The Challenge for Group Psychotherapy

Mental Health Groups: An Intensive, Low-Cost Treatment Method, Part 1

The Need for a Low-Cost Method
Every increase in the effectiveness of therapy proportionately reduces the total treatment cost to the patient.

As the effectiveness of the procedure increases, the patient either will come for a shorter total treatment period or—if limited by his financial circumstances—he will be able to reduce his weekly expense by decreasing the number of sessions. This paper presents a new and intensive method of psychoanalytic therapy—mental health groups—which the writers have developed under the auspices of the American Mental Health Foundation over the last nineteen years. The name Mental Health Groups was chosen in order to distinguish this form of treatment from others using the group process and also to link this method to the name of the Foundation responsible for the creation of the procedure.

The Foundation, which was established in 1924 by eminent civic leaders and psychiatrists, has dedicated itself to research and the advancement of reforms in the field of mental health.

The Foundation views research into the functioning and malfunctioning of the human mind as of paramount importance. Primary emphasis, therefore, has been placed upon such research and upon the testing and establishing of fundamental tenets of psychotherapeutic theory and technique. As an important part of its program, the Foundation has given great attention over the last twenty-three years to the development of better, and therefore less expensive, treatment methods. The urgent need for such methods was demonstrated by the Foundation’s follow-up study, started in 1954 and conducted over a period of nine years. The study showed that only about one per cent of applicants for low-cost treatment were able to find adequate therapy.

Long-term research by the Foundation has pointed toward certain forms of intensive psychoanalytic group therapy as particularly suitable for many emotionally ill people. These methods utilize all the psychoanalytic fundamentals, such as transference and resistance analysis, free association, and dream analysis, and have additional unique features as well.

An outstanding factor in psychoanalytic group therapy is the multitude and variety of the interrelationships that take place. A person seeing the therapist only for private sessions reacts to a single individual on whom he projects his emotional patterns. In a group setting, however, the different male and female members evoke in the patient a multitude of diversified emotional reactions, resulting in a far clearer emergence of the person’s emotional structure.

Nevertheless, in 1953 the foundation’s survey of the literature on group therapy revealed that the majority of psychotherapists believed it was merely a less intensive form of treatment used for patients with milder emotional disturbances. Most therapists would recommend group therapy only for patients who had previously been in intensive individual treatment, and once in a group most patients would continue to receive regular weekly private sessions.

The Foundation’s aim, therefore, was to develop a form of low-cost therapy, combining both individual and group sessions, that would show increased effectiveness, yet permit a substantial reduction in the number of individual sessions needed. The creation of such a treatment form would enable each patient—even those of limited means—to pay for his own intensive treatment without undue sacrifice. At the same time, the therapist trained in this procedure would not experience any reduction of income. Thus, such treatment would not require the financial support of a third party, private or governmental. Public and private funds can never suffice to take care of even a small portion of the vast numbers of emotionally ill persons.

The Development of Mental Health Groups
In view of the great need for an effective, genuinely low-cost method of psychotherapy, which, if successful, could be used by experienced psychotherapists everywhere, the writers began to experiment with the new method called Mental Health Groups. Patients were seen almost exclusively in group sessions and had only four to eight individual sessions per year. In this way patients who can pay only the equivalent of one individual session per week have been able for the first time to receive extensive and intensive psychotherapy. This is important in view of the fact that Foundation studies have shown that the majority of patients who have gone for only one individual session per week, even with a qualified therapist, are not able to make satisfactory progress in their treatment.

Seven such mental health groups have been conducted by the authors during the past nineteen years. In an effort to gain necessary material for comparison, evaluation, and validation of the techniques employed, four groups were led by one author and three groups by the other.

The method was originally presented in 1957 at the Second International Congress of Group Psychotherapy, in Zurich (de Schill, 1959). Progress studies of this treatment form were reported to the Sixth International Congress for Mental Health (Paris, 1961), to the Sixth International Congress of Psychotherapy (London, 1964), to the Twenty-Third Annual Conference of the American Group Psychotherapy Association (Philadelphia, 1965), to the Annual Meetings of the American Mental Health Foundation, and to other scientific meetings.

