of Counseling Psychology. 2005;**52**(3):310. DOI: 10.1037/0022-0167.52.3.310

[18] Yalom ID, Leszcz M. The theory and practice of group psychotherapy. Basic books; 2020

[19] Skogens L, von Greiff N. Recovery capital in the process of change— Differences and similarities between groups of clients treated for alcohol or drug problems. European Journal of Social Work. 2014;**17**(1):58-73. DOI: 10.1080/13691457.2012.739559

[20] von Greiff N, Skogens L. Understanding the concept of the therapeutic alliance in group treatment for alcohol and drug problems. European Journal of Social Work. 2019;**22**(1):69-81

[21] Flückiger C, Del Re AC, Wampold BE, Symonds D, Horvath AO. How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology. 2012;**59**(1):10. DOI: 10.1037/a0025749

[22] Stanhope V, Barrenger SL, Salzer MS, Marcus SC. Examining the relationship between choice, therapeutic alliance and outcomes in mental health services.

Journal of Personalized Medicine. 2013;**3**(3):191-202. DOI: 10.3390/ jpm3030191

[23] Horvath AO, Del Re AC, Flückiger C, Symonds D. Alliance in Individual Psychotherapy[w:] Psychotherapy Relationships That Work: Evidence-Based Responsiveness. Norcross JC: Oxford University; 2011. pp.25-69. DOI: 10.1037/a0022186

[24] Horvath AO, Bedi RP. The Alliance, [w:] Psychotherapy Relationships That Work: Therapist Contributions and Responsiveness to Patients. Norcross JC: Oxford University; 2002. DOI: 10.1093/ acprof:oso/9780199737208.003.0002

[25] Horvath AO, Symonds BD. Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology. 1991;**38**(2):139. DOI: 10.1037/0022-0167.38.2.139

[26] Cruz M, Pincus HA. Research on the influence that communication in psychiatric encounters has on treatment. Psychiatric Services. 2002;**53**(10):1253- 1265. DOI: 10.1176/appi.ps.53.10.1253

[27] Strauss JL, Johnson SL. Role of treatment alliance in the clinical management of bipolar disorder: Stronger alliances prospectively predict fewer manic symptoms. Psychiatry Research. 2006;**145**(2-3):215-223. DOI: 10.1016/j.psychres.2006.01.007

[28] Bernard H, Burlingame G, Flores P, Greene L, Joyce A, Kobos JC, et al. Clinical practice guidelines for group psychotherapy. International Journal of Group Psychotherapy. 2008;**58**(4):455-542. DOI: 10.1521/ ijgp.2008.58.4.455

[29] Lo Coco G, Gullo S, Albano G, Brugnera A, Flückiger C, Tasca GA. The alliance-outcome association in group interventions: A multilevel meta-analysis. Journal of Consulting and Clinical Psychology. 2022;**90**(6):513. DOI: 10.1037/ccp0000735

[30] Eubanks CF, Muran JC, Safran JD. Rupture Resolution Rating System (3RS). New York: Mount Sinai-Beth Israel Medical Center; 2015

[31] Stevens CL, Muran JC, Safran JD, Gorman BS, Winston A. Levels and patterns of the therapeutic alliance in brief psychotherapy. American Journal of Psychotherapy. 2007;**61**(2):109-129

[32] McLaughlin AA, Keller SM, Feeny NC, Youngstrom EA, Zoellner LA. Patterns of therapeutic alliance: Rupture–repair episodes in prolonged exposure for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology. 2014;**82**(1):112. DOI: 10.1037/a0034696

[33] Gersh E, Hulbert CA, McKechnie B, Ramadan R, Worotniuk T, Chanen AM. Alliance rupture and repair processes and therapeutic change in youth with borderline personality disorder. Psychology and Psychotherapy: Theory, Research and Practice. 2017;**90**(1):84- 104. DOI: 10.1111/papt.12097

[34] Safran JD, Muran JC. Resolving therapeutic alliance ruptures: Diversity and integration. Journal of Clinical Psychology. 2000;**56**(2):233- 243. DOI: 10.1002/(SICI)1097- 4679(200002)56:2%3C233::AID-JCLP9%3E3.0.CO;2-3

[35] Coco GL, Tasca GA, Hewitt PL, Mikail SF, Kivlighan JD. Ruptures and repairs of group therapy alliance. An untold story in psychotherapy research. Research in Psychotherapy: Psychopathology, Process, and Outcome. 2019;**22**(1):58-70. DOI: 10.4081/ ripppo.2019.352

[36] Binder JL, Strupp HH. "Negative process": A recurrently discovered and underestimated facet of therapeutic process and outcome in the individual psychotherapy of adults. Clinical Psychology: Science and Practice. 1997;**4**(2):121. DOI: 10.1111/j.1468- 2850.1997.tb00105.x

[37] Burlingame GM, Strauss B, Joyce A. Change mechanisms and effectiveness of small group treatments. Bergin and Garfield's Handbook of Psychotherapy and Behavior Change. 2013;**6**:640-689

[38] Garceau C, Chyurlia L, Baldwin D, Boritz T, Hewitt PL, Kealy D, et al. Applying the rupture resolution rating system (3RS) to group therapy: An evidence-based case study. Group Dynamics: Theory, Research, and Practice. 2021;**25**(1):89. DOI: 10.1037/ gdn0000137

[39] Eubanks CF, Muran JC, Safran JD. Repairing alliance ruptures. 2019. 10.1093/ med-psych/9780190843953.003.0016

[40] Cross TL. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center; 1989. DOI: 10.1037/ pst0000160

[41] Brown LS. Cultural competence: A new way of thinking about integration in therapy. Journal of Psychotherapy Integration. 2009;**19**(4):340. DOI: 10.1037/a0017967

[42] Comas-Díaz L. Multicultural care: A clinician's guide to cultural competence. American Psychological Association.

