Book synopsis: Group psychotherapy for mothers and fathers, focusing on the parental function

Authors: Enrique Ger, Elena Trullen & Emma Clarós. (Editorial Psicolibro. Buenos Aires 2021.)

This book is the result of work developed for more than twenty years within the Public Network of Mental Health Care in Barcelona. It focuses on an experience of the first decade of the current century, in the Psychoanalytic Psychotherapy Unit for children and adolescents of Sant Pere Claver Health Foundation.

It is focused on a group psychotherapy process that included 27 sessions, some of which are presented here, corresponding to the beginning and middle stages, as well as the final phase.

We will try to bring the reader closer to the contents of the task, exposing the clinical material corresponding to the 18th session. We accept and recognize that this approach is possibly limited and partial and, of course, different from the one that would offer the reading of the book. The book comprises comments that start from the clinical, towards the technique, the theory and the theory of the applied technique.

Starting from the clinical work, supervision and mastery of her mentor, Dr. Eulalia Torras de Beá, the parallel groups of children and parents constitute a powerful therapeutic tool for child mental health teams. It was essential to make a bridge from her proposals and teachings, to develop an adaptation of these to the needs of our team and thus develop the work with parents in parallel groups. With a lot of work, this intervention gained consistency and clinical solidity. To the same extent and gradually, the corresponding development of our experience and the evolution of the referrals received acquired a key place within the team’s care strategy.

For many children who come to our service, the parallel groups of children and parents are the first indication, and this acquires more relevance, to the extent that, for most of them, most of the problems that affect them, lie in the first years of life.

Our team, the Psychoanalytic Psychotherapy Unit for children and adolescents of Sant Pere Claver, Health Foundation (UPPIJ) has, as its main task, to develop a model of care applied to the public mental health of children and adolescents, as well as the training of professionals and research on care techniques and strategies. Group work with parents and their children, as well as individual focal psychotherapy, are two of the tools of our team’s assistance strategy which includes: exploration, inter-consultation, networking, diagnosis, indication, treatment and evaluation, all impregnated with a spirit of prevention. What we present here is the product of one of the intervention techniques used in the service of this strategy.

Conceiving the groups, building them, starting them up, carrying them out and sustaining them over time, represents, as we explained in Chapter I, multiple challenges, and at the same time, demands commitment, support and containment from the institution and the rest of the team. If we have all this at our disposal, if we manage to develop the coordination of the work of the network, if we gradually adjust the indications and fine-tune the application of the techniques, this work will bring us multiple benefits. Some of these are: clear incidence at a preventive level, facilitate the approach to parental functions, assist and orient the family, constitute a diagnostic tool (of the child, his parents and the interrelationship) and, above all, be a highly therapeutic instrument.

We do not intend to offer a manual, but a model. The way we conceive our task, and the way we work with parents in a group. Within the team, there are a variety of positions in this respect. We don’t all coincide in all the points treated and, during its creation, we discussed at length and learned in supervision groups, in order to reach a significant degree of consensus in the proposals we make.

As for the duration of the groups, we try to follow the Barcelona school year (September-June). The groups usually start in October and end in early June, two weeks before the end of classes. We do a weekly session of one hour and we give ourselves half an hour to meet and discuss what happened between the therapists of both groups and the observers.

Without pretending to make a historical analysis, we could say that, in the beginnings of therapeutic group work, a way of understanding and, therefore, of naming the work was imposed, with which the group entity was understood and considered as the one that, within the group experience, should be primarily treated. Perhaps it was natural that during the early days something of this nature happened, that there was a certain “idealization” and, therefore, a certain reductionism to the new discovery.

Many of the initiators of group therapeutic practices were psychoanalysts, but the theory of psychoanalytic technique was initially conceived and designed to address intra- and inter-relational aspects, and not to be applied to subjects in groups, such as the group of parents presented here.

Derived from this, as time went by, the same practical experience made evident the decoupling between the phenomenon to be treated and the theory of the corresponding technique, and gradually led to the need to re-evaluate the magnitude of the different components of the group phenomenon.

In this way, progress was made in considering that, in therapeutic group work, the group entity should be especially considered, but no less especially than the interrelationships that develop in it, nor less especially than the individuals  who come to the group.

