A New Form of Group Psychotherapy
- Author:
Joshua Bierer M.D.,
Visiting Psychotherapist, Runwell Hospital, Essex; Econ.D. (Vienna), Lieut., R.A.M.C. Clinical Assistant, Guy’s Hospital, London * iie experiment which this paper rec?r^.^. mental form of social clubs, two of them m a p t.patient hospital and four attached to *he <fjathem Apartments of voluntary hospitals, teaching hospitals.
^-Patients’ Clubs n We started with a club for in-patients at u with three main ideas in our minds. (a) Patients robbed of their freedom on entering an institution would probably improve if they were given at least the illusion of temporary freedom in the club.
(b) Patients might improve more quickly and relapse less readily if trained whilst in hospital to mix with other people in varied forms of social life which encouraged them to take responsibility and to use their own initiative.
Summary of paper given at the Royal Society of Medicine on December 16th, 1943. (c) Patients might be dealt with more effectively if situational treatment were used, and this could be provided by the club.
The first step we took was to gather a few suitable ‘ patients together in order to put the idea of a club before them, asking them to develop it and to suggest the things they wanted to do. In this way they were led to feel that the club was their own invention, and we found neither men nor women lacking in ideas.
This first club met three times a week at the beginning, but war conditions made it necessary later to reduce the meetings to once a week. The Council meets separately once a week, and various subsidiary meetings take place occasionally. The club is run in a democratic manner, a fresh group of officers being elected at a general meeting every three months. The chief officers on the Council are: Chairman, Vice-Chairman, Secretary, and the Conveners of Magazine, Sports and House Committees. These rather frequent changes of officers prove useful in giving more members a definite period of responsibility and a good opportunity to use their own initiative.
At its weekly meeting, the Council makes out the programme for the coming meetings, considers the suggestions or complaints of members, and organizes extra events.
Members of the hospital staff can attend the socials only by invitation from one of the patients. This is one of the details which help to make the patients feel that they have an opportunity of giving instead of always receiving.
Patients become eligible for the club on the recommendation of their doctor; they are then introduced as guests by members, and are eventually elected to membership at the next general meeting. This first social club was for chronic, but not deteriorated patients. In four years, 350 patients have attended it, and the average attendance has been 50. The members are of both sexes, ranging in age from 15 to 70 years, and there is almost as wide a difference in their social and intellectual standards, a fact which has not proved a drawback. From the diagnostic point of view, the types of disorders from which the members suffered included schizophrenia, anxiety states, paraphrenia, and paranoia.
Group treatment at the meetings took the form of community work?intellectual exercise in discussions and lectures; entertainment in games, cards and dancing; physical activities, such as sports and rambles; occupational therapy in the preparation of food; and finally, the training of officers in running a second club, for the more chronic patients.
The chief difficulties which are likely to arise may be enumerated as follows:?
(1) The relationship between the psychotherapist and a group is inevitably different from the relationship between the psychotherapist and an individual patient. There is no doubt in my mind that the majority of psychotherapists are of the schizothyme rather than the cyclothyme type, and, though they have learned to overcome their shyness with regard to individuals, they may have difficulty in contacting and handling a group. Similar difficulties are met with by assistants?social workers, occupational therapists and group leaders?although the last two have the advantage or dealing with groups continually.
(2) A difficulty which we have not yet solved is the probable conflict between the transference of a patient to his own psychotherapist and his transference to the therapist in charge of the club. There is no doubt that if the therapist in charge is also the patient’s own therapist’ he can do more for him than he can for the patient of another doctor. We have not actually experienced any difficulty on this transference point so far, but the problem does exist and will have to be dealt with sooner or later.
(3) It is interesting to note the relationship of the patients to each other. In clubs for so-called normal people, one often finds gossip, jealousy and petty personal encounters. We have never experienced the slightest tendency to any such behaviour in any of our clubs. The atmosphere is delightful, and practically a” new members notice this and comment on it.