*Perspective Chapter: Therapeutic Alliance, Rupture and Repair in Group Therapy DOI: http://dx.doi.org/10.5772/intechopen.110700*

Washington, D.C.; 2012. DOI: 10.1037/ 13491-000

[43] Guindon MH, Sobhany MS. Toward cultural competency in diagnosis. International Journal for the Advancement of Counselling. 2001;**23**(4):269-282. DOI: 10.1023/A:1014443901294

[44] Hayes SC, Muto T, Masuda A. Seeking cultural competence from the ground up. Clinical Psychology: Science and Practice. 2011;**18**(3):232

[45] Sue S. In search of cultural competence in psychotherapy and counseling. American Psychologist. 1998;**53**(4):440. DOI: 10.1037/0003-066X.53.4.440

[46] Pedersen PB. The making of a culturally competent counselor. Online Readings in Psychology and Culture. 2002;**10**(3):1-3. DOI: 10.9707/2307-0919.1093

[47] Sue DW, Bingham RP, Porché-Burke L, Vasquez M. The diversification of psychology: A multicultural revolution. American Psychologist. 1999;**54**(12):1061. DOI: 10.1037/0003-066X.54.12.1061

[48] Davis DE, DeBlaere C, Owen J, Hook JN, Rivera DP, Choe E, et al. The multicultural orientation framework: A narrative review. Psychotherapy. 2018;**55**(1):89

[49] Sylvia M. APA dictionary of psychology. CHOICE: Current Reviews for Academic Libraries. 2015;**53**(2):224- 225. Available from: https://link.gale.com/ apps/doc/A431198164/AONE?u=tel\_oweb &sid=googleScholar&xid=6caffd67

[50] Hall GC, Ibaraki AY, Huang ER, Marti CN, Stice E. A meta-analysis of cultural adaptations of psychological

interventions. Behavior Therapy. 2016;**47**(6):993-1014. DOI: 10.1016/j. beth.2016.09.005

[51] Goddard C. "Swear words" and "curse words" in Australian (and American) English. At the crossroads of pragmatics, semantics and sociolinguistics. Intercultural Pragmatics. 2015;**12**(2):189-218. DOI: 10.1515/ip-2015-0010

[52] Delgadillo J, Branson A, Kellett S, Myles-Hooton P, Hardy GE, Shafran R. Therapist personality traits as predictors of psychological treatment outcomes. Psychotherapy Research. 2020;**30**(7):857- 870. DOI: 10.1080/10503307.2020.1731927

[53] Giffin HJ. Client's experiences and perceptions of the therapist's use of swear words and the resulting impact on the therapeutic alliance in the context of the therapeutic relationship[thesis]. Northampton Massachusetts: Smith College; 2016

[54] Yeo E, Torres-Harding SR. Rupture resolution strategies and the impact of rupture on the working alliance after racial microaggressions in therapy. Psychotherapy. 2021;**58**(4):460. DOI: 10.1037/pst0000372

[55] Bandura A. Psychotherapy as a learning process. Psychological Bulletin. 1961;**58**(2):143. DOI: 10.1037/h0040672

[56] Safran JD, Greenberg LS, Rice LN. Integrating psychotherapy research and practice: Modeling the change process. Psychotherapy: Theory, Research, Practice Training. 1988;**25**(1):1. DOI: 10.1037/h0085305

## **Chapter 2**

## Genesis and Development of Group-Analytic Therapy in Great Britain: Bion, Bowlby, Foulkes, and the Relevance of Group Attachment

*Arturo Ezquerro and María Cañete*

## **Abstract**

A succinct account of the genesis and development of the Tavistock and groupanalytic models of group psychotherapy focuses on their creators, Bion and Foulkes, and on how their life circumstances and their interpersonal and group attachment histories shaped their thinking and perception of the group and its therapeutic potential. The methodology combines historical investigation and literature review with psychodynamic and group-analytic formulations; it also provides an attachment-based, critical analysis of both approaches, their similarities and differences, and their mutual influence. Likewise, the chapter investigates the evolution of the concept of group attachment, formulated by Bowlby in 1969, which has been largely overlooked in the specialist literature until the last two decades, despite the fact that group lives, as well as interpersonal and group attachment, have played a fundamental role in our survival as a species and in our well-being and healthy development as a person. The present research is also informed by anthropological, psychosocial, organisational, and cultural aspects of human growth. It concludes that group attachment is highly relevant to group psychotherapy and that studying its nature and therapeutic implications should be an integral part of the training of psychotherapists and other mental health professionals, particularly those working with groups.

**Keywords:** Bion, Bowlby, Foulkes, development, group analysis, group attachment, group psychotherapy, survival, Tavistock model

## **1. Introduction**

Groups are at the core of human existence and survival; for millions of years, they have been fundamental for healthy development and have contained healing properties. Today, optimally, we may define group psychotherapy as a democratic, cost-effective, and inclusive form of psychosocial treatment.

In fact, from the outset, group therapy has been strongly connected to survival, both physical and emotional. It is widely accepted that this treatment modality was pioneered by the American medical doctor Joseph Pratt in 1905, as he decided to put together a number of patients with pulmonary tuberculosis in Greater Boston: there was a life-threatening illness to fight.

These patients were segregated from the community, in a way similar to the many forms of discrimination and marginalisation inflicted upon patients suffering from serious mental illness.

Pratt actually thought that, for his patients, sharing the knowledge of their illness and their coping strategies would not only provide them with much-needed emotional support, but would also help them maximise their chances of survival.

Indeed, these group therapy sessions were complemented with a psychoeducational component, largely delivered by Pratt himself [1]. This combined approach raised an important issue about how to integrate harmoniously the *authority* of the leader with the *authority* of the group.

Interestingly, Pratt was not a psychiatrist or mental health professional, but an internist. Somehow, this speaks in favour of the universality and healing potential of group processes, as well as the fact that mind and body are inextricably linked.

Some of the techniques used at the time can still be found in a range of group therapeutic interventions today, particularly in homogeneous groups, in which all patients have a common condition.

In Great Britain, the birth of group psychotherapy had its own specific intensity and purpose, in the context of the Second World War. There was an overwhelming and urgent problem to solve: having to fight and survive the war. That was, undeniably, a group effort.

At a psychological and political level, and in different ways, the task of developing group therapy was greatly facilitated by the work and ideas of three leading figures: Wilfred Bion, SH Foulkes, and John Bowlby, as we will see throughout this chapter.

In 1952, the Group Analytic Society International (GASI) was created and, in 1971, the Institute of Group Analysis (IGA) started national training programmes, based in London.

From its inception, IGA (a member of the European Group-Analytic Training Network) has offered a comprehensive training in adult group psychotherapy. In order to qualify as an IGA group analyst, current requirements include a one-year introductory course, followed by a one-year diploma course and a three-year qualifying course.

Apart from the training requirements of attending academic seminars, writing clinical and theoretical dissertations, and receiving their own personal group therapy, trainees have to conduct on their own (under supervision) a heterogeneous and slow-open mixed group with adults who are strangers to each other. In addition, they must conduct a special interest group, which can be homogeneous and might involve children, adolescents, adults or older adults.

Malcolm Pines [2], a founding member of both GASI and IGA, suggested that, in therapy groups as well as in other group configurations, members (including the therapist, conductor, or leader) share a common space: the powerful universal symbol of the circle, which has been a setting for the development of human relatedness through our evolution as a species.

