Group Therapy for Adults with Severe Mental Illness

Adapting the Tavistock method

Diana Semmelhack, Larry Ende, Clive Hazell

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135084998
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Mental illness is prevalent in society with a quarter of individuals having a diagnosable mental illness. A growing percentage of these individuals develop severe disorders which incapacitate them and may leave them unemployed, lonely, isolated and untreated. In recent years, there has been a movement away from therapy, and a heightened emphasis on medicalization. This book argues that medication alone does not take away the deep emotional pain of feeling isolated and lonely, and considers the modification of the client's social relationships as a critical ingredient in any treatment.

Group Therapy for Adults with Severe Mental Illness explores a non-traditional application of treatment known as the group-as-a-whole model. This approach to group work derives from the Tavistock tradition, in which emphasis on the whole group versus any specific member makes the group a safe place to risk sharing and confronting painful issues. This text highlights the efficacy of utilizing this model in the treatment of severely mentally ill consumers in various settings including jails, nursing homes and group homes.

Included in the book:

-case studies using the Tavistock method
-the power of group-as-a-whole work in educating mental health professionals and graduate students
-the use of the model to enhance creative expression in the arts
-the use of the model to understand larger social systems

This text will be of value to mental health professionals, researchers and educators interested in the treatment of severely mentally ill populations in institutional settings, and individuals with a specific interest in group psychotherapy.

Chapter 1

Introduction

Much Madness is divinest Sense –
To a discerning Eye –
Much Sense – the starkest Madness –
’Tis the Majority –
In this, as all, prevail –
Assent – and you are sane –
Demur – you're straightway dangerous –
And handled with a Chain

Emily Dickinson

There are many books on group therapy, highlighting an array of models, including the cognitive behavioral, the interpersonal, and the psycho-educational. Contemporary theorists, however, do not tend to discuss Tavistock group work, at least in its use as therapy. What is more, Tavistock (group-as-a-whole) work, though it has many devoted adherents, has traditionally involved only conference work, mainly including mental health professionals, with some representatives from business and government (Rice, 1965; Rioch, 1970b). It is as if the work is suited only for a select few who can weather its rigors. Many assume that psychological work which, like the Tavistock approach, uncovers the unconscious, especially the powerful unconscious forces of the group mentality, can only be handled by the “worried well.” We believe, however, that the Tavistock method can be adapted to benefit clients in a wide variety of situations. We argue here that a modification of the method can produce significant therapeutic results with people in institutions who have severe mental illness. Malawista and Malawista (1988) have written an article that supports this conclusion, while adapting the method in a somewhat different manner than our research team. In addition, Schermer and Pines point out that Resnik (1994), Skolnick (1994), and other therapists “work with group-as-a-whole issues and interpretations” with clients who have severe mental illness (1999: 30). (The authors note that these therapists have extensive training in psychoanalysis and group-as-a-whole work.)

We support the proposition that Tavistock work can help these clients using studies we carried out in group homes, nursing homes, and a county jail. Unlike earlier work on the topic, this book presents empirical studies to support its conclusions. Our research team conducted these studies in group homes and nursing homes. Two chapters present our argument using case studies. These studies suggest as well something of the flavor of Tavistock work in institutions with clients who have severe mental illness.

Clients with severe mental illness have many needs, but our society provides meager resources for meeting them. We need to make available new treatment options. We believe that a modified Tavistock approach can help to meet these clients’ needs in a cost-effective manner. The approach can be used to treat many problems. Our studies emphasize the use of the Tavistock method to treat anxiety and depression and to increase group cohesiveness. We also show how the method addresses the pervasive need of these clients for intimacy, connection, and meaning.

Many people believe that the environment of a Tavistock group does not offer sufficient support for work with clients who have severe mental illness. Our modifications of the method, however, to be discussed further on, place increased emphasis on interpersonal connection within the group. The group needs to be experienced as a safe place, one where members with severe mental illness feel encouraged to engage in authentic expression (Malawista and Malawista, 1988; Schermer and Pines, 1994).