(4) It is of course difficult to keep within hospital rules and still give in-patients that freedom oi action which they so badly need. This is facilitated if the doctor and his assistants behave as ordinary members of the club, so that patients feel that they themselves are in complete control. Any work done by the staff” must be behind the scenes and not apparent to the members.
(5) This is perhaps a question of danger rather than of difficulty. We set out with a firm belief that we must trust the patients and give them as much freedom as possible. It meant taking a certain amount of risk, as the sexes are mixed, but we are happy to say that the patients did not let us down, and we have not had a single unpleasant incident in the whole four years.
In-Patient Club for Chronic Patients . A few months ago we started a second club for the more chronic and deteriorated patients. might say that at present it is run on the lines of the ” total push method ” popular in some American hospitals. This club is quite different from the other, and we have only recently taught the members to make it a self-governing affair. The programme is based on the need for movement and collective action, and very simple games, community singing and dancing go down well. The Club is a great treat to most of its members, who look forward to it eagerly each week.
The club also provides an extra field of activity for some of the ” older ‘’,membe^and run it. club, a few of whose ex-officers org ^ when Their task in the club fills the gap they tQ their official posts in their own club ar ^ find uew members, and it gives them S that is that they can really supply s ^ fortunate tremendously appreciated by thei fellow-patients.
Qut-Patients’ Clubs v,r?<mital When we decided that clubs outside t e t^oug^t could be used for mass psychother py, continue hey would help the discharged P^ents ^ the process of social adjustment beg ther> we from which they had benefite ? treatment, pondered how far, as part of theirj5? of possible ” might help us to lessen the numb P? relapses. We also wanted to see wbettjaMm ^ea could be used in treating out;P^n Jch clubs was difficult to know how to introduce^ carry -jdto avoid the stigma which they The idea that the social club might Reconsidered useful for out-patients struck us wh Nearly the enormous number of social ‘ ents has every patient in our out-patient dp stonishingly difficulties in social adaptation, an(i the rSe number have no social life ‘tisfactory. majority have one that is complete* unsa ^ ^ To counteract any stigma al precaution buildings other than the hospital. Every p uke is taken to make the premises apption wjth the those of any other club, and the co ^ people, hospital is never emphasized. muers and as Properly introduced, may become bee’n either a result we have several who have n m-patients or out-patients. for We started these clubs in the sam -ents and ^’Patients?by collecting a few Liable. In discharged in-patients who would be su^ both making our selection, we have to tient and how far the club will be good for eac P ^ it is how far he will be good for the club. ^ intellinecessary to have compatibility of aje smoothly? gence. Later, when the club is ru more mixed. 1 it does not matter if the members are m but ] The doctor and his assistants ho bs meet < one of them is always present. ? and one 1 once a week?three of them in the . t anc[ i on Saturday afternoons. Expenses as is j be defrayed by the members themseive , t done in two instances. . , , one in c In 1940, we opened two out-paUen war r East Ham and the other in Southend^in^ t forced us to close these down after .nce which hut we had collected some valuable exp ?y these helped us to avoid mistakes later. months g [wo original clubs were re-opened, a _?atients of ater two more followed?one fo Bartholouy’s Hospital and one for those ? ^ t^e a ^ew’s. It is interesting to see how eacn fi clubs strikes a different note.
il Guy’s Club meets near the hospital, but many t. of the patients live far away, some in Kent. Meetings i are in the evening, but it is significant that some a members, with over an hour’s journey, attend i regularly in spite of air raids and the blackout. The s average attendance is 15. In this club all the 3 members are either patients of the doctor in charge, or are seen by him in the hospital before attending the club. This is the easiest way to get the patient to attend, for he feels there will be at least one person . there whom he knows. There is no conflict over transference, and the doctor can see the patient ‘ twice a week as he and an assistant attend regularly. The atmosphere is good and the club flourishes. Southend Club has been running for just over a year with the help of a doctor and of the Occupational Therapist from Runwell. This club has a particularly intimate and intellectual atmosphere. Programmes contain very little dancing, but plenty of mental exercise. Most of the members are out-patients at the Southend General Hospital, but there are a few discharged patients from Runwell. The average attendance is 15.
