The Challenge for Group Psychotherapy

Group Psychotheraphy as a Method of Treatment in a Psychiatric Hospital, Part 4

We had observed since 1955 that some of the schizophrenics included in large diagnostically mixed groups had shown themselves to be suitable for group work in various specific ways. In the spring of 1963, therefore, we began to form a small group of seven to nine (at first there were five) twenty-year-old to thirty-year-old female schizophrenic patients. We were encouraged to do this by the experiences of Bour (1961), Brack (1962), Powdermaker & Frank (1953), Schindler (1958), Slavson (1961), etc. The selection of female patients only does not mean that we felt it was not possible in principle for both sexes to take part together. However, the therapist happened to be in charge of the women’s ward of the hospital and was naturally more interested in the psychotherapeutic treatment of women; and it was felt from the beginning that to take only one sex would avoid complicating still further a situation which would be difficult enough if the group was composed solely of schizophrenics.

One symptom of the serious breakdown of the schizophrenic’s ability to communicate was the ‘fact that during the first session the patients sat along the walls without speaking a word to each other. It took several meetings, at which they spoke only to the two therapists, before they entered into any relationship among themselves. It was a fortunate circumstance that a small room had been chosen for group treatment. It is true that the participants perhaps felt themselves too crowded together in the space allotted to them, but when their original fear of losing their individuality, or, as Benedetti (1964) put it, of being unable to separate themselves from their fellow beings, was diminished, the social distance to be bridged was smaller and presented less of an obstacle in a confined space.
As the group work advanced it was clear that the group situation can often interest patients in external events more readily than the psychotherapeutic tête-à-tête. This happened, for example, with a thirty-year-old hebephrenic, whose illness had lasted seventeen years. In the group, she frequently paid no attention to the others’ conversation, being fully occupied with the question whether the doctor in charge was God or the Devil. On several occasions when she voiced her insane notions aloud, seeing every action of this therapist as a “proof’ of his diabolical nature, the other group members would do their best to show her that her ideas were psychotic and disproportionate. When this happened, the patient often stopped talking and listened to the arguments of the others and even, for the rest of the sessions in question, took a sensible part in the conversation.

The record, kept by one of the two group leaders, of a meeting at which this patient again made these assertions about the therapist, may perhaps make it clear how the patient finally showed an adequate grasp of external reality.

Miss B began with her constant theme: fear of the group leader. She was being grilled, she said he was the Devil, and so on. After the others had at first tried to talk her out of it, they stopped taking her seriously, and laughed at what she said. She at once realized that she was being laughed at, became aggressive and threatened to box their ears. Miss B felt frustrated again, tried to escape, and when prevented from doing so, burst into helpless weeping. Her whole body trembled, she was obviously terrified, and expressed fears like “Dr. B wants to kill me; he wants to take me to Hell; they all want to hit me”, and so on. The group was thrown into confusion. Miss S and Miss M tried to help, and talked persuasively to her, but they were too uncertain, and this outburst of emotion left them baffled and somewhat intimidated. After some attempts to change the subject of conversation, interrupted for a long time by terrified outburst and weeping from Miss B, the emotional tension was suddenly relaxed. Miss M succeeded in calming Miss B by her sincere sympathy, and this brought a sudden access of cheerfulness and jollity to the whole group. It is interesting that from this moment on, Miss B herself began to laugh at her unreal ideas, and encouraged the others to do the same. The original tension had given place to complete relaxation. Miss B declared that she now saw the group leader in quite a different way—as a doctor who, as a nurse had explained to her, took care of all of them. She said she was no longer afraid of him.

This patient had been having individual psychotherapy for years and had also been psychopharmacologically treated. Individual treatment had certainly had the effect of making her substantially calmer than previously, and she had, in particular, lost at least some of her mistrust of her fellows. But it was really the group treatment that brought her nearer to social reality. We observed over and over again, with the other patients too, that the therapeutic group has a more intense feeling of reality than the classic psychotherapeutic situation of therapist and patient. The group is sometimes able to convince schizophrenics of the existence of their fellow beings and their relations with them more readily than the more exclusive relationship of doctor and patient. The group’s appeal to reality, as the above example shows, has naturally more effect on schizophrenics than on neurotics, since the difference between internal and external worlds is much more marked with psychotics. In a schizophrenics’ group, therefore, more spectacular changes in behavior can ensue than with neurotics.

