"Can I join online?" Hybrid group therapy integrating online participants in face-to-face groups

Efrat Zigenlaub

Ella Stolper

Abstract

This study explores opportunities and challenges involved in the transition to a hybrid

form of group therapy, in which one or more participants join the session online while

the rest of the group meets face to face. The study is based on nine psychoanalytically

oriented groups, four of which were psychoanalytic groups, and five were supervision

groups for group facilitators in academic setting. The paper proposes new angles on

psychotherapeutic work that combines both spaces (face to face and online therapy),

such as "transition to online therapy as a 'too available solution'", "dynamic technological administration", "online courage" and "emergence of new, different self states in hybrid therapy"). Case material and its theoretical analysis allows reflection on

the psychodynamic implications of the request to join sessions online and on the various

occurrences in the hybrid space1

Introduction

This paper was written in the midst of the fifth Coronavirus wave, during which the need

for a hybrid format of group therapy had emerged. ‘Hybrid’ became a popular term in

contemporary discussions, and group conductors, as well as universities and

organizations, are required to consider how to allow for online participation in face-to￾ face sessions.

The term ‘hybrid groups’ can refer to two possibilities: 1) some group participants join

online while others are physically in the same room, 2) some group meetings are

conducted online while others are conducted in person. This paper will address the

former type of groups and will attempt to explore how participants can use online

platforms to participate in predominantly face-to-face groups.. We will examine the

flexibility required from both conductor and group to combine the various platforms.

We will discuss whether the hybrid option is an opportunity or obstacle in the group

process, consider the conditions in which hybrid sessions can take place, and reflect on

the implications of the hybrid method for group work.

1 We thank Dr. Haim Weinberg for his comments and contribution to this paper.

Literature review

Since the outbreak of the Coronavirus, vast literature on online groups emerged (Stolper

& Zigenlaub, 2021; Weinberg, 2020; Weinberg & Rolnick, 2020). In a paper that we have

written on this subject, we described four central phenomena characteristic of the

transition to an online format: the visible and the hidden from view; the group conductor

as a "host"; the group state during the transition and the impact of physical distance on

the emotional intimacy. Our conclusion was that the transition to an online format

offered new possibilities and was not only an obstacle, and we proposed to group

conductors methods that can turn this two-dimensional experience into a tridimensional

one (Stolper & Zigenlaub, 2021).

In contrast to the growing body of research on online group therapy, the lack of research

on hybrid group therapy is evident. We therefore expand our scope to relate to studies

published on hybrid workplace meetings. A study by Ellis etal.(2022) pointed at several

advantages and shortcomings of hybrid meetings. The authors mentioned among the

advantages the saving of time wasted on getting to the meetings, the ability to invite

specialists and guests from faraway places and resilience to personal constraints or

quarantines. The shortcomings of the model include the difficulty of online participants

to follow the discussion and recognize the speaker, which can make them feel isolated,

marginal and estranged; distractions online participants experience in their home space;

and communication difficulties due to loss of nonverbal cues in the interaction. Further

studies on hybrid work meetings also suggest similar challenges, mainly communication

difficulties due to lack of nonverbal cues, eye contact and body language, and the

difficulty of online participants to feel included in the meetings (de Haas, 2021; Saatci et

al., 2019). Some of the studies in the field examined technological tools that can address

the challenges involved in hybrid sessions (de Haas, 2021).

The aim of the current paper is to examine the challenges involved in including online

participants in face-to-face groups and to explore the effectiveness of the hybrid format

in group therapy.

Method

The current study is a qualitative, phenomenological and descriptive study that describes

and conceptualizes phenomena that are observed in the field through based evidence,

and analyzes them using relevant terms derived from the literature (Mertens, 2014). The

study is based on our experiences as conductors of nine psychodynamic groups,

including four psychoanalytic groups, and five supervision groups for group conductors

in academic settings, when each group was conducted by one of the authors. The

phenomena described in these groups took place during 2021-2022, between the third and fifth Coronavirus waves in Israel.