Certainly, we can imagine our distant ancestors sitting in a circle around a comforting fire, after a long day, sharing true stories and fantasies, forming a natural (therapeutic) group and growing in their group belonging or affiliation and, also, in their *group attachment*, a more than useful concept outlined by Bowlby [3], the *father* of attachment theory. We shall elaborate on this later.

*Genesis and Development of Group-Analytic Therapy in Great Britain: Bion, Bowlby, Foulkes… DOI: http://dx.doi.org/10.5772/intechopen.111826*

Mark Ettin [4], the inaugural recipient of the American Group Psychotherapy Foundation's award for excellence, also referred to the healing properties of the group circle, about which he described a number of poetic metaphors. He pointed out that, in some religious traditions, circular motion has symbolised the sweeping, spinning, and stirring process of creation.

Furthermore, in some primitive communities, dancing a round (along a circle) was thought to animate the still forces of nature. Roundness became a sacred shape and evolved into a universal symbol of wholeness, a major goal in human developmental processes across the life course [5].

Likewise, the circle was associated with other healing properties, such as its inherent potential for mixing, arranging, and enveloping disordered and polarised multiplicities. The early psychoanalyst Carl Jung [6] suggested that, in a circular configuration, pointed edges can be smooth, relationships circumscribed, splits conjoint and chaos contained.

Other authors [7, 8] likened the group to the good-enough environmental mother, and equated the group's reliable felt presence with an internally held comforting mother image: an archetype representing the holder of life.

In the following sections of this chapter, we will explore the genesis and development of the two main methods of group psychotherapy in Great Britain, which were pioneered by Bion and Foulkes. They created two distinct approaches, respectively: the Tavistock model and the group-analytic model.

Moreover, in this study, we shall describe and critically compare both approaches from our first-hand perspective, having trained in both institutions: the Tavistock Clinic and the IGA. In addition, we will explore Bowlby's group mind, as well as core tenets of his attachment theory (such as the concept of group attachment) and his contribution to the field of group therapy.

## **2. Historical context to group therapy in Britain. Part I: the Tavistock model**

Prior to the Second World War, in the UK and in other European countries, group psychotherapy was viewed by many members of the mental health community with a variety of negative feelings, which ranged from doubt to suspicion to contemptuous rejection. The primacy of the one-to-one therapeutic relationship and the analysis of the so-called *transference neurosis* were seen as central elements in any form of psychodynamic psychotherapy [1].

After the war, the use of the group as a method of treatment flourished in its own right, despite early hostile attitudes. There were many reasons for this. For example, in the context of war calamity and its aftermath, the group approach made it possible for more people to be treated by the same number of therapists.

And group psychotherapy gradually came to be a highly cost-effective and beneficial form of treatment for many different conditions in a wide range of settings [5].

In 1946, Wilfred Bion (1897–1979) was put in charge of group psychotherapy at the Tavistock Clinic, in London. Like most of his colleagues over there, he qualified as a psychoanalyst in the post-war years and was strongly influenced by Melanie Klein.

Bion had a charismatic personality, despite having experienced a difficult interpersonal attachment and group attachment history. His parents (to whom he felt insecurely attached) sent him to England for his education as a young child, whilst they remained in India contributing to the might of the British Empire at its pick.

After the separation from his parents, he missed home, struggled at a very strict boarding English school, sustained a serious physical injury whilst playing rugby and, later, went through severely traumatising experiences during the First World War [5].

At the age of just under 18, Bion joined the British Royal Tank Regiment. He became a Brigade Major at 19 and was sent to France where he was on active service until the end of the war. It seems that his military experience and reputation played an important part in the development of his charismatic thinking, and in the perception that other people had of him during his later professional career.

In those early days, more often than not, tanks were death traps from which only few survived. The following episode, whilst Bion was in charge of a group of tanks, became legendary. The day before one of the battles, he objected to the order of an attack in daylight, because he considered it would be suicidal. He suggested to attack either at dawn or dusk, with the cover of some mist.

This occurred at a time when higher commands new little about the handling of tanks. Following Bion's objection, the divisional commander responded firmly, as reported by Trist [9]:

*Wilfred, you may be one of my best officers but you are a boy. You may know more about these new machines than I do but you know less about battles. We will attack at 10 o'clock.*

#### Bion rose again and said:

*Sir, as I am a soldier, I obey orders and will attack at 10 o'clock, but as a staff officer I have the right to have my technical advice recorded in writing in the minutes of this meeting. You neglect it at your peril.*

The following day, the tanks were wiped out; only Bion came back. In *The Long Week-End* [10], there is a moving autobiographical description of the fear and trauma of battle, looking back to that tragedy. He went further than that and actually wrote that his life concluded then.

We can imagine the deep sense of trauma Bion might have gone through, as he struggled to recover from the horror of the carnage of his companions, whilst he was also trying to make sense of his own survival. Interestingly, in his later professional life, he conceived a good therapist as one who has developed a capacity to think *under fire*. Surely, this conception relates both metaphorically and literally to the above war experiences.

It should be noted that the Tavistock Clinic opened in 1920, largely in connection with the need to provide psychological support to members of a society deeply traumatised by the First World War. However, at the time, the institution only offered individual psychotherapy.

Some 25 years later, when the Second World War had ended, there was an exponential increase of patient referrals. This pushed the Tavistock Clinic's management to develop therapeutic methods that would help the institution meet such an overwhelming demand.

With the arrival of the National Health Service (NHS) in 1948, the Clinic was under pressure to maintain a patient-load sufficiently large, as to satisfy the new NHS authorities that out-patient psychotherapy would be helpful and cost-effective [11].

In fact, by the time the Clinic entered the NHS, many of the senior staff were already running patients groups under Bion's headship. He also conducted groups for *Genesis and Development of Group-Analytic Therapy in Great Britain: Bion, Bowlby, Foulkes… DOI: http://dx.doi.org/10.5772/intechopen.111826*

industrial managers and professionals from the educational world. In order to attract patients for the therapy groups, he offered two options: to wait 1 year for individual treatment or to start group treatment immediately [12].

In the early years, the strategy worked and there was strength in numbers. Bion was very enthusiastic about injecting his group ideas into the Tavistock's post-war culture. Neurosis started to be perceived as a problem of personal relationships and, therefore, it had to be treated as a group phenomenon rather than as a purely individual one [13, 14].