Increasingly, the US places individuals with severe mental illness in nursing homes. Several of the groups we studied took place in this context. Nursing homes have been designed for people unable to care for themselves. They emphasize routine activities, such as meals, hygiene, and medication management (Jervis, 2002; Townsend, 1962). These environments can be harsh and alienating. They can increase rather than decrease the emotional needs of residents with severe mental illness. For such a resident, the highlights of the day may consist in stepping outside every few hours to smoke a cigarette. Residents may be focused on such matters as how to borrow change in order to buy a pop. Perhaps they spend much of the day watching TV and lying in bed, depressed and waiting in vain for a visit from relatives. They suffer from isolation, yet share a room with one or two others and have little privacy. Typically, they have few treatment options besides medication management. These environments tend to depersonalize and dehumanize residents. The environments practically cultivate a severe state of need.

Residents of nursing homes who have severe mental illness have endless potential for living more gratifying lives, but they need assistance. They need substantial, effective psychosocial intervention. A modified Tavistock group can introduce a more humane influence into a harsh institutional environment. Tavistock work improves members’ ability to interact with each other in meaningful ways. It does this by addressing the unconscious forces that affect group behavior. Members become more sensitive to each other as they become more sensitive to group dynamics. They become more sensitive to both conscious and unconscious group dynamics. A group “consultant” interprets events in terms of the group-as-a-whole as they occur in the here and now. Members explore group dynamics as they take place. Group-as-a-whole work appears to improve group cohesiveness. Group cohesiveness, strongly linked with a group's therapeutic impact (Yalom and Leszcz, 2005), helps to counter institutional life's tendency to make residents feel isolated. (Chapter 4 explores the Tavistock method's effect on group cohesiveness.) The group provides an alternative to the general institutional environment. Members in time come to internalize the group as a new object. This can increase trust, peace of mind, and self-esteem, as well as the ability to connect with others.

Nursing homes typically offer residents with severe mental illness very limited opportunities – or assistance – for cultivating intimacy (Jervis, 2002). Yet the absence of positive relationships makes up one of the most crucial components of mental illness. “The schizophrenic disorder,” says Skolnick, “has as one of its most prominent features the estrangement of the inner world of the self from the social world of others” (1998: 69). This applies to most clients with severe mental illness. On a related note, Yalom states, “Most psychiatric patients have an impoverished group history; never before have they been a valuable, integral, participating member of a group” (1985: 51). Individuals’ severe mental illness develops in intricate connection with their group; its treatment needs to help them reconfigure their relationships with groups. Concluding his discussion of the treatment of schizophrenia, Skolnick says, “I have tried to make the case that an understanding group dynamics and enabling the schizophrenic to rejoin the group as an emotionally alive contributing person… is essential to all meaningful treatment” (1998: 82).

The nursing home treatment orientation, however, rarely helps clients to explore the impact of isolation on their psychological well-being, or their need for positive relationships. Many nursing home staff believe in the inevitability of resident isolation. This becomes a self-fulfilling prophecy. A Tavistock group can interrupt this cycle and help to foster new kinds of relationships.

Group-as-a-whole work can also help nursing homes respond to the vast untreated trauma in these facilities. It is an astonishing reality how many mentally ill nursing home residents have been abused or neglected. Studies consistently show a 50–80 percent prevalence rate of physical and sexual abuse among individuals who later acquire a diagnosis of mental illness (Hopper, 2003; Stefan, 1996). According to Briere (2004), 35–70 percent of institutionalized female mental health clients have sexual abuse histories. Mental health nursing home staff often ignore these histories. Trauma based on abuse and neglect requires treatment other than medication management. Chapters 2 and 6 illustrate ways that group-as-a-whole work can help to address trauma.

How Tavistock groups work

Tavistock groups emphasize a group-as-a-whole approach to psychotherapy. The consultant makes interpretations that, first, are directed to the dynamics of the whole group and, second, reflect processes operating in the group in the here and now that seem to be outside of the group's current awareness. Tavistock theory uses the term “consultant” because the individual in this role consults to the group rather than leads it. The consultant's interactions with the members focus on making interpretations. These interpretations frequently respond to the group's relation to its essential task: examining its own dynamics in the here and now (Banet and Hayden, 1977; Rice, 1965).