Findings

Opportunities in the hybrid space:

● Online courage

Shmuel, a 30 years old man, had been participating in a therapeutic group for six months,

during which he avoided sharing personal information about his life and participated only

through cautious reactions to other participants. He asked to connect to one of the sessions online due to a medical procedure he underwent and I allowed it. He was silent for most of the meeting. A week later, he asked whether he could participate online again since he still hadn't recovered and I agreed once more. In the middle of the meeting, the thought came to my mind that his request was not related to avoidance of contact with the group but expressed his quest for a safer space for self-exposure- something that he didn’t dare to do so far in face-to-face meetings. I shared this thought with the group and in reaction, Shmuel started crying. He said that he indeed felt burdened with a big secret that he hadn’t dare to share with the group so far, and he felt that he needed to let it go already, and now, when he was physically distant from the group, he felt that he could finally tell his story. He shared his secret with the group with a determination that was not characteristic of him previously, and after the participants had contained him empathically in the physical circle, he said that he felt relieved and that the shame he felt was no longer as threatening as before.

This example shows that sometimes online platforms constitute a safe space that allows

self-exposure and confidence to speak that is not possible in face-to-face meetings. This

is consistent with the "proximity/distance" theme we discussed in our previous paper on

the transition of the whole group to online meetings (Stolper & Zigenlaub, 2021).

Interestingly, we found that the hybrid space can facilitate self-exposure of single

participants, but also of a subgroup that joins online, while the rest of the group meets

face-to-face. The following example discusses the case of a minority group that

connected online while the majority group met face-to-face:

During the terror attacks in Israel in April 2022, Arab students expressed fear of coming

to the campus, mainly due to their fear of using public transportation. As a result, the

college's management gave them permission to study online, while the Jewish

participants did not know of this request and did not receive a similar permission. That

week, I facilitated a practicum group that included a majority of Jewish participants

sitting together in a circle and a minority of Arab participants who joined online. In that

session, the Israeli-Palestinian conflict that hadn’t come up in during its six months of

meeting, entered the room for the first time. In that session, the group discussed in a

courageous and moving manner the issue of the Arab minority's belonging to Israeli

society, through personal stories related to belonging and exclusion. A Bedouin student

said that she possesses multiple identities, and in fact does not feel belongingness

anywhere, "in Mecca, I'm "damaged goods" because I'm Israeli, among the Palestinians

I'm "damaged goods" because I have a nephew who serves in the IDF, and I'm scared

of taking Israeli buses because I'm a Muslim".

Of course, this moving session was heavily influenced by the external reality that

brought the conflict to the group, but the special hybrid setting in which the majority

group sat in the physical circle while the minority group joined online contributed

significantly to the introduction of a subject that was not discussed until then.

This situation was unique, as the subgroup that joined online was a subgroup also before

that meeting and wasn’t established as such due to the mere joint online participation. In

therapy groups, we did not encounter situations in which there was more than one

participant online and it is interesting to continue exploring the group dynamics in such

cases.

● Different self -states online

Bromberg (1993) argues that the capacity of the individual to live an authentic and self-conscious life depends on the presence of a continuous dialectic between separateness and unity of his self-states, which allows each self-state optimal functioning.

Bromberg argues that in normal development, the individual is only vaguely aware of

the presence of individual self-states and their reality, since each self-state functions as

a part of a healthy illusion of a cohesive self-identity – a cognitive and experiential state

that is experienced as "me". Every self-state is a part of a functional totality, that is based

on an internal negotiation process with reality, values, influences and others' points of

view. Despite collisions and even hostility between aspects of self, it is unusual for each

self-state to function entirely outside the sense of "self" – that is, without the

participation of other self-states.

According to Bromberg, "mental health is the ability to stand in the spaces between

realities without losing any of them – the capacity to feel like oneself while being many"

(Bromberg, 1993, p. 166). Therapy aims, among other things, to allow the individual to

express and move between multiple self-states.

Ronen, a participant in his forties, had been participating in a therapeutic group for two

and a half years before the Coronavirus outbreak. Ronen often told the group of his

anger outbursts at his wife and children and sadly told that this had led his wife to want

a divorce. But in the group, there was no sign of this behavior and the participants were

always surprised to hear these stories that seemed inconsistent with his behavior in the

group. During the Coronavirus period, Ronen had to join one of the sessions online as

he had contracted the Coronavirus. During session, Ronen yelled angrily at two

participants, a man and a woman, who were trying to sort out their intimate relationship

and who in his view took all the space in the group. Ronen even threatened to leave the

group and attacked anyone who tried to protect the couple. The following week, when

he returned to the group face-to-face, Ronen apologized for this behavior but to some

extent was also pleased that the group had a chance to witness his aggressive side.. This

hybrid session allowed Ronen to express an aggressive self-state that he could not

express face-to-face sessions, possibly due to his fear that the group would reject him,

just as his wife has.