Some of the Clinic's new staff accepted that group psychotherapy was a most timely development, at a key moment when war survivors needed to learn how to help one another. Bion based his group therapy programme on his conception of man as a *political animal*, as he put it:

*… an animal whose fulfilment can only approach completeness in a group. (Bion, in [11], p. 144)*

However, there were difficulties getting in the way. Henry Dicks further pointed out that the newly-elected Tavistock's professional committee knew pretty well what the views of most colleagues on the old staff were:

*… disapproval of group therapy; there was difficulty in understanding that a community view of psychiatric disorders did not imply disrespect for the sanctity of the individual therapeutic relationship. ([11], p. 154)*

Despite being a hugely influential and captivating figure, Bion gradually started to lose control of the situation. Perhaps he employed too radical an approach, as he seemed to be treating only the group as-a-whole, as if it were a single individual, rather than treating the individual group members. Many patients deserted or dropped out of group treatment.

Bion, who presented himself as the *only* source of *authority* in his therapy groups, might have been disappointed with the therapeutic results or unhappy with the sceptical culture towards groups within the institution, or both.

In any case, by 1952, he gave up and stopped running groups for patients at the Clinic or elsewhere [9]. However, he delegated his leadership of the Tavistock's group therapy programme to Henry Ezriel and Jock Sutherland, who thoroughly described the application of Bion's ideas as a method of psychoanalytic group therapy.

Ezriel [15–17] and Sutherland [18] favoured a technique whereby nothing but rigorous group-as-a-whole, here-and-now transference interpretations need be used. Ezriel particularly considered that these interpretations had to be delivered in the same manner as in individual psychoanalytic sessions. In this approach, the group became a *quasi-individual*.

For several decades, the overall mood in the institution was that therapy groups did not work. In the mid-1970s, David Malan led a comprehensive piece of research: 42 randomly selected patients were interviewed 2–14 years after termination of psychoanalytic group therapy at the Tavistock Clinic. The findings were staggering [19]:

Comparison of psychodynamic changes in patients who stayed less than 6 months with those who stayed more than 2 years gave a null result. The majority of patients were highly dissatisfied with their group experiences. However, there was a strong positive correlation between favourable outcome and previous individual psychotherapy.

These results cast doubts on the appropriateness of transferring to group treatment the strictly individual psychoanalytic approach, and critically pointed at the stringent approach employed by Bion and his followers. By the late 1970s, there was a sharp decline (almost extinction) of group psychotherapy at the Tavistock Clinic.

However, with some modifications, the Tavistock model was beginning to pick up at the time we started our training at the Tavistock Clinic, in the mid-1980s.

This revival owes a great deal to the work of Sandy Bourne, who allowed for his group therapy sessions to be observed behind a one-way screen (followed by clinical discussions) as a learning method, and to Caroline Garland [20], who had recently completed her group-analytic training at the IGA (*next door*) and brought a newly found sense of enthusiasm and creativity to the Tavistock.

Both Bourne and Garland played a large part in the process of re-engaging the institution with a revised, more user-friendly, evidence-based, methodologically stronger, and more effective philosophy of psychoanalytic group therapy.

## **3. Historical context to group therapy in Britain. Part II: the group-analytic model**

In contrast to the Bionian or Tavistock model, SH Foulkes (1898–1976), a German-born psychiatrist and psychoanalyst who came to England as a refugee, paid specific attention to the individual needs of his group patients, whilst keeping in mind the group as-a-whole and claiming that, ultimately, the individual is an *abstraction* and cannot exist outside a group.

Foulkes [21–24] developed the group-analytic approach, in which the therapist or conductor usually provides *security* and *immunity* for as long as the group is in need of them. Like Bion [10, 13, 25], he also conceived man as a social animal whose fulfilment can only achieve completeness in a group.

However, Foulkes's therapeutic attitude comprised more distinct holding and containing qualities, towards both the group itself and the different individuals within it. For this, he took into account other levels of group life, such as its intrinsic sociability, together with conscious and unconscious understandings that people in the groupanalytic *matrix* demonstrate to each other. He believed in the *inner-authority* of his patients.

Whilst Bion was largely influenced by Melanie Klein, Foulkes's primary influence was Sigmund Freud [26], who himself had concluded that the psychology of the group is the oldest human psychology. This theoretical contrast between Bion and Foulkes was amplified by the differences in their real-life experiences.

Foulkes had a more benign interpersonal attachment and group attachment history than that of Bion. He was brought up in the prosperous city of Karlsruhe, in a liberal and middle-class Jewish family. He experienced sufficiently secure attachments with both his parents; he was a popular boy at school, and thoroughly enjoyed playing football and tennis [27].

At the age of 18, Foulkes was enlisted in the telephone and telegraph section of the German Army, during the First World War. He served in France in the rear, where he discovered the power of *communication* for maximising survival. This idea would become one of the cornerstones of his conception of group psychotherapy [28, 29].

After the war, Foulkes undertook his psychiatric training in Berlin and his psychoanalytic training in Vienna. But his career and his family life were disrupted by the Nazi danger. Together with Erna (his first wife) and their three children, he had

#### *Genesis and Development of Group-Analytic Therapy in Great Britain: Bion, Bowlby, Foulkes… DOI: http://dx.doi.org/10.5772/intechopen.111826*

to run away from Germany to the relative safety of the UK, in order to evade an order that Hitler dictated in 1933 for him to surrender his passport.

Upon his arrival in London, he changed his German-Jewish name (Siegmund Heinrich Fuchs) to a phonetically British one, in order to disguise his identity of origin and, thus, maximise his chances of survival. Officially, he became SH Foulkes. In addition, he asked his family and friends not to use his first or middle name, but to call him Michael [30].

With the outbreak of war, London was no longer a safe place and Foulkes moved to the provincial town of Exeter, where he led his first therapy group in 1940. This group was made up of a number of patients he was treating individually. He felt curious about what they may have to say to each other if they were put together as a group. Indeed, he was experimenting, as Pratt had done some three decades earlier. And he also did it with a *safety net*.

In the group, Foulkes [22] listened to the conversations of his patients with a technique that he would later describe as *free-floating attention*, a kind of equivalent to the *free association* of the individual psychoanalytic method.

He also paid attention and tried to be sensitive to how the words were expressed and connected to one another (or otherwise), including the tone and modulation of the voice and the non-verbal language. That was the birth of what is known today as group-analytic psychotherapy.

Generally speaking, Foulkes [23] conceived his therapeutic role as that of a conductor and facilitator of communication and understanding amongst group members. In fact, he emphasised that the most important factor in group therapy is the process of communication itself, rather than the mere information that is transmitted.

Over time, perhaps influenced by his work as a *communicator* during the First World War, his views became quite radical, suggesting that psychotherapy is about keeping the communication process alive. Therefore, in his mind, psychotherapy and communication came to be the very same thing.