Addressing processes operating outside the group's awareness, the Tavistock approach often makes use of psychodynamic theory. The work does not prescribe the exact nature of this theory, but one quite frequently finds elements of traditional and object relations theory in Tavistock consultations.

Consider an example consultation. A consultant operating in the Tavistock tradition might perceive a group that discusses travel, vacations, and far-away destinations as possibly avoiding the task. A group-as-a-whole interpretation might be, “This group feels anxious about addressing something in the room and wishes to move far away from it.” In this case, the focus of members’ comments on events outside the group's process alerts the consultant to the group's flight from its task. The consultant's interpretation aims to bring the focus back to the dynamics emerging in the here and now. Sometimes, a group yokes its task to another one. This might involve examining interpersonal relationships, gender roles, authority relations, addictions (Roth, 2004), and so on.

As groups engage with these tasks, difficulties emerge. Interpretations may present these as resistances to the group work. Frequently, a complex of fantasies, often related to power and authority, impede collaboration between the members and the consultant. Consultations often consider these ideas as they operate in the group. For example, the group might launch a veiled attack on the consultant's authority by talking about the nursing staff's inability to meet patients’ needs. A consultant might say, “The group feels angry at this consultant for not adequately meeting their emotional needs in the here and now.” Tavistock work pays close attention to boundaries. It especially examines boundaries of role, person, time, space, and task. Consultations frequently address boundary issues.

Members experience the group-as-a-whole in terms of a range of positive and negative qualities (Greene, 1999). They may unconsciously experience the group, for example, as a “good mother.” The group may have protective and holding abilities (Scheidlinger, 1974). Members may also unconsciously experience the group as a “bad mother.” This figure can alienate or annihilate an individual (Agazarian, 1989). In the literature, writers describe in detail these opposite experiences based on projections. Other group processes examined serve defensive or work-avoidant needs (Bigelow, 1998). Bion (1961) explored how members’ anxiety often leads to patterns of unquestioned dependency (for example, on the consultant), fight–flight, or delegation of a strict, turn-taking exchange of ideas (Rioch, 1970a). Consultants need to address such patterns to shift the group toward less defensive, more task-oriented behavior (Ettin, 1992; Yalom and Leszcz, 2005).

In attempting to deal with anxiety, groups can form us-versus-them, or in-versus-out polarities. Members here disown aspects of themselves and project them into another part of the group, or into an external group (Agazarian, 1997). These externalizations typically serve as defenses. They can undermine a group's ability to fulfill its task. Consultants need to address unconscious splitting (for example, into us and them) and externalizing.

Members split off unwanted parts of themselves and project them into the group. The group in turn (unconsciously) projects these unwanted parts into particular members, who serve as scapegoats. Consultant interpretations encourage members to own their projections, take them back in, and process them. This promotes insight for members and discourages scapegoating.

The consultant's approach to interpreting group dynamics stresses how members interconnect. This reduces scapegoating during discussions of controversial subjects. In addition, the approach helps to create a holding environment, an emotionally safe environment that encourages clients to share and face painful issues (Malawista and Malawista, 1988).

Members in time develop skills in observing and working with the group's dynamics. They become what Bion called a “sophisticated” group, or what in the US Tavistock users call a “working” group (Bion, 1961). A working group is a place of considerable psychological safety. In such a group, members make therapeutic gains by examining roles they typically play in groups and considering the usefulness of changing these roles (Bollas, 1987; Ganzerain, 1989).

Finally, in this safe environment, group members explore issues of personal history (as these issues relate to the group-as-a-whole), interpersonal relatedness, and transference, especially as they occur in the here and now. Group-as-a-whole analysis reduces the likelihood that a member can be used as a container for the group's disavowed anxieties, because its focus is on the whole group versus any member's individual process. As a result, the group becomes a safer place in which to take a risk in sharing or confronting. Members feel safer that they will not end up as the repository for emotions the group is unwilling to work with. The group's ability to accept, own, and process its emotions continues to develop (Hazell, 2005; Resnik, 1994).

Tavistock work with clients who have severe mental illness engenders a high level of respect for them. This promotes their ability to function in the group. The respect derives from the assumption, absent from much work with these clients, that they are able to respond thoughtfully to deep issues. Tavistock work provides intellectual stimulation both for clients and staff. It cultivates an attitude of receptivity toward the clients. Since the environments the clients live in tend to have little receptivity toward them, the receptivity of the Tavistock group provides an important benefit for them.

