On Therapy
My psychiatric residency was at MUSC all of 1974 through 1976. My last year was done particularly in group therapy. I am partial to hospital treatment and am willing to take on almost any patient regardless of their diagnosis. The major diagnoses and diagnostic categories I treated are: Schizophrenia, Bipolar Disorder, and Major Depression. These 3 are the most likely to have delusions. Some clinicians call the most intense delusions “hallucinations”, which are expressed in the most severe cases of these illnesses.
The best known name in group therapy in this country is Irvin Yalom’s, who was at Stanford for many many years. He wrote many books, initially on group therapy on an in-patient setting, and some on out-patient treatment. He was also an existential psychotherapist and wrote several novels relating existential philosophers to group therapy in his novels, some titles being “When Nietzsche Wept”, and “The Schopenhauer Cure”.
In hospital psychiatric in-patient units, 99% of the patients’ treatment include group therapy, usually on a daily basis. My initial experience in group as a medical student involved AA meetings. On the unit where I did my rotation, there were also a number of addiction patients who were seen in an AA group unit. There are 3 types of AA groups: Open (anyone from the public may attend), Closed (attendant wants to become sober), and 12-step (specific workgroup). In some ways there is a reduction down to the individual person in this progression of groups. The emphasis shifts from a group-based dynamic in open groups to a more individual process in 12-step programs. Once the individual has achieved sobriety and is in recovery, the 12-step is to help others do the same.
From the interest that it created on me about group when I did my residency at MUSC, the program offered us a residence group with a psychologist in our department that would be our group leader. I found this to be comforting and exciting at the same time, and it carried on to almost all my work during my career. For me, approaches to treatment outside of the hospital revolve more around group and family therapy than individual therapy (adolescents in particular). I found adolescents hard to treat without group and family sessions.
There are some parallels that I think seem to exist when you have group therapy vs. individual therapy. In individual therapy, the patient is talking to the parent, while in group therapy they are talking to their family all at once. In individual, they regress to their childhood, while in group they regress to adolescence, which is a more volatile stage. Other examples are family therapy vs. individual, family therapy vs. parent, and adolescent vs. toddler. These are in the context of separation vs. individuation. The toddler is individuating from the mother figure, and the adolescent is separating from the family and becoming part of their social group. According to Freud, groups start with family, religion, individual social life, the national culture, country association, and then the world. This can also be seen in allegiance to athletic teams, becoming more intense in junior high school (middle school), most intensely in the family. From then on, as the group gets larger the attachment gets weaker.
Although I did both individual and group therapy, my personal preference was not to see the same patient in both. Many excellent therapists do see both, but the reasoning behind keeping them separate is the same as a parent with their own family: the children start to feel as if another one is the favorite (which in fact occurs unconsciously). It also ends up with the group therapist unconsciously pushing the group members they see in individual therapy during the group session to express their conflicts. In family and/or couples therapy, I make an effort to see the designated patient before the family sessions. I don’t see the rest of the family/other partner individually, because everyone that decides what person you see first assumes that you are on that person’s side, which is important in adolescents. Unconsciously you do attach to the first person above the others, and without evidence, you assume the parents are unable to parent properly. However, this is a misconception and is probably the therapist’s excuse and way of repairing their ego by blaming the patient’s parents.
To return to process group, the group leader in England “the conductor” is a parent figure, and the group members fill a number of multiple niches pertaining to roles in the family. In my view, it is interesting to think of Adler’s theory of psychoanalysis and assigned roles of the children’s hierarchy in the family. He attaches this to their birth order. It is important to cut down on cliques within the group, made from outside the group; either previously or outside contact during the period of time that the members are part of the group. This is different than the family of origin, but it makes thee cliques observable by the therapist as well as the group members. Generally, the therapist announces some rules during the first part of the first session. For me, the main instruction was not to touch each other, in or out of the group. No touching neither physically nor sexually.
Many therapists also do not want foul language in the group. I do not believe in this rule. My instruction is foul language implies anger, and the group has the right to question that group member about what is bringing up their anger from in the room and brought on by the regression. Any time there is more than a meeting of an authority figure and subordinates, a process group (in businesses and/or community organizations for example) occurs, but without pre-rules and instructions. As Irv Yalom suggests, the best measure of a successful group is how much cohesion there is developed between group members. He gives several other less important measures, but I don’t remember them.