There was another important background to the evolution of his ideas. In 1943, Foulkes was called up as a British Army medical officer to replace Wilfred Bion and John Rickman, who had jointly led a therapeutic project called the First Northfield Experiment. Northfield was a military psychiatric hospital near Birmingham, in the heart of England.

This hospital had been reorganised with a view to helping the Army identify which soldiers had the possibility of making a recovery from their mental problems, in order to return to the front lines, and who should be discharged as unrecoverable.

The usual diagnosis used at that time was *shell shock* or *war neurosis*; what is now called post-traumatic stress disorder had not yet been clearly conceptualised.

Bion and Rickman [14] had introduced a radical treatment regimen. Neurosis was seen as the enemy; soldiers had to learn to face such an enemy and develop the courage to pick up their rifles again.

It would appear that Bion and Rickman tried very hard to get sick soldiers back on active duty as quickly as possible, perhaps without fully addressing their mental health problems. Since the war context had generated highly dangerous and critical situations, from their point of view, the survival of the group and that of the nation had priority over the survival of the individual.

For reasons not entirely clear, this first group therapy project crashed before taking off. The military authorities, puzzled by the disturbance caused within the hospital environment, decided to close it down after only 6 weeks [5].

We have the impression that Bion and Rickman failed to anticipate the tremendous impact of their drastic measures, not only on the sick soldiers but also on the therapeutic community they were trying to create. However, they laid key theoretical foundations, which turned out to be seminal for the study of group dynamics, both in therapeutic and institutional contexts across the world [13, 25].

Soon after Bion and Rickman left, Foulkes set up a new programme, called the Second Northfield Experiment. He incorporated some of the notions of his predecessors, but used group psychotherapy more specifically for the emotional well-being of soldiers than as a tool for returning them to the battlefields to face death.

His attitude was so benign that he often began a group therapy session with the following remark:

*As long as we are in this psychotherapy group, we are not in the Army. (Foulkes, cited in [27], p. 203)*

Although Northfield's two experiments differed in pace, technique, and effectiveness, they both shared many underlying concepts, such as social responsibility and the therapeutic use of the environment or milieu. In other words, both Bion and Foulkes perceived the hospital as-a-whole and tried to develop its healing potential as a therapeutic community [2].

Despite his doubts and hesitations, Foulkes made Northfield's second experiment a success. From 1943 to 1945, he treated vast numbers of soldiers, all in groups, as psychiatric casualties in the Army came to increase on a massive scale. With care and patience, Foulkes designed an innovative and powerful psychotherapeutic tool [27].

Although he drew heavily on psychoanalytic ideas, his technique was not a direct application of psychoanalysis to the group, but a form of therapy, *in* the group, and *by* the group, including its conductor [21–23].

This Foulkesian conception is similar to what has been called second-order cybernetics, in which the observer is part of what is observed or treated [30].

In this way, Foulkesian group-analysis gradually became an idiosyncratic therapeutic philosophy. In this philosophy, patients are conceived as possessors, not only of problems, but also of sufficient internal resources to help each other and, ultimately, become a *group of co-therapists* [31].

It is true that Foulkesian theory has often been criticised as vague or imprecise, even within group analysis itself. However, this vagueness or imprecision has been perceived by others as one of its strengths and a valuable element, since it avoids dogmatism and adapts relatively flexibly to the needs of the patient.

Over time, group analysis has become a solid theoretical and clinical discipline, particularly with regard to the study of interpersonal, intragroup, and intergroup relationships and their therapeutic potential (in small, medium and large groups), as well as to the promotion of healthier communities [5].

In recent decades, group analysis has extended its approach to the study of social thought, power dynamics and political tensions [32], as well as the so-called collective or social unconscious [33].

## **4. Bowlby's conception of group attachment**

John Bowlby (1907–1990) was born in London only 6 years after the death of Queen Victoria. He was brought up in an upper-middle-class family where Victorian *Genesis and Development of Group-Analytic Therapy in Great Britain: Bion, Bowlby, Foulkes… DOI: http://dx.doi.org/10.5772/intechopen.111826*

tradition was the norm. He could not establish secure attachment relationships with his parents, who left his care to a nursemaid with whom he developed an intimate attachment. However, he lost her before the age of four—a departure that he considered almost as tragic as the loss of a mother [12].

Bowlby was only seven when the First World War erupted. His father was immediately sent off to the Front. During the course of the war, Bowlby and his brother Tony were dispatched to boarding school because of the danger of air raids on London or, at least, that was what they were told. As an adult, he reflected that it was just an excuse, as part of a traditional step in the time-honoured barbarism required to produce English gentlemen [34].

Sometime later, Bowlby indicated that he had been sufficiently *hurt* but not sufficiently *damaged*, as a result of his childhood experiences*.* Although he never criticised his parents, his views on the attachment needs of young children could be seen as an indictment of the type of upbringing to which he had been subjected and of the culture that had fostered it [30].

In 1946, the very same year Wilfred Bion had set up the Tavistock Clinic's group therapy programme, and in competition with Donald Winnicott, John Bowly (who had trained as a child and adolescent psychiatrist and as a psychoanalyst) was appointed as Chair of the Children and Parents Department at the Clinic.

In the early days, Bowlby was significantly influenced by Bion, but he developed his own way of applying group methods therapeutically. In fact, he laid the foundations of therapeutic group work with families, by seeing all members of the family together. And he described his work in a ground-breaking paper, *The study and reduction of group tensions in the family* [35], the first European publication in the field of family therapy.

In addition, Bowlby established a weekly therapy group for mothers and their babies or young children, which he called the *Well-Baby Clinic*. He put aside one afternoon, every week, for this group therapy project and conducted it during the course of three decades.

Not unexpectedly, group membership changed when some mothers improved and were replaced by others. He succeeded in creating a therapeutic group dynamic and culture. And he gave priority to:

#### *… trying to help the less experienced learn from those who knew more. ([36], p. 29)*

However, Bowlby [3, 37–41] became so involved in his research into the nature of the child's tie to his mother and, subsequently, into the evolutionary roots and functions of human attachment throughout the life cycle, that he did not provide a detailed account of his group-therapy clinical findings, nor did he link these to his attachment theory.

At one point, he confessed that he left to others the task of integrating group therapy and attachment-based thinking [5].

Another major contribution of John Bowlby was the creation of the first research unit at the Tavistock Clinic. He promoted an aspiration that a research component should be built in to all current and future therapeutic work. That was with the aim of refining knowledge and feeding the conceptual refinement back into the subsequent clinical activities of the institution: no research without therapy and no therapy without research [11].

