Group Psycho-Therapy and the Psychiatric Social Worker
- Author:
Erika ChanceH, B.A.
Psychiatric Social Worker, Warlingham Park Hospital Although group treatment as a means of resolving personal difficulties has been practised for some time, it has but recently received recognition in the psychiatric field. Since Pratt treated T.B. patients by these means in 1905, the advent of the shock therapies and the pressures of the late war have done much to focus attention on a technique of psychotherapy which, it was hoped, would be time saving.
Psychiatry has for some years taken a wider view of its function in relation to the community than that which would restrict it to the treatment of the mentally sick. Research into methods of group therapy and sociometrics shows that the Mental Health Service has a vital contribution to make in terms of guiding interpersonal relationships. Indeed, it can have no less a goal than that of the International Congress for Mental Health: ” The task of preparing the way for individuals to become citizens of the world.’’ The formation of the groups described here and the specific way in which they are linked are the product of a Mental Health Service which sets itself this goal.
Group therapy may be defined as the re-orientation of the patient by means of specific relationships between the individual and the group leader, the individual and the group, and between individuals in the group. Two main divisions in group treatment techniques may be distinguished; discussion therapy and activity therapy. In this article, the writer will describe her experiences in the past year in conducting group therapy jointly with a psychiatrist for the following groups; (1) a discussion group for In-Patients, (2) a discussion group for Out-Patients and (3) a Social Therapy Club for Out-Patients. The psychiatric social workers function in these groups will be described and the writer will endeavour to assess the contribution she can make by participating in treatment groups, both to group therapy and to psychiatric social work.
THE FIELD
(1) The In-Patient Group This group has met once a week since November, 1946 for an hour’s discussion of psychiatric problems. A wide variety of techniques have been used, ranging from free discussion of problems raised by patients, to discussion illustrated by dramatic acting out of situations, to the didactic lecture discussion method.
Of the three groups to be described, recruitment for this unit is least selective. Most patients attend on the invitation of their doctor, but some are brought by friends.
The membership of the group is subject to constant change as patients attending are mostly on the road to recovery. There have, therefore, been large variations in attendance, ranging from 7 to 16. Male patients tend to be in the majority. The place of this group is ancillary to the general treatment plan. Patients are also, as a rule, under Insulin, E.C.T. or analytic treatment.
This group has failed to develop any social structure although there are a number of practical tasks for which patients could usefully take responsibility, such as preparation of the meeting room, acting as secretary, etc. It differs in this respect strikingly from the Social Therapy Club. It is the only one of the groups described in which movement is almost entirely absent and in which certain stereotyped features have developed. Men and women tend to sit at opposite sides of the room and, irrespective of the technique used, the members contributions are nearly always directed to the leaders. Attendance is entirely voluntary and, by the very nature of the group, patients come to it largely because they hope to derive from their attendance some information which will enable them to leave the group permanently.
(2) The Social Therapy Club for Out-Patients This club was opened in January, 1947, under the leadership of the writer and of the psychiatrist in charge of the In-Patient group. Meetings are held once a week and a committee of members decide questions of programme and club management.
The programme includes discussions on questions of general interest as well as on psychiatric problems, dramatic and musical evenings, dancing, games, outings, etc. A social is held every six weeks to which members invite friends and relatives. An invitation to the In-Patient group has become one of the traditional features of these social evenings. A quarterly magazine, largely concerned with articles on mental health is produced by the patients. Members take it in turn to bake for the canteen. Recruitment is selective. Patients attending for out-patient treatment and some of those discharged from the Mental Hospital are invited to join by the leaders. Information about each member prior to enrolment is obtained from a psychiatric interview and a social and psychiatric history. In the course of his attendance the patient’s social problems are noted. Intelligence is tested. The number of active members has remained at about 30 throughout the year and the bulk of the membership has remained constant. The average attendance is 19. Men and women attend in approximately equal numbers. About 40 per cent, of the members are former in-patients. It is the aim of this group to provide patients with all the facilities which a good club may offer, including an ever-increasing scope for self government and responsibility. The treatment aim of the club is openly accepted by each patient in relation to the staff. Repeated sociometric tests show that although patients do in fact carry full responsibility for all the mechanics of group management their personal dependence is centered upon the leaders. It is felt that both these factors, the self governing, highly structured aspect of the club, and the extreme personal dependence on the leaders combine to give this group the family atmosphere of a living community; structured enough to provide a realistic social background, and yet sufficiently flexible to allow therapeutic situations to arise naturally and to be easily controlled and guided.