Levin, in his paper on combined individual and group therapy with the same therapist,

argued that in individual and group therapy people express representations of different

self-states, and these move and develop in parallel, consistent with the developmental

needs of the patient who then can shift between different modes in therapy (Levin, 2016).

We believe that as in combined therapy, hybrid group therapy, too, allows transition

between different self-states. The physical distance from face-to-face sessions and the

position behind a screen provides an illusion of safety and sometimes allows brave

behaviors that are not always possible when sitting next to each other, as we have

demonstrated in the previous section. Additionally, participation from the patient's

"home" sometimes serves as a "safe space" and allows him to express his more shameful

and hidden self-states. Finally, the feelings of "aloneness" and "separateness" in the

presence of the group that is meeting face-to-face are realistically increased in the hybrid

setting, forcing the individual to cope with issues of lack of belonging, rejection and

exclusion in an intensity that is different from what is experienced in the presence of the

group.

Challenges in the hybrid space

● The transition to online therapy as a "too easily available" solution

Before the era of online therapy, a large part of the unconscious information was

revealed through exploration of moments of "missing out" or "absence". Group

reflection and exploration of lateness, absences and missed out experiences deepened

the dynamic understanding of the group-analytic symptom of the group. Nowadays, as

online participation has become such an available option, that to a large extent it "fills

the spaces" in the group. The access to hidden, complex, and unconscious materials of

the group is denied. Foulkes (1964) wrote of the role played by the disorder's "Location",

that is, recognition of the "hot spot" in the group, the area that the group is preoccupied

with. Location is usually expressed through implicit information, one of which is

participants' absence from certain meetings (for instance, after conflicted or difficult

sessions). Location work may suffer from immediate connecting to sessions from

anywhere that hides from view precious nonverbal information.

Transition to online therapy is an easy, accessible solution and it is tempting for both

participants and conductor to use it in situations in which participants can't come to

meetings. However, we see that this solution sometimes becomes a "too easily available

solution" that constitutes quick and absolute gratification of the patient's wishes, instead

of the conductor being a “good enough mother” (Winnicott, 2007) who gradually allows

participants to cope with the demands of reality.

● The screen barrier in hybrid therapy

David, a student in a supervision group for group facilitators at the university, joined the

group online throughout the whole fall semester due to a medical condition. During the

following (spring) semester he was able to come to face-to-face sessions. In retrospect, the

David I had met in the fall semester was completely different from the one revealed to me

in the spring semester. During the online sessions, David had a difficult time participating

in the group. Even though he was present in all the sessions, joined on time and complied

with all the rules of the setting, his presence was absent: he was silent throughout whole

sessions and I had to make active efforts to include him in the group discussion. I cleared

him time and space and addressed him directly in every session, attention that I didn’t give

the other group participants. Since I haven’t seen David face-to-face before, I imagined a

quiet, introverted and distant participant who needed active help to participate. However, in the face-to-face sessions of the spring semester, I discovered a David who was completely different: happy, vibrant, active and full of life, and surprisingly – one of the most talkative participants in the group.

The extreme difference between the two appearances of the same participant was

striking. The difference may be partly attributed to David's medical condition in the fall

semester, which had improved in the spring semester. However, we presume that his

special status as the only online participant throughout a whole semester played some

part here – as he had to watch the whole group working face-to-face, while he was

disconnected from the discussion from time to time, and at times felt uninvolved and

had trouble "overcoming the screen barrier".

In other groups, we have encountered this phenomenon in situations in which one or

more participants were forced due to different reasons to connect online throughout a

long period of time, while the rest of the group continued meeting face-to-face. In such

a continuous situation, we saw that online participants were usually quieter and less

involved and needed our active help to take part in the group.

● Special treatment from the facilitator

Online participation undermines the group rule that "everyone is equal" that is

maintained in the circle regarding various aspects, and gives a participant an opportunity

to receive special treatment.

The special attention begins even before the meeting, through the technical effort to send

a link and check, sometimes through a phone call, if it worked, and sometimes involves

even the facilitator's preoccupation with her cellphone during the session in an attempt

to contact an online participant in the case of disconnection – something that is of course

unheard of in regular groups.