The present form of this new treatment method is the culmination of the work of many Foundation research efforts. Expanded knowledge of psychotherapeutic theory and techniques and the various forms of group therapy have been carefully tested and reorganized. Data collected over these years reveal that: (1) The increase in effectiveness with this form of treatment permits a drastic reduction in the frequency of individual sessions required. (2) Most patients can be placed in such groups at the beginning of treatment. (3) A great many emotional disturbances, even of a severe nature and previously considered not amenable to group psychotherapy, can now be treated in this setting. All of these factors contribute toward a substantial reduction in the cost of intensive and effective treatment.

The Setting of Mental Health Groups
Based on their experience with psychoanalytic group therapy, the writers carefully planned the composition of each Mental Health Group, placing emphasis on optimum heterogeneity.
As much as possible, each member selected for such groups had personality traits and structures different from those of the other group members. Patients with symptoms, forms, and degrees of emotional illness that were previously considered treatable only in individual psychotherapy were accepted in the Mental Health Groups. The only persons not admitted were those whose emotional problems might render group work impossible, e.g., psychotics who had no contact with reality, severe stutterers, feebleminded persons. To this list—as will be explained later—psychopaths have now been added.

The authors had a wider choice in their selection of patients than therapists in private practice ordinarily have. This is due to the fact that all patients applying to the Foundation for referral are first sent for a diagnostic interview with one of the psychiatrists especially assigned for this purpose. By studying these diagnostic reports the authors were able to select the more challenging and interesting cases for the mental health groups.

The age range of the group members was from twenty-two to fifty-five, with most members being between twenty-four and thirty-five. The number of persons in each group varied from seven to ten, with approximately as many men as women. Whenever a member left a group for any reason, he was replaced by a new patient, selected with care to maintain the proper balance of the group.

Usually psychoanalytic group therapy meetings last one and a half hours. The authors found that this limited time thwarts the withdrawn members, such as the silent and submissive. To avoid the submergence of these passive members, more time was allowed, thereby reducing considerably the competition for attention by the dominant and aggressive personalities who tended to monopolize the session. The meeting time in Mental Health Groups began with a duration of two and a half hours per session and later was increased to approximately three hours per session.

The occasional private sessions proved to be a helpful component in the mental health group method. Certain patients who were able to function in the group setting manifested anxiety when alone with the therapist. Others needed private sessions to reveal embarrassing material that they could not yet express in the group.

Each of the different situations—regular group sessions, alternate group sessions, and private sessions—provided diversified settings and often stimulated different conflict areas to be worked through by the patient. To these a fourth situation was advantageously added: the therapists suggested that the group members stay together for a while after sessions, perhaps over coffee at a nearby restaurant. In this social situation, additional aspects of each person’s reactive and defensive patterns may become apparent.

Preparation of Patients Selected for Mental Health Groups
Mental Health Group members receive only two private sessions with the therapist before entering the group. The purpose of these sessions is to collect data, in addition to those obtained in the diagnostic psychiatric interview, in order to tentatively evaluate the psychodynamics and to help the patient overcome any fears and misapprehensions about joining the group.

Many persons initially object to going into therapy with others because of an inner dislike or fear of people, and they feel that in a group they would not be able to speak freely about their problems. Such resistance—in view of the limited number of individual sessions—is voiced even more frequently by patients to be placed in mental health groups.

In 1956 the Foundation published the “Introduction to Psychoanalytic Group Therapy.” This text is directed to professionals and patients and describes the nature and purpose of psychotherapeutic groups. Having new patients read this publication often eases their initial anxiety about entering the group.
The new patient who experiences anxiety is helped to understand that his fears about entering a group are related to his problems and that it would, therefore, be more advantageous to work these through in the group rather than avoid them. By supplying the introductory booklet and by careful handling of anxieties and resistances, the initial period in the group proves to be of no particular difficulty for most patients. The rare exceptions are those patients who become overwhelmed with anxiety when exposed to emotion-arousing situations that occur through interaction within the group. Such persons need the protection of the therapist to temper their anxiety and may be instructed not to attend the alternate meetings at first.
Some therapists tell the group members initially that they must “help” each other, that they will have to behave in a “democratic” way, or that they must “relate in an adult manner” to each other. Such demands tend to inhibit the patient and may obscure the emergence of his individual behavior patterns.
In the Mental Health Groups the therapist emphasizes, as one basic fact in psychoanalysis, that the success of the procedure is greatly dependent on the patient’s efforts toward awareness and honesty in revealing and understanding of all his feelings and actions. Although primarily for his own benefit, such efforts on his part automatically become a real contribution to group work, even when the expressed emotions may seem hostile, destructive, or embarrassing.