(3) The Out-Patient Discussion Group This group has met once a week since January, 1947 at the Social Workers’ Office. Prior to the discussion, tea is available in informal surroundings for patients coming from work. While meals are in progress the psychiatrist and the writer interview individual patients who have specific problems. At intervals they return to the tea room and join in the conversation around the table. At the end of the meal patients assemble for the treatment group.
Of the three groups described, recruitment here is most selective. Only patients with average or good intelligence and with a real need for verbalizing their problems are asked to attend. Attendance ranges from 7 to 10 patients and at times patients are asked to bring their husbands, wives, or other relatives to the group when it is felt that they might usefully take part in the discussion.
With the exception of one case all patients attending this group also attend the club. They look upon the club as a field in which to practice insight and understanding gained in the discussion. About half of these patients are former members of the discussion group for in-patients. The techniques used in this group are similar to the methods used in the In-Patient group, but the members’ contributions tend to be more group centered. Patients state their personal problems spontaneously and, because they participate more actively, it is possible to bring into the group discussion material which would be too disturbing in the setting of the In-Patient group.
This group shows no specific social structure, but members demonstrate their individual feeling for the group by assisting in the preparation of meals and of the meeting room and in helping to tidy up after meetings. After an hour’s discussion patients walk over to the club in groups of twos and threes, often continuing the discussion on the way.
In concluding this description of the field, the degree of interaction between the three therapeutic groups should be stressed as an important factor in treatment. To the in-patient who visits the Club on a social evening it is an encouraging experience to meet former in-patients who look well and happy. Members of the Out-Patient discussion group are more conscious of the treatment purpose of the club and help to keep club aims in the minds of other members. The three groups represent stages of mental health and social adjustment.
THE PSYCHIATRIC SOCIAL WORKER’S FUNCTION
The joint leadership of any group presents a problem in that it taxes the leaders’ capacity for co-operation and team work. The psychiatric social worker and the psychiatrist have complementary functions in the normal working of a Mental Health Service. These are usually performed separately in time and place. Joint work in group therapy requires detailed preparation of a treatment plan for each session and discussion which clarifies the role of each worker in the treatment plan as a whole. It requires careful assessment of each patient’s problem, of his relationship to other members, and to the leaders, so that the optimum use can be made of all therapeutic resources. From the foregoing it will be seen that it is doubtful whether the advantages of group therapy lie in an economy of time.
(1) The Psychiatric Social Worker’s Contribution to Group Therapy
All psychotherapy aims at the individual and it has been our experience in preparatory discussions and in the assessment of treatment that the psychiatrist tends to concentrate on the treatment of the individual in the group. The social worker tends to focus her attention on treatment through the group and on inter-personal relationships. She is, therefore, much concerned with group cohesion and group structure. If she has previous experience in work with groups this is of assistance. Her contribution in this sphere consists largely in the creation of opportunities for the group’s growth in the desired direction.
For instance, it was noted that the In-Patient group showed considerable resistance at the beginning of each session and the results of a sociometric test showed a marked absence of inter-personal relationships. As a result of these observations it was decided that each meeting of this group should be preceded by a symbolic communal meal “, a cup of tea and a bun, shared by all participants. This feature was found to shorten the warming up process.
In activity therapy as practised in the Outpatient Club the creation of suitable roles for the patient is important. These must be within the capacity of the patient and they should enrich the social structure of the group. Their fulfillment should give the patient release, satisfaction and a feeling of achievement. Yet any steps taken by the leaders should leave the patient with the feeling that it is he who has taken the initiative. The case of patient F.l illustrates this point. She is a psychoneurotic woman, aged 31, whose conversion symptoms are due to intense conflict between a desire to be accepted as a model mother and complete rejection of her three children, between a wish to dominate (as expressed in her unhappy marriage to a man six years her junior) and a need for dependence. The Club Committee asked this patient to undertake the management of the canteen. This work gives her ample opportunity for organizing others for baking, serving, and washing up. She looks upon the provision of food as a maternal role and this aspect of her treatment has been re-inforced since she has begun to escort patients from the club, who were unable to travel alone. She has met her need for dependence by forming an attachment for the writer. In the three months of her attendance she has progressed sufficiently to formulate her conflict concerning her sexual relationships and her children. She accepts her symptoms now as a passing expression of this conflict.