According to Bowlby [3, 41], attachment (like food and sexuality) is a fundamental and integral part of our existence and survival, all the way from the cradle to the

grave. The strength of the instinctual component of attachment gradually allows for the establishment of meaningful, intimate and enduring interpersonal and group attachment relationships.

John Bowlby was no doubt a group person who conceived the human mind as a social phenomenon. Whilst he originally investigated the nature of the child's attachment to the mother within the family environment [37–39], the compass of his work included other manifestations of interpersonal attachment and of group attachment through other developmental stages in the life cycle:

*During adolescence and adult life, a measure of attachment behaviour is commonly directed not only towards persons outside the family but also towards groups and institutions other than the family. A school or college, a work group, a religious group or a political group can come to constitute for many people a subordinate attachment figure, and, for some people, a primary attachment figure. In such cases, it seems probable, the development of attachment to a group is mediated, at least initially, by attachment to a person holding a prominent position within that group. ([3], p. 207)*

Inevitably, humans are born into a group. From birth onward, infants start to internalise group experiences, either directly or through their interactions with their attachment figures, who have mental representations of their own previous group experiences. In our evolution as a species, the group became an adaptive social organisation in the service of survival. The group is a humanising environment *par excellence*, and can also be a therapeutic and attachment space [42].

Undeniably, attachment theory is firmly grounded on Darwin's theory of evolution. Primarily, attachment serves survival (both physical and emotional) and gradually becomes the basis for healthy psychosocial development throughout the life cycle. Attachment is both an in-built force for human connectedness and a significant relationship that makes life more meaningful:

*Intimate attachments to other human beings are the hub around which a person's life revolves, not only when he is an infant or a toddler or a schoolchild but throughout his adolescence and his years of maturity as well, and on into old age. From these intimate attachments a person draws his strength and enjoyment of life and, through what he contributes, he gives strength and enjoyment to others. ([41], p. 442)*

## **5. Discussion**

We have suggested elsewhere [5] that Bion's traumatic experiences during the two world wars and his difficult interpersonal and group attachment history contributed to his conception of the individual as a group animal who is at war with his *groupishnes*s—an assumption which he did not revise and which, in many ways, became deified and dogmatised.

Foulkes also had to endure trauma, but he was able to establish more secure interpersonal and group attachments. His group-analytic mentality, the *matrix*, is not at war with the individual. According to him, the broad range of negative and positive responses generated in a well-functioning group enhances, both, the person's individuality and groupality.

This *group matrix*, with its emphasis on a deepening of group members' capacity for personal insight and mutual understanding through their own contributions,

*Genesis and Development of Group-Analytic Therapy in Great Britain: Bion, Bowlby, Foulkes… DOI: http://dx.doi.org/10.5772/intechopen.111826*

as well as those of the conductor, adds a more democratic therapeutic dimension or group culture that is lacking in the defensive *group mentality* that Bion [25] had originally conceptualised.

In terms of attachment theory, the therapeutic *group matrix* (including members and the therapist or conductor) has been described as constituting a *secure base* or, at least, a secure-enough base [5, 12, 43–46].

In its purest form, Bion's technique provokes a significant amount of frustration; it may lead to disappointment, even hostility. However, this is not necessarily a bad thing; after all, learning to tolerate frustration without resorting to destructive anger and aggression is an important developmental task.

Having said that, too much frustration and disappointment can generate unbearable levels of anxiety and dysfunctional, even aggressive, group mentalities—particularly in the more vulnerable patients.

Foulkes gathered that, as well as repressed hostility, patients bring a feel for group connections, collaboration and meaningful and intimate social relatedness. These elements combined can contribute to the formation and development of *group attachment*, as conceptualised by Bowlby [3].

Group members present themselves with many different symptoms and problems, but also carry with them a wealth of experience and a capacity for supporting one another, as well as other strengths that can be used therapeutically in the group situation.

In the Bionian model, the analyst is paradoxically the sole (*leaderless*) group leader, and becomes the *only* source of higher-level functioning, interpretation and knowledge. In the Foulkesian model, the conductor is *not* the sole group leader, but takes the lead in enabling members to eventually constitute themselves in a *group of co-therapists* [31].

A group-analytic conductor is meant to foster not so much frustration, but tolerance and appreciation of individual differences—a real challenge in its own right. This distinct attitude is an effective way of encouraging members to participate actively in their own therapeutic process. Sometimes, but by no means always, such a conductor allows the group to cast him or her in the role of *leader*.

As the group matures through reliance on its own strength, the conductor or therapist's role evolves from being a leader *of* the group to becoming a leader *in* the group: the *authority* of the conductor is integrated into the *authority* of the group [5].

Group Analysis is not psychoanalysis of the group as if it were a *quasi-individual* [17, 18, 25] or individual analysis in the group [47], but therapy *of* the group, *by* itself, including its members and the conductor [23].

Bion and Foulkes were on common ground in their recognition of an unconscious mind, with transference defence mechanisms, both in the individual and in the group. With that said, Foulkes also gave himself permission to become a *member* of the group and introduced a new frame of reference, in which the transference develops in a different way due to its multi-personal distribution [28].

Some group analysts have attempted to integrate both approaches [2, 5, 20, 28, 48, 49]. But these attempts at working towards a rapprochement of the Tavistock and group-analytic models have been an exception to the norm. The reality is that neither Bion nor Foulkes (or their followers) appeared to significantly influence each other, although they both approached group therapy from the perspective of the group as-a-whole.

Certainly, there has been more emphasis on the differences between the two theories and subsequent clinical modalities. By the time Foulkes came to group

psychotherapy, he was an experienced psychoanalyst and saw the group as a set of individuals whose interactions and communication became his focus. In contrast to that, when Bion approached group therapy, his experience was in a large organisation (the British Army) and he focussed on the group as an entity in itself. Hence,

*Foulkes applied individual psychology to groups; Bion applied organisational psychology to groups. ([49], p. 353)*

In attachment terms, we may say that, in the traditional Tavistock model, it is more difficult for members to perceive the group as a *secure base*, although they are confronted more openly with group transference interpretations, particularly regarding possible manifestations of their unconscious hostility.

In contrast, in the group-analytic model, there is more room for the exploration of multiple aspects of the transference, including transferences of individual members to the therapist or conductor, as well as transferences amongst members themselves.

Optimally, the so-called *group matrix* can become a *secure base* for the patient to explore safely.

Nevertheless, it is striking that, in his many publications, Foulkes hardly referred to attachment or human development. In fact, the words development or attachment do not appear in any of the indexes of his books.