In hybrid meetings, we saw that the group had complicated reactions to online

participants that included a combination of ignoring and jealousy. Often, the difficulty

of online participants to overcome the screen barrier led to the group's ignoring of them.

Still, we often reacted by active mediation that reminded the group to relate to online

participants, something that often aroused in the group jealousy of online participants.

In such incidents, we invited the group to discuss the associated feelings.

Issues involved in facilitation of a hybrid space:

● Understanding the psychodynamic implications of the request to join online

In a therapy group that I led, there was a high frequency of requests to participate via Zoom.

When I brought the topic up for discussion in the group, one of the insights was that due to

the group's expansions recently, participants felt that they didn’t have enough room and thus unconsciously chose a group solution of "sending one participant to connect online every time", as a way to supposedly decrease the number of group participants.

This example suggests that the transition to online participation was not only a

technicality but involved many unconscious considerations on personal and group

levels, and that often it constituted an unconscious solution the group found for coping

with complicated group dynamics.

We see this act as a "mumbling symptom" (Foulkes, 1956) of a group that tries to reveal

unconscious aspects of group communication that are not yet ready to be expressed in a

direct, overt manner.

The mumbling symptom is not only expressed in the mere transition to online

participation but also in the attention to what happens in every given moment in the

online space and between spaces, beginning with the participants' positions and their

changes from session to session, through their body language, preoccupation with other

things, people or pets that enter the space, the timing of the decision to speak or remain

silent and the timing of disconnections.

● The importance of technological holding

Dynamic administration is a term coined by Foulkes (1948) to describe the conductor's

routine actions and chores for creating the group setting and boundaries and their

dynamic meaning in the group. In normal conditions, these actions include arranging the

chairs, making sure that the room temperature is comfortable, taking care of payment,

and informing participants of setting related issues and of changes, absences or lateness

or introduction of new group participants. The dynamic implications are revealed before

the group when a group discussion of each of these actions develops.

In the transition to online therapy we discovered the importance of what we call

"technological dynamic administration". Technological dynamic administration refers

to the technical setting and boundaries of a group that meets online and their dynamic

implications on the group. It includes aspects such as participants' location, instructions

regarding open camera and microphone, limitations on entering the group in various

situations, such as during driving or in the presence of family members in the room,

stable internet connection, checking that the equipment works and of course,

psychodynamic interpretation of the occurrences.

In facilitation of hybrid groups, the facilitator is responsible for managing and holding

two spaces at the same time: the real group room and the room of the "online

participants'". He is also requested to facilitate optimal movement between the two

spaces, while considering the psychodynamic aspects of participants' requests to join the

group meetings online. In fact, we believe that hybrid work creates a "third space", since

the group participants are divided between a virtual space and the real group room and

meet on these two levels at the same time.

Management of hybrid group spaces requires advanced skills and technological

equipment to overcome the challenging movement between the different dimensions

and the facilitator must insist on reflecting on these transitions as dynamic materials in

the group life.

In our discussion of previous themes, we emphasized the psychodynamic reflection on

the occurrences in the hybrid space, beginning with the request to join online, through

every supposedly technical group occurrence, such as disconnection, not seeing, not

hearing etc. In this theme, we want to emphasize the aspect of technological holding,

which includes ensuring stable internet connection and advanced equipment, the

decision where to position the camera and rules that determine from what locations

participants can connect and how.

The group state during the transition to a hybrid format

One of the phenomena we observed was the relation between the group's ability to cope

with the hybrid space and its state before the transition. Our impression was that groups

that were more mature, that had a more stable, secure and intimate foundation before the

transition to a hybrid format , adapted more easily to hybrid work and even found new

opportunities in this space. In addition, groups that were more mature were more willing

to work through the psychodynamic implications of various aspects of hybrid work, on

both personal and group levels. Thus, participants were more willing to explore

occurrences and reflect on them, something that in turn helped the group overcome

various enactments. In contrast, in groups that were characterized by tense and

conflicted relationships and atmosphere before the transition, the hybrid space increased

the volume of the conflicts. Those findings are similar those described in our paper

"From the circle to the square" (Stolper & Zigenlaub, 2021) on the transition of a whole

group to an online format.

Discussion

In this chapter , we examined the hybrid model of group therapy, that combines face-to￾ face groups with online participation of one or several participants. We found two

opportunities presented by the hybrid model: online courage and movement between

different self-states online, and three challenges: the transition to online participation as

a too easily available solution, the screen barrier in hybrid work and special treatment

from the facilitator, as well as three issues characteristic of the hybrid space: the

dynamic implications of the request to join online, the importance of technological

holding and the group state before the transition to a hybrid format.