The psychiatric social worker as an auxiliary to the psychiatrist can be of assistance in breaking down resistance in discussion therapy. The social worker’s contribution as a lay member of the group encourages patients to voice their ideas. In psychodrama and sociodrama her function as an auxiliary ego has been fully described by J. L. Moreno. The therapeutic possibilities inherent in the double leadership of groups have not yet been fully explored. Patients certainly look upon the leaders as father- and mother-figures and usually develop a stronger transference to one of these. In some cases it has been possible to maintain group membership while allowing a negative transference to one therapist to develop.
Lastly all psychotherapy aims at the re-orientation of the patient so that he may be better able to adjust to his environment and enjoy improved relationships at home, at work and in his leisure time. In-patients are much concerned with problems of social adjustment and they frequently bring to the discussion group such questions as: ” Should I do full-time work immediately after my discharge ? ” ” Should I tell my employer about my breakdown ? ” ” Should I keep in touch with the hospital or should I try to forget all about my illness ? ” Consideration of this type of discussion brings us to the second aspect of group treatment to be considered here.
(2) Participation in Group Therapy as an Aid to Psychiatric Social Work
On admission of a patient it is the social workers’ task to interpret the hospital to the patient’s family, to soothe the feelings of fear and guilt which arise from the relatives’ reaction to the patient’s illness and from the dread of ” the asylum “, and to obtain the active co-operation of the family in treatment. In the past year, 14 members of the Out-Patient Club have been admitted or re-admitted to hospital. In each case the patient came into hospital freely and without undue distress. Their relatives, having established easy and informal relationships with the staff and gained a better understanding of the nature of mental illness in the Out-Patient Club, gave active and intelligent co-operation.
For example, on one occasion a manic depressive was advised to apply for re-admission to hospital because of an impending relapse. During his last period of treatment as an in-patient his wife had shown considerable hostility to the hospital and had made every effort to persuade him to discontinue treatment. On this patient’s second admission, his wife suffering from a reactive depression due in part to a deterioration of marital relationships, herself applied for admission to the hospital on the same day. The couple, who are devoted parents, asked the social worker to make suitable arrangements for their three small children while they obtained treatment in the Mental Hospital.
In the mid-treatment stage the social worker’s presence in discussion groups helps her to understand the patient’s specific problems. The patient, knowing that she has listened to his contributions on such topics as work and leisure time problems as described above, derives a feeling of security from the fact that he, his illness and his rehabilitation are treated as a whole. He tends to apply insight gained in the discussion group more readily to the solution of his practical difficulties.
M.2 for instance, a boy, aged 18, suffering from petit mal and psychoneurosis, discussed the stigma of mental illness in the group. He described his tendency to escape from difficulties into day dreams, explaining that an over-protective mother had always allowed him to evade reality and had, on occasions, prevented him from striking out on his own. After the meeting he requested an interview with the psychiatric social worker. He asked her to find him a job on a farm. He said: ” Since the discussion I realize that you can’t run away from your illness … but I’d like to get another job. This one is too easy. I have plenty of time to dream over it. I’d like to get away from home, too … .”
Members of the In-Patient group tend to request on their own initiative an interview with the social worker to discuss problems they may have to face on discharge. The same occurs in the Out-Patient groups concerning social problems of all kinds. But for the In-Patient, the fact that he considers the question of social adjustment long before his discharge, helps to make him look upon his stay in the hospital as a period in which he may gather strength to face the outside world. This attitude is of great assistance in after care.
Nearly all patients discharged from hospital after a period of treatment exceeding four months, find the transition from the sheltered routine of hospital life to the noise and bustle of the outside world, difficult. Social therapy clubs have been recognized as a useful means of cushioning the shock of this transition. Klapman describes the need of the ex-hospital patient to establish a positive transference to some one who has detailed knowledge of his in-patient experience.