The reciprocal emotional relationships between the schizophrenics in a group and the therapist are often different from those of neurotics, both quantitatively and qualitatively. The patients in the group we have mentioned showed both affection and aversion with great intensity, or wavered between the two opposing affects, so that their emotional attitude became completely ambivalent and their inner confusion clearly visible.

Transferences, too, are often incalculable in schizophrenics’ groups. A patient can speak to one of the therapists or a fellow patient as if to her father or sister and then say nothing more about it at the next session. The patients identify with each other very quickly, often because of a similarity accidentally noticed; but these identifications do not last long as a rule. On the other hand we notice that when schizophrenics belonging to this group tend to stereotyped movements and attitudes, the group continually questions their behavior and thus places them in a dynamic situation which at first makes them anxious, but then obliges them to change their attitude.

Group psychotherapy leads to emotional relationships and transferences that are more intense, though more transitory, than those found in individual psychotherapy. Participation in a therapeutic group gives schizophrenics a greater incentive to emerge from their psychotic world into external reality. Psychotics can thus regain, within the group, a sense of their human environment.
Work with the relatives of schizophrenics presented some initial difficulties. This is not to say that the parents or siblings ignored our invitation to a preliminary meeting. However, with the exception of a mother with an overprotective attitude towards her thirty-three-year-old daughter, a hebephrenic of ten years’ standing, they failed to attend regularly the weekly group sessions we arranged. We decided therefore, to hold a group meeting only once a month, and the participants appeared at these at almost full strength. In all, eight relatives took part, led by two therapists. Schematically speaking, they showed three broad types of attitude and behavior towards their schizophrenic relatives.

1. Suspicious Paranoid Attitude
These relatives are deeply mistrustful of medical treatment. They let it be seen that they have no confidence in the therapy and are even of the opinion that it does more harm than good. The father of a twenty-one-year-old schizophrenic, whose mother is in hospital for degenerative schizophrenia of many years’ standing, tried, on the occasion of a short paranoid episode on the part of the patient, to convince the group that she, too, would remain chronically sick, and that, all considered, it would have been better if she had never been born. When the therapists gave a relatively good prognosis—as a matter of fact the daughter has in the meantime been out of hospital for a long time, is staying with her former foster parents and earning an independent living—he became suspicious and said the doctors knew very well how serious her illness was and were hiding the truth from him. He could, moreover, be really cruel to the patient and compare her quite openly to her mother. He would not even listen to the arguments of other relatives who backed up what the doctors said. He simply became more suspicious still and later stopped coming to the group sessions.

2. Overprotective Attitude
Two mothers of young schizophrenic patients showed an overprotective attitude. One in particular, whom we have already mentioned, the mother of a thirty-three-year-old hebephrenic, was very willing to talk about her sick daughter. She has seven children besides the patient; and in the group sessions she talked constantly about how, in the family and outside it, she had to take responsibility for the patient, protect her at home, give her her chloropromazine tablets, go with her to buy clothes and shoes, etc. Her manner became markedly more lively as she spoke, and we had the impression that since she was constantly dissatisfied with her husband, a railwayman, and her other children had married and left home one after another, she was glad, in a way, to be able to look after and protect her daughter. But on the other hand, it came out in the group that this woman, who identified to a very high degree with the patient, suffered greatly from the condition of her schizophrenic “child.” Relatives of this type are not entirely easy to fit into the group, since, with their flow of information about their sick relatives, they often make demands on the others that can sometimes be more than they can bear.

3. Coldly Objective Attitude
These mothers, or other near relatives, have an almost terrifying objectivity in describing the symptoms of their relative’s illness. They may perhaps insist on their sympathy in words, but there is nothing to show that they are really moved by their daughter’s or sister’s illness. They are mostly very polite, formal people, who behave correctly in the group in all circumstances. They even listen with great interest when other relatives talk about their worries and their patients’ symptoms. In this connection we were particularly impressed by the mother of a twenty-two-year-old patient, whose illness began seven years ago, after she had confessed to incestuous relations with one of her brothers {she has nine siblings}. It presented at first the picture of a compulsion neurosis, but then developed definite catatonic features. This woman, who, like the father, tends towards religious fanaticism, showed in the group remarkably little feeling for her daughter but plenty of “understanding” when it came to asking the doctors for explanations of her daughter’s illness or helping other relatives over their troubles.