Gradually, a way of understanding the group phenomenon as something that happens in the work with individuals  within a group device emerged. It is considered that within the group there are always three elements, which in turn mean three levels of expression of the unconscious: what is inherent to the individuals  that compose it, what is inherent to the interrelationships that the members of the group establish among themselves and those resulting from the group dynamics .

Obviously it must be said that these three levels of expression of the unconscious, as we develop in chapter I, imply for therapists a great challenge in terms of how to grasp, understand, position and intervene therapeutically. Within the challenge and from the practice, we understand that it is possible to understand the group phenomenon and to advance therapeutically, considering as a priority the attention of the individuals  within the group and considering at the same time the interrelations and the group dynamics.

The work consists of three blocks, the first includes the theoretical and technical bases, the second includes the clinical material of the sessions and the third focuses on the evaluation.

In the clinical work of the group, we consider a first phase, which corresponds to the meeting session, in which the therapist offers the parents of each child a brief time, so that they can expose the “big headlines” of what is happening to the child and what is happening to them in the family; in short, the “reason for the consultation”. In turn, the therapist, with his interventions, gathers from each presentation important questions, which obviously cannot be deepened in those first moments, and offers the members of the group a bridge, announcing that, starting from the next session, it is planned to dedicate a session to each child, their parents and their family.

The second phase begins in the second session, in which the time is dedicated to listen first to the parents of one child, then a question and answer session is opened. Questions are asked by the other parents in the group. The therapist collects the questions and makes others that will be necessary “to think together”, to clarify and, in this way, while the work is being done focusing on the child chosen for that session, the framework is being built and a second bridge is offered towards the next phase, the third one.

The third phase begins when all the children have already been introduced. From then on, the task will focus on the issues mentioned above and through the active participation of the parents by bringing concrete situations, such as, for example, what happens in the afternoon in every house where there are children. In a short time, snack time, homework and after-school activities overlap and, a little later on, bath time, dinner and then bedtime, all of which constitutes a staging of what happens with the relationships, interrelations and group dynamics of a family.

The fourth phase begins when, generally spontaneously, some allusion to the end date comes up in the group. From then on, and to the extent that it has already been mentioned, the work focuses on the feelings that the termination triggers in its members.

As public mental health professionals, we consider that integrating assessment into care is a challenge that we should not and cannot avoid. For this reason, Block III, which includes chapters 6 to 12 inclusive, is devoted to evaluation.

In our service we attend to the age range from 0 to 18 years old, although in reality we receive children from 4 to 18 years old. Specifically, the group we present is attended by the parents of 5 boys and 3 girls, who are, at that time, between 9 and 10 years old.

As a guide, we present the names and ages of each mother or father attending the group, the name of their child and the reason for the consultation.  It can be seen that, in general, the mothers are around 40 years old and the fathers are close to 50 years old.

Estela (42) and Juan (48), parents of Nicolás, who presented with high levels of hyperactivity and impulsivity. Low frustration tolerance, difficulties with authority and peer relationships. Fights with his brother. The parents, who separated a year ago, have a good relationship.

Celia (40), mother of Alberto, who presented with bad behavior, competition and jealousy with his sister. Problems of differentiation and inhibited attitude in the relationship. Parents separated a year ago, still in mourning.

Laura (44) and Marcos (48), parents of Luis, who presented with conduct disorder, tantrums, problems in handling rules, always calling for attention. Low results in attention tests, although the professional who referred him said that it was because he was trying to go too fast.

Oriol (46), father of Ismael, who presented with possible attention deficit and some learning problems. Intelligent and with imaginative capacity, but with many fears. He was lost in fantasy and this made it difficult for him to pay attention.

Sandra (46) and Julian (48), parents of Monica, who had low self-esteem, complexes and inhibition in relationships. Problems at school, she repeated a grade. Anger at home.

Pedro (44), father of Elisabeth, who presented with anxiety with food and fear of sleeping alone. Very dependent on the mother, with difficulties to accept a third one. Relationship problems at home and at school.

Mireia (42), mother of David, who presented with sadness and had been diagnosed with depression. Problems concentrating at school.

Juana (38), mother of Nerea, who presented with bad behavior at home and at school. Difficulty in relating to her peers. In spite of everything, she had a good bond with her teacher. Separated parents, mother with a new partner who felt overwhelmed by the child.

SESSION 18

In attendance: Celia (Alberto); Sandra and Julián (Mónica); Laura and Marcos (Luis); Estela and Juan (Nicolás); Mireia (David); Oriol (Ismael).