These terms are also absent in the index of *The Practice of Group Analysis* [50]. This book, with contributions from early generations of group analysts, is still largely considered a blueprint of group-analytic psychotherapy.

Consequently, in the thinking, training and practice of group analysts, past and present, there has been a concerning absence of attachment-based thinking, with only a few exceptions [5, 12, 30, 43, 44, 51–54].

Fortunately, in the last two decades, other clinicians and researches have contributed to the study of attachment into the field of group psychotherapy, particularly in North America and in Europe.

In this sense, we would like to direct the reader towards the work of McCluskey [55, 56], Flores [57], Markin and Marmarosh [58], Page [59], Marmarosh et al. [60], Marmarosh and Tasca [61], Marmarosh [45, 62, 63], Tasca [64], Wajda and Makara-Studzińska [65, 66], Tasca and Maxwell [46].

We may say that, in different ways, these authors have postulated that there is a group attachment system which, based on evolution, predisposes humans to seek security and form bonds with social groups, in addition to the dyadic or interpersonal attachment system. Although these two attachment systems (dyadic and group) are different, in many ways they overlap, have important similarities, and influence and complement each other [5].

Our own view is that person-to-person attachment and person-to-group attachment represent two relatively independent but interconnected domains. In order to further investigate and understand the nature of group attachment, it is essential to identify what exactly people are attached to when they interact *in* the group and *with* the group, not only with group members or leaders, but also with the group as-a-whole.

In fact, one of us had put across a tentative definition of this important concept, which tries to integrate group analysis with attachment-based thinking. Of course, this description can be revised and improved as further research moves along:

*Group attachment can be conceived as a construct that brings together a complex constellation of significant attachment relationships, in the group and with the group;*  *Genesis and Development of Group-Analytic Therapy in Great Britain: Bion, Bowlby, Foulkes… DOI: http://dx.doi.org/10.5772/intechopen.111826*

*that is, with its members, with its leaders and with the group as-a-whole, in order to maximise survival, protection, development, creativity and full realisation of human capabilities, as a person and as a species. [67].*

## **6. Conclusion**

The group is a deeply humanising entity with healing properties, and so can be a therapeutic and attachment space. In our evolution as a species, the group became an adaptive social organisation in the service of survival—a theme that has been at the front, in the origins of group therapy.

In fact, having to fight and survive two world wars had a strong bearing in the genesis and development of the two main models of group psychotherapy in Great Britain, those of Bion and Foulkes. Despite their differences, these approaches can be integrated and complement each other.

Certainly, no individual, however isolated in time and space, should be regarded as outside a group or lacking in multiple manifestations of group lives, including group attachment, as formulated by Bowlby in 1969 and further investigated by a number of authors, particularly in North America and Europe, in recent decades.

Group attachment is highly relevant to group psychotherapy; studying its nature and therapeutic implications should be an integral part of the training of psychotherapists and other mental health professionals across the board, especially those working with groups.

In an appropriate group climate, patients can perceive their therapy group as an attachment figure.

## **Author details**

Arturo Ezquerro1 \* and María Cañete2

1 International Attachment Network and Institute of Group Analysis, London, UK

2 Institute of Group Analysis, London, UK

\*Address all correspondence to: arturo.ezquerro@ntlworld.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] Kaplan HI, Sadock BJ, editors. Comprehensive Group Psychotherapy. Baltimore, MA and London, UK: Williams & Wilkins; 1983

[2] Pines M. Circular Reflections: Selected Papers on Group Analysis and Psychoanalysis. London: Jessica Kingsley; 1998

[3] Bowlby J. Attachment and Loss, Attachment (1991 edition). Vol. 1. London: Penguin Books; 1969

[4] Ettin MF. Foundations and Applications of Group Psychotherapy: A Sphere of Influence. Boston, MA: Allyn and Bacon; 1992

[5] Ezquerro A, Cañete M. Group Analysis Throughout the Life Cycle: Foulkes Revisited from a Group Attachment and Developmental Perspective. London: Routledge; 2023

[6] Jung C. Collected Works. Vol. 9. Princeton, NJ: Princeton University Press; 1969

[7] Hawkins D. Understanding reactions to group instability in psychotherapy. International Journal of Group Psychotherapy. 1986;**36**(2):241-260

[8] Hearts LE. The emergence of the mother in the group. Group Analysis. 1981;**14**(1):25-32

[9] Trist E. Working with Bion in the 1940s: The Group Decade. In: Pines M, editor. Bion and Group Psychotherapy. London: Routledge; 1992. pp. 1-46

[10] Bion WR. The Long Week-End 1897-1919: Part of Life. Abingdon, UK: Fleetwood Press; 1982

[11] Dicks HV. Fifty Years of the Tavistock Clinic. London: Routledge & Kegan Paul; 1970

[12] Ezquerro A. Encounters with John Bowlby: Tales of Attachment. London: Routledge; 2017

[13] Bion WR. The leaderless group project. Bulletin of the Menninger Clinic. 1946;**10**:77-81

[14] Bion WR, Rickman J. Intra-group tensions in therapy. The Lancet. 1943;**2**:678-681

[15] Ezriel HA. A psychoanalytic approach to group treatment. British Journal of Medical Psychology. 1950;**23**:59-74

[16] Ezriel HA. Notes on psychoanalytic group therapy. Psychiatry. 1952;**15**:119-126

[17] Ezriel HA. The role of transference in psychoanalytic and other approaches to group treatment. Acta Psychotherapy. 1959;**7**(suppl):101-116

[18] Sutherland J. Notes on psychodynamic group therapy. Psychiatry. 1952;**15**:111-117

[19] Malan DH, Balfour FH, Hood VG, Shooter AM. Group psychotherapy: A long-term follow-up study. Archives of General Psychiatry. 1976;**33**(11):1303-1315

[20] Garland C, editor. The Groups Book. Psychoanalytic Group Therapy: Principles and Practice. London: Karnac; 2010

[21] Foulkes SH. Group analysis in a military neurosis centre. Lancet. 1946;**1**:303-313

*Genesis and Development of Group-Analytic Therapy in Great Britain: Bion, Bowlby, Foulkes… DOI: http://dx.doi.org/10.5772/intechopen.111826*

[22] Foulkes SH. Introduction to Group Analytic Psychotherapy. London: Heinemann; 1948

[23] Foulkes SH. Therapeutic Group Analysis. London: George Allen & Unwin; 1964

[24] Foulkes SH. Group Analytic Psychotherapy: Method and Principles. London: Gordon & Breach; 1975

[25] Bion WR. Experiences in Groups. London: Tavistock; 1961

[26] Freud S. Group Psychology and the Analysis of the Ego, Standard Edition of the Complete Works of Sigmund Freud, (1953 edition). Vol. 18. London: Hogarth Press; 1921

[27] Ezquerro A (2004a) El grupo en la clínica. Primera parte: Aspectos históricos. En Caparrós N (ed) Y el Grupo Creó al Hombre. Madrid: Biblioteca Nueva, pp. 193-211.