Work with the relatives of schizophrenics made it clear how far the patients’ disturbances are the products of their environment. None of the relatives showed an adequate, sufficiently sympathetic, open kind of approach to their fellows. The communications of these near relatives of the patients were always disturbed in one way or another. This group of relatives thus presented a picture which, superficially viewed, was not very different from that of the patients’ group; it is all the more essential to try to influence the relatives in this way. To carry out the “treatment” of the relatives in a group not only saves time but helps them to feel less isolated by putting them among others with the same problem.
In collaboration with social workers specially appointed for the welfare of alcoholics, we had a succession of meetings with ten to fifteen wives of alcoholics who were being treated in our hospital. We saw again and again how these women, often of a very maternal type, have suffered from their husbands’ alcoholism and in spite of everything are still ready to stand by them and support them. In the group they relate their sufferings, expecting and usually receiving the others’ approval of their perseverance. They have a great need to express themselves; each of these women wants to tell the others about her experiences. Contact between the group, like that of the alcoholics themselves, was good from the start. The group for them is above all a place where identification can bring them relief. There are, however, individual women who do not present this picture of the anxious, maternal wife, but appear youthful and distinctly feminine. These latter were usually the ones who found their alcoholic husbands a heavy burden, felt neglected by them, and were hovering on the brink of divorce.

If the husbands of female alcoholics are collected into a group, it is at once obvious that their understanding of their sick spouses is as a rule much less than that of the wives of male alcoholic patients. They often utter very severe criticisms of their wives. In these groups we see very little in the way of loving care; on the contrary, these men are very ready to judge their wives, to “write them off” and turn towards a new future. The husbands of alcoholics show no feeling of “togetherness,” either existing from the beginning or gradually appearing; the main reason for this seems to be that the emotional ties between them and their wives have already loosened perceptibly. Nevertheless regular work in groups with these men can perhaps improve the outlook for their marriages. We feel that in view of this, group psychotherapy is indicated for these relatives also.

Analytical Training Groups for Doctors
We agree with Kemper (1964) when he says that we can acquire a fundamental knowledge of group psychotherapy only by personal experience. Realizing this, we began in 1962 to form analytical training groups for hospital psychiatrists. We did so on the basis of our own experience as a participant of the “Lindauer Psychotherapiewoche” (Stolze, 1960) since 1960 and also based on reports from various authors such as Beukenkamp et al. (1958), Ganzarin et al. (1958), Friedemann (1963), Hulse (1958), Stokvis (1960) .

Besides forming the doctors into training groups, we also make them co-therapists with patients’ groups, let them lead therapeutic groups under supervision, and give them theoretical instruction in lectures, seminars, and discussions, all as part of their training. In the work with training groups (Battegay, 1964)—at the time of writing (February 1965) the third has been in action for more than a year—it was from one point of view an obstacle that a doctor employed in the hospital itself (as a senior physician) acted as leader of the group. The members of the doctors’ group could not feel entirely impartial towards a leader whom they met, as colleague or superior, in the everyday work of the hospital. However the arrangement had the advantage that a therapist belonging to the hospital was familiar with the special conditions and was in a better position to integrate the group work as smoothly as possible in the hospital’s daily life and in the postgraduate training program.

Six doctors took part in the first group and seven in the other two. It became clear in all the groups that the participants did not regard themselves as therapists so much as human beings with their own more or less unconscious problems of the kind met with in patients.

In this way they learn to recognize what happens to patients in group psychotherapy. A difficulty that arises almost always at first with groups of doctors is that they are led into intellectual debates, distracting them from the actual problems which come to the surface.

Naturally there is no question, in the training group, of creatively discussing and finding solutions for all the problems hinted at or openly brought forward by the participants. It is much more important that the attitudes and behavior of individuals towards each other and of the various members towards the “therapist” should be analyzed. Once insight into their approach to the group is achieved, definitions and possible solutions to their questions wll appear of themselves. As we accept colleagues into the group who have not yet had a training analysis, membership of the training group can serve as an incentive to begin an individual psychoanalysis. As we have already said in an earlier chapter, the group therapist should never be the individual analyst of one of the group, since that might lead to transferences that could scarcely be ignored.