The hybrid model- threat or opportunity?

We started this study with the aspiration to examine whether the hybrid model poses a

threat or an opportunity, and received a complicated answer to this question, that

involves both. We would like to discuss two emerging themes that supposedly

contradict. The first – "online courage" – sees in this model an opportunity, whereas the

theme "online participants' difficulty overcoming the screen barrier" sees it as a threat.

The theme "online courage" is consistent with the "proximity/distance" theme that

emerged in our previous study, according to which participation in a group from home

through online formats could serve as an opportunity for exposure and openness that are

not always possible in face-to-face sessions. Previous studies that found a similar

phenomenon in online groups explained it through the "screen effect" (Vaimberg &

Vaimberg, 2020). This effect results from the idea that when people separate their actions

from their real world and identity, they feel less vulnerable and less obligated to endure

the consequences of their actions. This effect in fact creates operative dissociation

between the individual and his image on the screen. Leszcz, too, argued in his interview

with Weinberg that participants express more courage in online groups than in face-to ￾face groups because of the distance between them (Weinberg & Rolnick, 2020). We found

it interesting that the same effect occurred even when a participant saw the rest of the

group sitting in the physical circle. We could have expected that the situation of being

"one versus many" would be threatening and eliminate this effect.

However, another theme we discovered was the "difficulty of online participants to

overcome the screen barrier", which showed that exposure in the hybrid model is more

cautious and limited than in face-to-face groups. How can we explain the difference

between these themes?

One possible explanation is related to the difference between a one-time or temporary

situation of hybrid participation, which we described in the theme "online courage", and

a continuous situation of hybrid participation that we described in the theme "the

difficulty of online participants to overcome the screen effect". In a one-time situation

of hybrid participation, the participants holds in mind the whole group and can "tolerate"

this temporary change, and as we have showed, can even see it as an opportunity.

However, in a continuous situation in which a participant is "born" into a situation of

being "one versus many" or when needing to stay in such a situation for a long time, the

difficulty to overcome the screen barrier increases.

Another possible explanation is that the hybrid model suits some groups more than

others, for example, groups that are found in more advanced developmental stages, as

we have shown in the paper. In addition, perhaps some participants find the hybrid

setting as more suitable to their needs than others. In a contemporary review presented

by Weinberg (2020b), he argued that some patients (e.g. patients who are in the midst of

an acute crisis) find online therapy as less suitable, while others (e.g. patients with

intimacy problems or social anxiety) prefer it over face-to-face group therapy. These

variables were not studied yet regarding the hybrid model and would be an interesting

theme for future research.

One of our main insights in this study is that the "transition to an online format" is not a

simple matter and it is not purely technical. The transition to an online format can tell a

whole group story, as we have demonstrated in the example of a group that grew and

"sent" one participant to the online space every time to deal with the issue of room. The

dynamics of disconnections and connections and the possibility to see and hear is not

purely technical and it is important to explore and realize when they occur.

In sum, based on the findings above, we formulated several suggestions to conductors

of hybrid groups:

● When a participant asks to join a meeting online, it is important to consider this

request through a psychodynamic lens, in addition to the concrete reasons for the

request. The conductor should try to understand whether the request expresses a

wish to escape the face-to-face group or whether the transition to a different

space calls for the emergence of different self-states and allows the participant

more courage for self-disclosure.

● In addition to considering the psychodynamic implications of the request, it is

important to understand whether the request expresses a group voice that reveals

a story that has not yet been told.

● We see in the transition to the hybrid space a "too available solution" that often

constitutes a too quick and absolute gratification of the patient's wishes that

misses the opportunity to explore moments of "missing" something that would

have been available face-to-face. This solution should be used cautiously,

holding in mind the aforementioned considerations.

● For hybrid work to be effective, it is important to acquire advanced equipment,

including a screen positioned on a chair inside the circle and an external

microphone located at the center of the circle. In addition, it is recommended to

use an external camera, in addition to the laptop camera. Furthermore, it is

important to check during the session that the online participant is still

connected.

● We recommend using the hybrid model with groups found in more advanced

stages and not with groups that are in their beginning or that are in the midst of a

crisis. In addition, it is recommended to use this model for a session or two and

not for extended periods.

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