Affect and Therapeutic Process in Groups for Chronically Mentally Ill Persons

The ravaging effects of schizophrenic and bipolar illness on thought and affect remain a therapeutic challenge. The multiple biological, social, and emotional needs that are the basis and consequence of severe and persistent mental illness defy simplistic solutions. Medication may alleviate some of the chaos but fails to reverse or halt impairment in essential areas of human functioning—relations with the self and with others from which come a sense of wellness and comfortable regard. For many patients, the illness may have begun in childhood, even before overt clinical features were present or were of sufficient intensity to justify a clinical diagnosis. Many first-person reports attest to patients' recollections of feeling different, estranged, or isolated from peer groups. Before the onset of a diagnosable illness, impairments may be expressed in the social domain as diminished interpersonal responsiveness, poor eye contact, and failures in expression of positive affect. Subtle motor symptoms add to these individuals' relational awkwardness.1 After the onset of clinical illness, the personal and societal costs escalate. Innovative psychosocial treatment approaches have been partially effective in alleviating patients' disabilities. Case management and assertive community treatment have focused on providing services to severely impaired individuals who require assistance in everyday living. Social skills training and vocational rehabilitation address aspects of social impairment. Psychoeducational programs, including family management, are valuable additions to the overall treatment armamentarium. Amidst this plethora of interventions, the place of psychotherapy, and in particular long-term group psychotherapy aimed at assisting patients in their efforts to improve their psychosocial functioning, has been relegated to lesser overall importance. Research findings for psychotherapy of schizophrenia have not been robust, and as a result research efforts in this area have nearly vanished. This has occurred in part because of the hypothesized lack of effectiveness of psychotherapy when compared with medications and in part because of problems inherent in funding and conducting psychotherapy research. The difficulties are magnified when it comes to research on group treatment. Reviews of psychotherapy for schizophrenia suggest that outpatient group treatment may help patients improve social functioning.2,3 The treatment process is described as occurring in a two-step sequence: 1) a stabilization phase, which focuses on reducing and stabilizing positive symptoms and maintaining patients in the community; and 2) a rehabilitation phase, in which emphasis is on social adjustment relationships, interpersonal relations, and vocational possibilities.4 In the stabilization phase, treatment emphasizes patients continuing their medications and becoming more informed about their illness through supportive and educational strategies. This approach is particularly salient with the current practice of brief periods of hospitalization. In the rehabilitation phase, the emphasis shifts to exploration of patients' capacities to form and sustain social relations and to determination of vocational capacities. Change in these latter sectors takes place much more slowly and is more difficult to assess. Yet it is in this rehabilitation phase that long-term psychotherapy, including group therapy, can have a significant impact on interpersonal and intrapsychic functioning. In this process patients can slowly gain greater control over their affects and develop insights into aspects of their relationships with others and with self. The salience of addressing the social and interpersonal sectors of functioning in chronic mental illness was reported in a survey by Coursey et al.5 Chronically ill patients in rehabilitation settings were asked to rate the importance of 40 therapeutic topics. The highest rated items clustered in a category described as “illness-intensified life issues” and encompassed independence, developing self-esteem, relationships, and feelings. Other categories, rated important at least two-thirds of the time, included adverse secondary consequences of the illness, self-management of the disorder, and coming to terms with the disability. These findings bring into focus patients' awareness of a continuity in their life and an appreciation that their condition has added a particularly devastating dimension to difficulties that may have been present prior to the onset of their clinical illness. In the context of a history of social disappointments and emotional injury or rejection, it would be unrealistic to expect patients engaging in treatment to rapidly reveal their inner experiences and risk being retraumatized without thoroughly testing their environment. They will test and retest the therapist and the group to assess the safety of the situation. The clinician who “sticks with it” despite the personal difficulties—which may include both countertransferences and the real aspects of the relationships—will find opportunities to gain understanding of patients' efforts to cope, protect themselves, and work toward making positive changes in their lives.