The Role and Work of the Therapist in Mental Health Groups
Difficulties Encountered in Mental Health Groups. The work with Mental Health Groups had to be conducted under rather difficult conditions, requiring great effort and perseverance on the part of the therapists.

The extended time period was made necessary by some of the following major difficulties: The extreme limitation in the number of individual sessions meant that almost all of the therapeutic work had to be done in the group. This included the working through of difficult situations and problems, which previously were dealt with in individual sessions.
The handling of resistances—particularly in the early development of this method—became an almost insurmountable problem. The intensity of the patients’ reactions was never encountered to such a degree in combined individual and group therapy. The anxiety-ridden patients experienced more anxiety than they would have otherwise, the withdrawn patients were more withdrawn, the hostile patients more hostile, and there was a far greater tendency for the patients to act out. Only with the development of more effective approaches were the writers able to overcome these prime obstacles.

Another factor increasing the difficulty in Mental Health Groups was the inclusion of a considerable number of severely disturbed patients who would customarily not be accepted for group therapy. Many of the patients were not as sophisticated and tended, therefore, to be more impulse-ridden than those usually seen in private practice.
In order to develop and maintain a feeling of participation and personal meaningfulness in the procedure, it was necessary for the therapist to relate to each patient during every session.

The writers came to the conclusion that it is essential to have as much knowledge of each patient’s psychodynamics as if he were being treated in intensive individual therapy. To accomplish this, the therapists devoted much time outside the Mental Health Groups to careful rethinking of what happened during the session. Also, new patients were asked to write down all their dreams and phantasies so that they could be studied by the therapist, even though these might not be reported during the session.

Therapeutic Tools for Coping with Resistances in Mental Health Groups. The procedures used in Mental Health Groups are based upon theories and techniques tested and developed as part of the research program of the American Mental Health Foundation.

Traditionally psychoanalytic techniques are applied—that is, analysis of transference and the laying bare and working through of the various defense mechanisms and patterns. The therapists formulate tentative hypotheses concerning the unconscious forces and patterns active in each group member. These hypotheses are based entirely on the productions of each patient and not upon any rigid, dogmatic a priori position. As group work progresses, significant material that is detected in the patients’ defenses and transferences, expression of feelings, free associations, dreams, phantasies, and behavior make possible continuous revisions of these hypotheses.

A major responsibility of the therapist is to focus on and clarify, at appropriate times, the direction of the efforts to be made by the patient. Mental Health Group members are channeled by the therapist toward meaningful exploration of the group interaction and understanding of underlying currents and mechanisms. The therapist constantly attempts to focus the group’s attention on emotions and behavior as they arise, establishing their significance and function within the individual psyche by linking them with the near and distant past. (Direct interpretations, of course, are avoided as much as possible.) Thus the patient’s childhood gradually becomes alive, and therapy is made an understandable, vital experience to the patient.

Such focusing diminishes the resistive digressions of the over-intellectual, who tends to lose himself in theoretical speculations, and of the patient who engages in long-drawn-out recitals of his life history or recent happenings. It also minimizes repetitive acting out of transferences and multiple transference reactions, which does not result in any therapeutic exploration. Members are encouraged to express their reactions to any given group situation, which in turn serve as stimuli to the other patients. Therefore, at any given time a therapeutic situation exists for everyone, and the danger of merely having a series of individual sessions within the group setting is avoided.

The major difficulty in Mental Health Groups is coping with resistances. It is easier, in the Mental Health Group setting, for the patient to conceal or to act out his resistances and to frustrate the efforts of the analyst to work through the problem. The severity of this problem is in direct proportion to the degree of hostility prevalent in the group.

It has been found that resistances in Mental Health Groups are far more intense than in the usual combined treatment, and they frequently reveal themselves in manifestations that never appear in individual therapy. For instance, some group members tend to form seemingly “warm, positive relationships” that are, in effect, resistances to constructive therapy.

The handling of severe resistances in Mental Health Groups is always difficult since the therapist does not have recourse to frequent individual sessions. On rare occasions, it is advantageous to remove from the group a patient who constantly acts out his hostility or sadism and refuses to engage in any therapeutic effort. A number of these patients were psychopaths. Such discontinuance is likely to benefit the patient, since it might induce him to cooperate with his next therapist.