Training to become a Tavistock consultant is available through the A.K. Rice Institute for the Study of Social Systems. The trainee is assigned an experienced consultant member and engages in a variety of personalized learning experiences, including the attendance of conferences. The individualization of the training program allows for great flexibility in terms of where the training takes place.

Issues in research

A review of group psychotherapy literature suggests that since the 1960s, research has deemphasized analytic group work with institutionalized populations (Kapur et al., 1986). Many researchers have deemed the analysis of transference issues and in-depth emotional material to be largely inappropriate and impractical. Group psychotherapists in institutional settings emphasize active problem solving and psycho-educational techniques.

Many therapists particularly object to the use of group-as-a-whole work with clients who have severe mental illness. According to Schermer and Pines (1999), the majority of therapists believe that group-as-a-whole interpretations alienate clients with psychosis. The therapists believe that these interpretations “interfere with the crucial and fragile one-to-one connection to the therapist as a benign parental figure” (Schermer and Pines, 1999: 30). In addition, they believe that group-as-a-whole interpretations may evoke in these clients the experience of a “delusionally persecutory object” (Schermer and Pines, 1999: 30). Yet some therapists, including Resnick and Skolnick, do use these interpretations with psychotic clients. These therapists appear to bring about a holding environment that enables clients with psychosis to respond to the difficult ideas and experiences encountered in group-as-a-whole work (Schermer and Pines, 1999).

Malawista and Malawista (1988) have described in some detail how they modify the Tavistock method in order to use it with clients who have severe mental illness. Most therapists, these researchers point out, believe that psychotic clients cannot handle group therapy unless the therapist actively supports them and uses a structured group. Kanas says that the therapist needs to provide advice, and that “insight-oriented techniques may [do] harm… and should be avoided” (1986: 114). Malawista and Malawista (1988), however, say that a modified group-as-a-whole format can enable these clients to experience the therapist as supportive.

Malawista and Malawista (1988) describe an influential 1976 study suggesting that group-as-a-whole therapy could be harmful to clients with severe mental illness. Malan et al. (1976) conducted a study of 42 non-psychotic clients who had received group-as-a-whole therapy. The study took place 2–14 years after the group therapy ended. This therapy was modeled after the work of Ezriel, who was considered an exemplary practitioner of group-as-a-whole work. In Ezriel's model, interventions consist only of here-and-now interpretations of the transference to the therapist created by the group-as-a-whole. The clients in the study, it was determined, found the therapy experience to be depriving and frustrating. They also viewed the therapist as uncaring.

Malawista and Malawista (1988) suggest that this study demonstrates not the harmfulness of the group-as-a-whole approach, but the danger of a Tavistock approach that focuses only on interpreting group-as-a-whole transferences to the therapist. Hume (2010) makes a related point, saying that group therapists at the Tavistock Clinic, while they rely on the work of Bion, have found that if they make only group interpretations, the members may feel abandoned or neglected. Malawista and Malawista go further, believing that group members’ subjective experience needs to take precedence over the group-as-a-whole process. These researchers base their approach on Horwitz’ “inductive paradigm” (even though it was not designed for work with severely mentally ill clients). The paradigm asserts that:

A member's contribution should first be dealt with and responded to in terms of his individual, idiosyncratic, characterological features. As the contributions increase… the therapist may generalize from the individual instances and formulate comments of a group-wide nature. Usually these interventions will stimulate other members to respond with their dominant affective reactions, ...

Table of contents

• Front Cover
• Group Therapy for Adults with Severe Mental Illness
• Advances in Mental Health Research series
• Title Page
• Copyright
• Dedication
• Contents
• List of figures
• Foreword
• Preface
• Acknowledgments
• 1 Introduction
• PART 1 Demonstration of group-as-a-whole work
• PART 2 Empirical studies of group-as-a-whole work
• PART 3 Connecting group-as-a-whole work to other fields
• PART 4 Applying group-as-a-whole work to the community
• Bibliography
• Index