Missing: Luisa and Pedro (Elisabeth).

They enter the room, where the observer is at the door. They greet each other and sit down.

There is silence, everyone looks at each other, some smile (looking uncomfortable), others look at the floor.

Therapist: “How would you like to continue today?”

Estela: “It’s always hard for us to get started at the beginning and then we get going.”

There is a brief silence.

Laura: “Luis still has nightmares at night… Now we don’t see anything that triggers them. Before it was because of the beginning of school, but now there is nothing and he still has night terrors. Also, he calls us at night and when we go, he is angry with us and yells at us and tells us to leave.”

Marcos: “It’s really hard for us to understand why this is happening”.

Therapist: “What would others say, how could we approach thinking about this?”.

Sandra: “I don’t know… what I see is that our children have different ways of expressing themselves. Just yesterday, with Monica, we had a fight because she goes to catch-up lessons, because she is very far behind in school. As it is the end of the trimester, I had a meeting with the teacher and before going in we made a pact. I said to her: “Do you want to go in first or me? She told me she wanted to go in first. Then, when there were twenty minutes left, I went in and she became hysterical saying no, that she wanted to leave, that she didn’t want me to stay… She threw herself on the floor, I wasn’t going to give in, I had to talk to the teacher and that was it. Going home was the easy thing to do, because she was embarrassing me in front of the teacher, but I thought no, that, besides, if I went home, it was a question of her winning. It wasn’t a matter of her winning or losing, but I had to talk to the teacher. When I started talking to the teacher, she calmed down. I don’t know if it was because we were no longer paying attention to her or because she saw that what the teacher was saying was good and she had been afraid that what she was going to say was bad”.

Estela: “I am sure that what happened was that she was afraid that they would say something bad about her. And that’s why she wanted to leave, so she wouldn’t hear it”.

Sandra: “Yes… because she knows she is having difficulties at school and it creates a lot of insecurity… Anyway, these days we see Monica feeling better, as Easter is coming, she won’t have to go to school, she will be on holiday…”.

Therapist: “I propose to stop at this point. If we look closely at  Marcos’s question, by recognizing the lack of understanding and the desire to understand, we see that we are at a point of misunderstanding: the parents do not understand the child and the child does not feel understood. But, to the extent that we can begin to put ourselves in the child’s shoes and place, the possibility of understanding them begins to open up and, perhaps, to get out of the misunderstanding. If we focus on what Marcos and Laura raise and we start from the parents’ frustration, an incomprehensible child appears: “We don’t understand him, first he calls us to go to his room and then he throws us out”. The same in the case of Sandra and Julian: “Monica, first, accepts that mom comes in and then, it turns out that she doesn’t want her to”. If we start from the children’s behaviour, we continue with the open question, but if we go into their feelings, perhaps we can find a meaning to what happens to them and what they do. We can begin to acquire degrees of understanding that create the basis to get out of misunderstanding and disagreement . We have also been talking about Álvaro, Nicolás’ brother. At the beginning, the episodes he suffered were presented as enigmatic, but as we started to put ourselves in his place and began to acquire degrees of understanding of what is happening to him, the episodes stopped appearing to our eyes as enigmas”.

Comment (47): Parents, with their children, feel, more and more, as if they were at a crossroads. If they recognize the incomprehension, let themselves be guided by their desire to understand and put themselves in their children’s shoes, instead of concentrating on their behaviour, they begin to recognize their children’s feelings and then their own, then they make the lived experience of relief, non-intellectual. On the other hand, what they observe and begin to understand gives them responsibility, commitment and makes them uncomfortable. From the affection towards their children and the desire to understand them, they support the therapeutic task, and from their character, they feel attacked and express the need to rebel. They rebel not only against what is transmitted to them by the therapist and their colleagues, who are becoming sensitized, but also, “paradoxically”, against the evidence offered to them by the life experiences they are having and sharing.

Estela: “Well, now that we have talked to so many specialists, the doctor, the psychologist,… we are seeing that many of these episodes are real, but others are exaggerated. As he sees that we pay more attention to him, the child also takes advantage of it. Poor thing! It is true that there are many episodes that are real because they are seen, but there are also other moments that you can see that they are not… Last week we had a meeting with the therapist of the children’s group and she told us that Nicolás is a child who constantly needs to be the center of attention and that is what has happened at home all these years, and that is why his brother, with everything that has happened lately, has said enough is enough. I am very similar to Nicolás in terms of character, that’s why we clash so much, the two of us”.