As a general rule, even intense resistances can be worked through in the group, frequently with the help of other group members. The methods used often go beyond what is customarily done in individual or group therapy. Experience in individual analysis and particularly in group psychoanalysis is increasingly forcing the abandonment of the concept that the analyst must be an impersonal constant and that interpretation is his only valid tool. It is becoming evident that the therapist must employ his own personality and experience.

Analysis of defense and of content, which many believe to be the only acceptable ways to work through resistances, are based chiefly on the reasoning that eventually the rational forces of the ego will help to overcome the irrational defense. The resolution of conflicts is supposedly brought about by the patient’s understanding of the psychodynamics involved. Freud, however, said that the analyst must use all available means of suggestion to persuade the patient to give up his defenses. Going a step further, the writers are convinced that the therapist, guided by his knowledge and understanding, must use all possible techniques—of which suggestion is only one type—to bring about therapeutic progress. Whenever appropriate, the writers use the widest choice of instruments, whether or not they are interpretive steps. In Mental Health Group sessions, the therapist applies different procedures and rationales to the various group members.

Patients come to therapy primarily for relief of pain and gratification of emotional needs, but not for the kind of inner changes the therapist knows are necessary to accomplish lasting results. Therefore, when the analysis of defense and content are unsuccessful in working through a patient’s resistance, the writers use the patient’s own drives, neurotic motivations, and secondary gains for this purpose. Such techniques amount to an actual strategic handling of the patient and the group, a principle that influences analytic work in any case, as for instance in the use of the so-called “positive transference.”

Some simple examples may serve as illustrations:
A female patient was on the verge of terminating therapy because of strong resistances. The patient had often spoken about her absent mother on whom she had been extremely dependent. Another group at the time included an older woman who manifested characteristics similar to those the patient attributed to her mother. The patient was placed in the group with the older woman and became sufficiently involved to remain in therapy until the resistance was worked through.

A patient who complained that his parents had been overprotective and doting was allowed as much freedom as possible by the therapist, who made only the most necessary comments in his direction. On the other hand, a patient who had experienced lack of paternal love in childhood was shown consideration and affection by the therapist. Any fears that such procedures interfere with the emergence of basic patterns are unfounded. The patient who was overprotected in childhood still complained that the therapist tried to control him, and the patient who was deprived of love accused the therapist of ignoring and neglecting him. These distortions in the transference relationship are far more readily observed by the other group members than by the patient himself, and they are used to work through the problem.

The analyst again and again applies pragmatic procedures in chess-like moves in order to subtly maneuver the group toward interaction producing the desired insights. He thus almost becomes a “subliminal” orchestrator, eliciting responses from one or more group members in order to stimulate insights in another member. The therapeutic process within the Mental Health Groups requires an appropriate balance of gratifying and frustrating the patient. At times, learning theory is applied in an attempt to give the patient rewarding experiences. By fostering and reinforcing properly timed ego-strengthening experiences within the transference relationships the therapist brings about positive emotional changes. In other situations frustrating a patient’s needs or desires is useful and necessary. There are infinite possibilities to the application of such techniques, which require, however, most careful consideration by the therapist.

Even at best, the patient can acquire only partial cognizance of the processes involved. Conscious insight by the patient, while certainly sought, is usually far from complete and is but one of the factors bringing about personality change.

Patients are continuously encouraged to make certain specific efforts in the Mental Health Group treatment. They are urged to scrutinize their reactions to each situation in the group and to report truthfully their feelings toward the situation and toward group members who stimulate feelings within them. They are prompted to describe accurately to the group significant behavior as well as their phantasies and dreams. The therapist stresses that after-reactions to each group session are important and should be carefully remembered and brought up at the next meeting.

The group members are persuaded furthermore to seek out the “Why?” behind each feeling, behavior pattern, dream, or phantasy by establishing the connection with similar feelings and memories from childhood. They are made aware that childhood experiences are very important in analysis because they have influenced decisively the development of deeply ingrained emotional patterns. The patients are encouraged to relate all memories and associations, particularly those that are embarrassing. These may involve thoughts and feelings relating to the bodies of father, mother, siblings, or their own bodies and physical functions, such as bowel movements or early sexual behavior. Eventually a comprehensive picture of the patient’s early childhood should emerge.