East Ham Club has been open about eight months and is just finding its feet. There is a bright and happy atmosphere. Nearly all the members are discharged in-patients from Runwell and the doctors attend from time to time, although the Occupational Therapist and the Social Worker are there regularly. The average attendance is 15.
Bart’s Club has been running for eight months and has an average attendance of 30. Members come from the hospital, with a few from Guy’s; some are private patients and a few are not patients at all. The link between Bart.’s and the club is provided by the Sister from the Psychiatric Outpatient Department, as the Doctor in charge of the club does not work at Bart.’s. It was deliberately decided that he should not make personal contact with the Bart.’s patients, so that there should be no split in transference, and so that we could find out how far the club was useful as an institution in itself. It was about six months before it achieved the right atmosphere, but it is now very successful and indispensable to many of its members.
Apart from the difficulties which we have already mentioned in connection with in-patient clubs, one has to keep in mind that the organization of a club outside a hospital has difficulties of its own. People live far away, they are working and must therefore adjust their timetable to attend, they usually do not previously know each other, and there is no administrative control over them. There is also the difficulty of finding the right locality?the management is different, and the problem of ” stigma ” must be taken into account. We can say now, however, that we have succeeded in overcoming all these difficulties.
Situations and Symptoms combated by the Clubs These may be enumerated as follows:?Shyness and loneliness; general and social inferiority feelings; sexual maladjustment; lack of incentive and aim in life; inability to co-operate with others; claustrophobia and agarophobia; parental domination; acute disappointment (e.g. a love affair); psychological effects of physical defects (e.g. alopoecia generale, etc.). As we continue the work, this list will probably be extended.
Suggestions
Our experience appears to justify the putting forward of the following suggestions:? (1) Any mental hospital could try to organize both in-patient and out-patient clubs for its patients, but to avoid disappointment this should only be attempted where there is an enthusiastic doctor (or leading member of staff), an understanding superintendent, and assistants who are ready to learn and adapt * themselves to new methods.
(2) Out-patient departments not connected with mental hospitals might well organize clubs for their patients. Sometimes it may be necessary to exchange patients with other hospital departments, where the patient’s home or his free time fit in better with the hour and locality of another club. But it should be emphasized that it will always be necessary to make a personal bridge and to remember that the club is never a treatment in itself. (3) Not every psychiatrist is able, merely by virtue of his position, to use Group Therapy successfully. The same applies to social workers and occupational therapists. Only those who feel that they possess the ability should attempt it, and should seek the necessary experience. It is necessary to train people as assistants. Just as there are ” occupational therapists “, there should also be ” group therapists In the meantime, some social workers could do ths work of the out-patients’ clubs, and sofl|e occupational therapists the work of : in-patients’ clubs.
To sum up, these social clubs achieve results ofl three different levels:? .
(i) As institutions they aim at helping shy peoP to lose their shyness and to develop initiative. This is achieved by other types of clubs too* but in them our patients cannot be helped s successfully because of the lack of tl1 personal links which are needed if they ar*j to be brought out of their over-protecteo . environment. The particularly congei*1*1 and well-planned atmosphere is an antidp1 against ideas of reference and persecute and against inferiority feelings, and in menta hospitals the very fact of having a club their own helps patients to forget the restflC’ tions to which they are otherwise subjec ? (ii) As a forum for different kinds of group therapy’ the clubs provide for mass treatment O-6’ group suggestion), class treatment (lecture and discussion), and collective treatme0 (different forms of group-analysis and group activity). .
(iii) As an opportunity for the psychotherapist his assistants to apply as unobtrusively possible, different forms of ” situational treatment.
In conclusion, I have great pleasure in expressing my indebtedness to Dr R. Strom-Olsen, Dr R- P’ Gillespie and Dr E. B. Strauss for their construct^ criticism and encouragement in this work, to Felix Brown for his useful advice, to Dr MBrody and Dr M. Duncan for their co-opera tic11! and to Miss K. Thompson, Miss M. Hastie-JoneS and Miss D. Butcher for their help.
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