Comment (48): Estela is very ambivalent. She begins to recognize the evidence that, in what happens to Álvaro (Nicolás’ brother) there is a strong load of accumulated feelings, but at the same time, and quickly, she attributes manipulation to the child. She then acknowledges again that, with all that has happened, it is understandable that Álvaro has finally said enough is enough. She then goes a step further and acknowledges that her own way of being is very similar to Nicolás’ and that this is why she clashes with him so much. Her realization could relieve her, but, for the time being, it is very painful and uncomfortable and she is living it with contradictory feelings.   

Sandra: “We have the meeting this week. What happens is that we see that, if Monica is this way now, when she enters adolescence we don’t know how she will be… Julian sometimes likes to watch this big brother program and you see these children who hit their parents, hit, insult… We don’t suffer this, but Monica, when she is very angry, she insults us, she swears at us, she doesn’t hit us, well, sometimes, when she is very angry, she even hits me… That’s why I think that, if she is like that now, I don’t want to know what it will be like in a few years”.

Comment (49): Sandra, who in previous sessions has begun to be sensitive to Monica’s feelings, expresses her ambivalence again. Now she has once again labelled her daughter’s behaviour, in this case as “violent” and it seems that, in order to keep her own character firm, she will rebel today, activating the anticipatory fear of what will happen when Monica enters adolescence.

Estela: “I think this is everyone’s fear”.

Therapist: “What would the other side of the room say? It seems that today only those from this area are talking”.

Celia: “Yes, here we are in the quiet zone (she laughs). Well, the truth is that Alberto is much better. I talked to the teacher last week and she told me that she saw his changes, much more open, responsible, able to make jokes, and that he relates better… I also see a big change at home. He is very responsible, when he arrives he starts doing his homework by himself, without me having to tell him anything. On Wednesdays, when he comes home for lunch, he brings his backpack full to get his homework done at noon, because he knows that afterwards he spends the afternoon with his father and they don’t do anything. I say to him, “But why do you come so loaded?”. And he says: “You know, Mom, we are with Dad this afternoon”. I was amazed, because he told me like… you know what it is like… And yesterday he also came very loaded and I asked him why, he told me he had a lot of homework, but, for example, he only has religion once a week, so he doesn’t have class until after Easter, but he told me he wanted to bring it forward, and he said: “Mom, you know what they say: don’t leave for tomorrow what you can do today”. And I thought… look at him! (She laughs). In this sense, he is fine, even the teacher told me that in class he is very hardworking, that when they finish the class work they can do the homework they have left and that he always makes the most of it. But, on the other hand, there is everything related to his father, which I can no longer control. Now he is in a bad mood because the father has told them that at Easter his partner will be with them permanently, and he takes this very badly. He tells me about it, but of course, I try not to let it show that I don’t like it either, but of course, he knows me perfectly well and my non-verbal language gives me away, I can’t do anything… I try not to, but it is very difficult for me”.

Comment (50): The therapist points out that there is one side that has remained silent and Celia begins to speak, who, with her exposition, makes a counterpoint with Sandra and Estela. Celia acknowledges her son Alberto’s development and advances and, at the same time, recognizes that, regarding Alberto’s relationship with his father, she cannot control it and has difficulty controlling herself. Perhaps she expresses with this that she would love to control, she is stirred by having to accept the reality and accepts that she has a pending task. Finally, she shows how her son can pick up and understand her nonverbal language, despite her efforts to avoid being noticed, which opens a great chapter on how children pick up on their parents’ feelings and how parents pick up on their children’s feelings.

Therapist: “Celia is showing us that she has made the process of rational understanding of what she can and cannot control (she points to her head), but that here (she points to her chest), the emotional one, she is still digesting”.

Celia: “It’s just that it’s a very heavy digestion” (she laughs).

Therapist: “How do the others hear all this? What do they think?”.