[28] Ezquerro A. The Tavistock and group-analytic approaches to group psychotherapy: A trainee's perspective. Psychoanalytic Psychotherapy. 1996;**10**(2):155-170

[29] Ezquerro A (2004b) El grupo en la clínica. Segunda parte: Enfoques grupoanalíticos. En Caparrós N (ed) Y el Grupo Creó al Hombre. Madrid: Biblioteca Nueva, pp. 212-227.

[30] Ezquerro A. Apego y desarrollo a lo largo de la vida: El Poder del Apego Grupal. Madrid: Editorial Sentir; 2023

[31] Ezquerro A. Group psychotherapy with the pre-elderly. Group Analysis. 1989;**22**(3):299-308

[32] Blackwell D. Psychotherapy, politics and trauma: Working with survivors of

torture and organized violence. Group Analysis. 2005;**38**(2):307-323

[33] Hopper E. The Social Unconscious: Selected Papers. London: Jessica Kingsley; 2003

[34] Holmes J. John Bowlby and Attachment Theory. London: Routledge; 1993

[35] Bowlby J. The study and reduction of group tensions in the family. Human Relations. 1949;**2**:123-128

[36] Bowlby J. The role of the psychotherapist's personal resources in the treatment situation. Bulletin of the British Psychoanalytical Society. 1991;**27**(11):26-30

[37] Bowlby J. Maternal Care and Mental Health. Geneva, Switzerland: World Health Organization; 1951

[38] Bowlby J. Child Care and the Growth of Love. Harmondsworth, UK: Penguin Books; 1953

[39] Bowlby J. The nature of the child's tie to his mother. International Journal of Psychoanalysis. 1958;**39**:350-373

[40] Bowlby J. Attachment and Loss, Separation, Anxiety and Anger (1991 edition). Vol. Vol 2. London: Penguin Books; 1973

[41] Bowlby J. Attachment and Loss, Loss, Sadness and Depression (1991 edition). Vol. Vol 3. London: Penguin Books; 1980

[42] Cañete M, Ezquerro A. Bipolar affective disorders and group analysis. Group Analysis. 2012;**45**(2):203-217

[43] Ezquerro A (1991) Attachment and its circumstances: Does it relate to group analysis? [Theoretical dissertation for membership of the Institute of Group

Analysis (IGA)]. Archives IGA Library, London

[44] Glenn L. Attachment theory and group analysis: The group matrix as a secure base. Group Analysis. 1987;**20**(2):109-126

[45] Marmarosh CL, editor. Attachment in Group Psychotherapy. New York: Routledge; 2020

[46] Tasca GA, Maxwell H. Attachment and group psychotherapy: Applications to work groups and teams. In: Parks CD, Tasca GA, editors. The Psychology of Groups: The Intersection of Social Psychology and Psychotherapy Research. New York: American Psychological Association; 2021. pp. 149-167

[47] Burrow T. A Search for Man's Sanity: Selected Letters with Biographical Notes. New York: Oxford University Press; 1958

[48] Brown D. Bion and Foulkes: Basic assumptions and beyond. In: Pines M, editor. Bion and Group Therapy. London: Routledge; 1992. pp. 192-219

[49] Hinshelwood RD. Bion and Foulkes: The group-as-a-whole. Group Analysis. 2007;**40**(3):344-356

[50] Roberts J, Pines M, editors. The Practice of Group Analysis. London: Routledge; 1991

[51] Adshead G. Psychiatric staff as attachment figures. British Journal of Psychiatry. 1998;**172**:64-69

[52] Maratos J. Self through attachment and attachment through self in group therapy. Group Analysis. 1996;**29**(2):191-198

[53] Marrone M. Attachment and Interaction. London: Jessica Kingsley; 1998

[54] Zulueta F. From Pain to Violence: The Traumatic Roots of Destructiveness. London: Whurr; 1993

[55] McCluskey U. The dynamics of attachment and systems-centred group psychotherapy. Group Dynamics: Theory, Research, and Practice. 2002;**6**:131-142

[56] McCluskey U. A model of group psychotherapy based on extended attachment theory: A preliminary report. Irish Association of Humanistic and Integrative Psychotherapy. 2007;**52**:71-81

[57] Flores PJ. Group psychotherapy and neuro-plasticity: An attachment theory perspective. International Journal of Group Psychotherapy. 2010;**60**(4):546-570

[58] Markin RD, Marmarosh CL. Application of adult attachment theory to group member transference and the group therapy process. Psychotherapy: Theory, Research, Practice, Training. 2010;**47**(1):111-121

[59] Page TF. Applications of attachment theory to group interventions: A secure base in adulthood. In: Bennett S, Nelson JK, editors. Adult Attachment in Clinical Social Work. New York: Springer; 2010. pp. 173-191

[60] Marmarosh CL, Markin RD, Spiegel E. Attachment in Group Psychotherapy. Washington, DC: American Psychological Association; 2013

[61] Marmarosh CL, Tasca GA. Adult attachment anxiety: Using group therapy to promote change. Journal of Clinical Psychology. 2013;**69**(11):1172-1182

[62] Marmarosh CL. Empirical research on attachment in group psychotherapy: *Genesis and Development of Group-Analytic Therapy in Great Britain: Bion, Bowlby, Foulkes… DOI: http://dx.doi.org/10.5772/intechopen.111826*

Moving the field forward. Psychotherapy. 2014;**51**(1):88-92

[63] Marmarosh CL. Attachment in group psychotherapy: Bridging theories, research and clinical technique. International Journal of Group Psychotherapy. 2017;**67**(2):157-160

[64] Tasca G. Attachment and group psychotherapy: Introduction to a special section. Psychotherapy. 2014;**51**(1):53-56

[65] Wajda Z, Makara-Studzińska M. Attachment in group psychotherapy. Part 1: Theoretical aspects. Psychoterapia. 2018a;**186**(3):7-17

[66] Wajda Z, Makara-Studzińska M. Attachment in group psychotherapy. Part 2: Empirical research. Psychoterapia. 2018b;**187**(4):57-67

[67] Ezquerro A (2019) The power of group attachment. Group Analysis North Open Seminar, University of Manchester, UK
