Reflections on Co-Therapy

Pia Hirsch, Australian Association of Group Psychotherapists (AAGP) 

Pia’s paper forms a pair with Peter Hengstberger’s paper, which follows.

Pia Hirsch has worked in mental health and run groups for over 40 years, following a basic training in Occupational Therapy. She has been a member of the AAGP since 1998 and is the current Immediate Past President. She is also a member of the AAGP Training Committee. Over the past 20 or so years Pia has worked with co-therapists, running a group analytic therapy group, and a support group for women who have been diagnosed with metastatic breast cancer. She has recently retired from all clinical work.

I am going to say something about our experience as co-therapists; how we started, and how, how we work has changed and developed over the more than 20 years we have worked together. I refer to The Group, although over time as people came and left it didn’t look like the same group, but importantly the history and the beginnings were still present.

We both completed our AAGP training as group therapists in the late '90s, and soon after that we met up and talked about the idea of running groups together. We had not known one another well before then, so we met and talked and thought together over a period of time, not rushing, getting to know one another more, thinking about how we would go about this in very practical ways - fees, rooms, times, assessments etc.

At that stage Peter had rooms in a practice in the Mater, and when I started my individual work, I rented a room there on a sessional basis as I needed.

Once we had agreed that it was now time to start the work of gathering a group, we began to assess patients, mostly people who Peter was already seeing in individual therapy who he thought would benefit from being in a group with others. We had started supervision well before this "gathering” - a group starts at the time it is conceived in the minds of the therapists, and the time between that and the actual realisation of the group may be protracted.

It is a generalisation, but one I think is correct, that in the main people are wary of joining a therapy group. Our lives are led in groups of one sort or another, and not all these experiences have been good, so the idea of talking in front of and with others can be daunting. There are rarely between 5 and 6 people queuing to join a group at the same time, so this time of gathering needs taking care of, thinking about and holding, and the people who have signed up before a group is ready to go, which may be months, need keeping in mind too. The process of starting to assess, to talk to Peter’s patients involved their meeting me, getting used to me as a therapist, and for a long time was one of the aspects of our working together that would contribute to a hierarchy; people mostly knew Peter and not me; I am not a doctor; I am a woman.

Throughout our working together these elements have been present, very usefully so, to be looked at and talked about in the group.

In the Mater the rooms we had available to run groups were not suitable. We had to make do, and that making do was rarely ideal, and often unreliable.

After a while we started thinking about finding our own place, where we could have a room dedicated to the running of groups, not just a space we had to make do with. We found a two-bedroom unit that was rated for both residential and commercial use and after making some changes, including walling off a section for a dedicated group room, we moved in.

Because it had been someone’s home before we moved there, it had a particular feel about it that was nothing to do with hospitals or clinics. The bedrooms became our offices, there was a kitchen, and a second bathroom. It was and is a lovely place to work.

Initially in our first working together we had been cautious, and both assumed that the other was more expert than we were ourselves. Peter had worked as a therapist far longer than I had, and I had more, and more varied group experience than he’d had. So, we were both tentative in what we said, and were often silenced by this passing of our expertise over to the other. However, over time we became more confident in working together, and in the manner of our working together, and how we worked differently from each other. Gradually we grew to complement one another as we gained more confidence in ourselves and in one another, and how we each worked.

From the beginning we had similar beliefs in the basic principles: beginning and ending on time, the need for confidentiality, a space to talk about anything, our roles, and the importance of boundaries. I would always invite members into the room, from the waiting room, and at the end of the group would open the door to usher them out. Peter would always already be waiting in the room and would always call time at the end. Our sense of this was about a clear maternal and paternal function.

The way that we both worked was to offer people individual sessions with one of us, as well as a place in the group. There are those who run groups who frown on this, with the thought that the group should be enough to hold people and be what they need as its own therapeutic intervention. It has been our experience that offering people both has been extraordinarily helpful in a variety of ways. The small group may be seen as a representation of a move from a dyad to the larger family, and we have held the view that in a family wanting to speak with a parent alone is both normal and helpful. But as I said, not all those who run groups agree with this.

This way of working led to an interesting idea: shortly after the move to our own rooms Peter was on leave and was concerned about one of his patients in the group who was distressed and potentially suicidal. Earlier in his practice he would have asked a fellow psychiatrist to cover for him, but given I was not away, and would be available, and knew this patient well, he suggested she contact me if she needed to, which she did. This led us to think that while all the patients in the group had individual access to one or other of us, none of them had that with the other of us, and whether we might offer that. So, after much thinking, much discussing with our various supervisors, both group and individual, and with the thought that this was an experiment and we would watch the outcome carefully, we did so. One of our supervisors commented on the “rich rainbow of treatment” we were offering. So, we did tell the group members that if anyone wanted to see the other of us, that would be possible. The invitation remained for some time, a small number took this up, some for some time, during which they would be seeing both of us individually as well as in the group. And then it ceased of its own accord. We thought we could do this, and that it worked, largely because of the physical structure; there was no secrecy about this, we were both in the same place, the other therapist was known to be on the other side of the wall, the patients knew that we both were OK about this happening, knew that we would discuss them together as we did about the groups anyway, and that they were obviously at liberty to talk about either of us in the group.

When a new member joined, we wouldn’t give current members any information about the new member, other than the fact of someone joining in 3 - 4 weeks. They would ask, and we would talk about their curiosity and imaginings, but on the grounds that before technology ways of gauging the sex of an unborn child was to swing a magnet, or watch a feather, we thought it more helpful to allow free reign rather than define and thereby in some way pin something down about a prospective new person. Or try to gain some control over the anxiety of what might be stirred by the new person joining. The template of The New Person was enough to manage, without a gender or age template being there before someone even arrived.

Some points to finish:

In all the time we have run groups together we have had consistent weekly supervision with a group supervisor.

Not everyone works in co-therapy, many work as a single conductor of a group. We have enjoyed working together, and there have been times when patients have commented on how good it has been to watch us work together, clearly comfortable with one another, not afraid to disagree or to add to what the other has said. Many who join a group have had a difficult time in their family of origin, so to see a couple working constructively has been helpful to them. And while we have each run the group on our own when the need required us to, which was helpful in reassuring ourselves that we actually could do that, we have very much enjoyed working together, being able to talk together about the group, about what we thought and felt. It has been richly rewarding, we have both grown and developed in that time, and most importantly, it has been fun.