One inconvenience of group analysis with the medical personnel of a hospital is that the composition of the group is more or less accidental. Everyone who asks to take part must be accepted into the group. This caused difficulties in the first group, for which some of the doctors who came forward were friends before entering the training group. A “group within the group” was formed, which sometimes impeded free interaction and led to resistances that could be cleared up only with great difficulty.

The doctors’ groups meet once a week for a session lasting one to one and a half hours. The end of the training in the first two groups came chiefly because colleagues had to leave. The first ended after eighteen sittings, the second after forty-six. The third group, after forty-nine meetings, is still in progress and will probably end when a colleague goes to another hospital for further training. The departure of one member gave rise to an entirely different group situation, so that the remaining members had to give up the idea of carrying on the same self-analytical work with the same group. We take care that before the group closes the participants should be as clear as possible about the processes and transferences that have taken place, so that they can learn to recognize the therapeutic possibilities and limitations inherent in a group, and also to evaluate their own reactions as reflected in the therapeutic circle.

As with the patients’ groups, there is usually a phase in which the members seek the reasons for their difficulties in outward circumstances only. This can lead to really emotional outpourings of long-suppressed resentment or aggression against near relatives, colleagues, or other persons in their environment. But the very fact that they can express feelings they have hitherto revealed to no one often has a liberating effect on the participants. It is then for the therapist to point out to the members that many of their tensions are subjective in origin. As a rule reciprocal transferences come to light, making it clear that their handling of the patients is not always based on objective facts but is also determined by some transference situation. The doctors thus have the opportunity to examine the motives for their treatment of the patients and place it on a more professional basis. In all these groups the various members relived emotions stemming from earlier group experiences in childhood or later periods in life, such as, for example, rivalry with siblings, ambivalent relationships with parents, and so on. It was usually one of the members of the group who drew attention to this fact (Horwitz, 1964). If the group did not see it, it was up to the therapist to offer for discussion the attitude that had come to light, or even to suggest a meaning for it. Frequently in all these groups one of the participants took over the role of therapist spontaneously; during this time he, instead of the group leader, made a substantial contribution to the clarification of unconsciously based attitudes and behavior through his questions and observations. By acting as “assistant therapist” in this way, the future group leaders learn how a therapeutic group should be conducted. But it is essential that the same doctor should not always assume this position or he will take over the group, and its free development will be hindered.

We can see how deeply group work can penetrate in the following transference-based dream of a woman colleague who was taking part in a self-analytical group.

I was in a room in which there was a table. In the room were Dr. X and a female figure which alternated between Dr. Y [a member of the same group] and an earlier acquaintance,. a contractor’s daughter, who resembles Dr. Y. The room had to be cleaned. There was a lot of dirt under the table. Dr. X and Dr. Y were lying on the floor. I thought—with my innate passion for cleanliness—”there’s still some dirt there,” and, seeing that my two colleagues looked very relaxed, I wondered whether they were drunk. Besides, Dr. X was lying under the table.

A detail that came to light was that in reality she thought Dr. X very hard-working. But, earlier, her husband had been (unjustly) called lazy by her mother on account of his calm, easy manner. She herself had had to learn gradually how to combine leisure with work. The changing image of the female figure was seen as a thread spun from the present to the past; and the whole group together insisted that their colleague had obviously not yet completely solved the question of relaxation and leisure on the one hand and devotion to duty on the other. The group member Dr. X served within the group for the transference of an obviously still unsolved emotional conflict which had at one time arisen in her marriage. It cannot be an accident that this old conflict came up again within the group. The therapeutic group obviously reactivated the old family image and the demands of her mother, which had meanwhile been taken over by her own superego. Our colleague could thus recognize that she was still measuring new events by old standards, and she found it easier to detach herself further from her severe and intolerant superego.

Above all, the experimental group helps the doctors to recognize which emotions come up in a group and what their origin is. They will not in future be at the mercy of whatever emotions of theirs may come to the surface in a group situation but will be able to trace them to their original motives as they did in the training group. They will also be capable of detecting emotions in the social field that might cause groups to degenerate into unruly mobs and could thus be dangerous.

We consider that the doctor who is engaged in a group analysis should undertake an individual training analysis if he has not begun one already; and we are also of the opinion that individual training analysis not complemented by a training group is incomplete. However, we leave it to the free choice of the doctors whether they want to take a training analysis or not, as we believe on the one hand that their personal freedom should not be compromised, and on the other hand that they will become aware, in the course of their activities, of the need to throw some light on their unconscious motivations.