F.3, a girl, aged 21, who made a good recovery from a schizophrenic illness formulates her attitude as follows: ” I have always been afraid of talking about my illness, but since I joined the club, I don’t seem to mind telling perfect strangers.” It is suggested that the creation of a positive attitude towards this patient’s breakdown is the direct result of membership of a community in which such an experience is taken as a matter of course. Patients in need of supervision after discharge can be divided into those who are aware of their need for help, and those who lack insight. The first category presents little difficulty, as a rule, in after care. But for those who lack insight, provision of satisfying recreational activities and of opportunities for unconscious learning through social situations, have proved a surprisingly efficient means of keeping contact. Some of these cases have made exceedingly good progress through social therapy.
F.4, a schizophrenic girl, aged 18, with an I.Q. of 52 came to the club in January, 1947. She was ill-dressed and appeared at the club with long unkempt hair. She was at that time unemployed. She was unable to respond to the members’ attempts to draw her into their activities and sat for most of her first attendance, hiding her face beneath a flow of hair. Work was found for her in a perfume factory and she kept this job for 9 months. She has attended every meeting of the club during the past year with the exception of one (when she went to a dance). She dresses well and has begun to make use of cosmetics. She takes part in all games and social activities without further encouragement and she does her share in the canteen. She has brought several friends to the club and our present difficulty lies not so much in ensuring her participation in activities, but rather in damping her enthusiasm for the other sex !
There will, of course, be always those cases to whom club life and groups make no appeal. But a progress analysis six months after the opening of the Social Therapy Club showed that of 42 cases in which referral had been effective only 8 were lost because patients no longer wished to attend.
SUMMARY AND CONCLUSIONS
(1) This study is a survey of one year’s experience of group therapy. The writer has endeavoured to evaluate the contribution which the psychiatric social worker can make by her participation, both to group therapy and to psychiatric social work.
(2) Three groups have been described; a discussion group for In-Patients, a discussion group for OutPatients and a Social Therapy Club.
(?) Recruitment for the In-Patients’ discussion group is least selective and there are great changes in the membership and attendance. This group has developed stereotype features. It lacks spontaneous movement, social structure and cohesion. (?) Recruitment for the Out-Patients’ discussion group is most selective. Here too, there is little social structure, but great spontaneity of movement. There are no stereotype feature in this group. (c) The Out-Patient club is sufficiently structured to leave responsibility for all the mechanics of group management to the patients. By virtue of their personal dependence on the leaders the group remains sufficiently flexible to allow therapeutics situations to arise spontaneously and to be easily controlled.
(d) The three groups are closely linked. Their interaction is considered an important factor in treatment.
(3) The Psychiatric Social Worker’s contribution to group therapy has been described:
(a) She is particularly concerned with structure and cohesion of the group as a whole.
(b) She is responsible jointly with the psychiatrist for the creation of social roles for the patient which offer release, satisfaction, and a feeling of achievement.
(c) As an auxiliary to the psychiatrist her task consists in breaking down resistance as another lay member of the group in discussion, psychodrama and sociodrama.
(<d) She presents the possibility of an alternative transference. It was possible to maintain group membership by these means while a negative transference to one therapist developed.
(e) She assists in creating a permissive family atmosphere, the background essential for therapeutic groups.
(/) In the guiding of discussions on social adjustment her special knowledge is used.
Participation in group therapy is of great assistance in psychiatric social work :
{a) The social worker’s participation in group therapy facilitates interpretation of the hospital and of the patient’s illness to his family on admission.
(b) It helps to enrol the active co-operation of the family in the mid treatment stage.
(c) The patient tends to take the initiative in discussion of rehabilitation problems. He applies insight gained during treatment more readily to the solution of his practical difficulties.
(e) On discharge the Social Therapy Club counteracts the stigma of mental illness. Membership of the club provides the necessary positive transference which allows the patient to look upon his illness as an integral part of his life experience.
(/) Patients lacking in insight who normally present a problem in the provision of after care were found to respond well to the facilities provided by the Social Therapy Club.
(g) While it is too early to say for what proportion of patients Social Therapy provides a satisfactory means of after care, it was found that of 42 cases referred in the first 6 months of the establishment of the Club only 8 failed to continue their attendance because of personal difficulties of adjustment.
In looking back over one year’s experience of work in these three groups the writer feels that her participation in group treatment has enriched her concept of psychiatric social work, it has helped her to a better understanding of patients and improved her relationship with them in each case.
She is indebted for the opportunity to take part in this work to Dr T. P. Rees, Director of the Croydon Mental Health Service, and to Dr R. A. Sandison, the psychiatrist in charge of the groups described.
Bibliography
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