Oriol: “Well, my son is very different from yours… My son never gets angry, he doesn’t get into fights, on the contrary, if someone has to give in, it’s always him. If there is a toy for two to play with, he will be the one who withdraws because he thinks: “Arguing, what for?” So, he is always the one who gives in. In this sense, I was thinking about what you were saying about Álvaro, Nicolás’ brother (he looks at Estela and Juan), because sometimes I think that at some point Ismael will take  it out somewhere. He has already done it once at school, he got very angry and started yelling at the teacher and even threw the books on the floor. Later, when I talked to the teacher, she told me that, of course, she didn’t expect it from Ismael… that, of all people, he was the last one she thought would do something like that. On the other hand, he is a child who has a hard time getting things done. With homework, he can do all the multiplications well and then be distracted and do them all wrong, you have to be on top of him to get him to do things”.

Therapist: “Oriol makes us understand that Ismael would have a style of holding on and keeping everything inside, until he reaches a point where he explodes”.

Estela: (cutting the therapist off) “Yes, I see that what Álvaro comes up with when he has these episodes are things from months or even years ago. I think: but how can he remember this? These are things that don’t seem to affect them, but they stay with them and then you are surprised that that thing had affected him so much, when it seemed that it didn’t”.

Comment (51): Oriol, who had also been defensive in previous sessions, stimulated by what Estela expressed in relation to Álvaro, can be sensitized, put himself in Ismael’s shoes and come closer to understanding the pressure he may be experiencing in his feelings. Estela, entering inside her children, rediscovers them and is surprised at the load of feelings accumulated by Álvaro, who begins to be able to talk about it. In this way, Estela comes closer to recognizing and understanding the suffering that Álvaro may experience if he does not express what he feels and remains blocked inside. It is possible to observe, in this passage, the strength of the group dynamics, since what Estela expresses can reach Oriol’s feelings and what Oriol expresses activates Estela’s feelings and understanding. We can think that this dynamic is generating a similar movement of activation of feelings and thoughts in all the members.

Therapist: “And I wonder: what does Mireia think?”

Mireia: “Well, David doesn’t fight much… Only with his older brother, with him they do fight. He is more like his son (pointing to Oriol), you always have to push him to get things done”.

Therapist: “If we look at it, there would be a common ground in all the situations we are dealing with, and that is that, if we focus only on our expectations or frustrations and on our children’s behavior, we cannot take into account what is happening to them and, in that way, we easily settle in the misunderstanding that leads to disagreement. As they are growing up and have to mature, it is often impossible for children to enter into our logic. Under these conditions, vicious circles or relational loops are built. Thus we come to feel misunderstood and alone and, paradoxically, our children come to feel the same way. Now, as is already happening in the situations we observe, it is also possible for us to enter into their logic, into their world, and begin to know what they feel, think and do. This opens up the possibility of understanding what is happening to them, of being able to accompany them and, gradually, to begin to meet them, so that we can begin to dismantle the vicious circle. The things you are bringing show us that development is taking place, that you are generating development and  the children are also beginning to develop, even if we do not understand very well what is happening. With these developments, the relational vicious circle is transforming and, with this, more than a circle, it is as if it were a square”.

Laura: “Well, but with edges that are still a bit oval” (She laughs).

Estela: “Yes… (looking at Laura)”.

Therapist (also laughing): “Okay, then, a square with slightly oval edges. The point is that it is no longer a circle and, in this way, we can avoid entering the war between parents and children, in which both sides hurt each other, defend only their reason, no one apologizes and in which, whatever the outcome is, it is a defeat for everyone. That is why it is important that we can use the key offered by our abilities and understanding to enter into their logic and be able to accompany them, because it is much more difficult for them to enter into ours.

Now the time has come. Let’s leave it here for today and we will see each other after Easter”.

They all get up, say goodbye and wish each other happy holidays.

Comment of the session (52): The sensitization of parents and children is generating development that allows living experiences of emotional encounter with their children. This livens up, relieves and gives hope to the parents. But these new experiences are received with strangeness and, at the same time, with certain drama, since, at the same time, they confront them internally, make them uncomfortable and make them feel responsible. Faced with this conflict within themselves, the parents can experience a very strong temptation to go back and reaffirm the way they have been working for many years. This leads to an unequal struggle between the new experiences of affectionate encounters with the children, which represent “little offspring”, and the hard, rational and intellectual “character shell”, built up over time from many situations of frustration and suffering.

To overcome this moment represents, at the same time, a challenge for each parent, for the group, for the therapist and for the whole order, and opens questions about how to reach the end of the experience and what will be the evolution of each parent and each child.

Enrique Ger, Elena Trullen & Emma Clarós