Group Psychotherapy and Schizophrenia

The following piece on group psychotherapy in the treatment of persons with psychosis by Dr Manuel González de Chavez can be located on the www.isps.org website. I thought this would be of strong interest to many of our US members. I have circulated it to my NYU students.

Brian Koehler

The importance of group psychotherapy in the treatment of schizophrenia

Article by Dr Manuel González de Chavez, ISPS board member and chairman of the organizing committee of ISPS Madrid 2006.

We believe that group psychotherapy should occupy an outstanding site in therapeutic programs and combined therapies used most in schizophrenia, not only because its implementation and viability is easy in any health care system and because its action is synergic with other interventions of combined therapy programs, but also mainly because group psychotherapy has specific uniquenesses with great therapeutic potential that are derived 1) from the therapeutic context created, 2) from the Mirroring phenomenon produced, and 3) and from the therapeutic factors characteristic of group dynamics.

1.-GROUP THERAPEUTIC CONTEXT

Group psychotherapy creates a realistic, equalitarian, safe context that facilitates the patients' independence and therapeutic relationships. An active and productive context that permits the acquiring of an agreed upon reality and better self-knowledge of the patients, that socializes and motivates them, and that becomes a reference group for them.

Group psychotherapy provides persons who have psychotic disorders and similar problems in common an exceptional opportunity not offered by other therapeutic modalities: a site and time and a context where they can mutually know each other, communicate and learn, leave the experience of uniqueness, acquire a more realistic vision of themselves and become aware of their own problems.

Group therapy with adequate management to maintain group cohesiveness and a climate of respect, listening, help and reciprocity also constitutes a safe context to overcome attitudes and behaviors of lack of confidence and defensive isolation. It is an empathic and receptive audience that facilitates self-revelation and more sincere communication.

The group, with its horizontality and neutrality, facilitates the patient's independence. The patient establishes more independent and balanced relationships with the therapists and group members. The group multiples and extends the transferences, correcting idealizations or distortions and facilitates the therapeutic relationships on more realistic bases.

Group psychotherapy also creates an active and productive context that makes cognitive decentering of the patient possible. It is multifocal and has multiple intersubjective relationships, observations, associations, perspectives, contrasts, information and redefinitions. It favors the acquiring of a reality that is more agreed on and better self-knowledge.

Group psychotherapy is socializing and motivating, increases expectation of improvement and stimulates the patients to surmount relapses and demoralizations. The group combats denials, amnesias, self-deceptions, resistances or regression. It promotes the efforts to accept and face difficulties and conflicts and to make the adequate changes and solutions.

Group therapy becomes a reference group that allows the patients to acquire a more dynamic view of themselves, of their own lives and of their progresses in the achievement of their personal objectives. The perspective of the other members of the group is a basic reference in the therapeutic process and in the realistic reconstruction of their own identity.

2) - GROUP MIRRORING

Group mirroring is probably the most specific phenomenon of group psychotherapy. It is that which clearly differentiates group psychotherapy from other psychotherapies and grants it its original therapeutic potential.

Group mirroring is the intersubjective process of multiple mirroring, multidiadic, simultaneous, reciprocal and emphatic reactions of observation, examination, revelation, reflection and mutual knowledge between group members.

It unblocks the difficulties to achieve insight. It promotes and accelerates self-knowledge of the patients, exploiting their capacities of observing and knowing others, even when they are not capable of observing and knowing themselves.

Each patient is a mirror for the others and the group members are mirrors for the patient. Each patient sees him/herself in others. Or he/she sees parts of him/herself reflected in the others. Each one shows themselves to the others and sees themselves in the others, reflects and is reflected in the group, reflects on the others and themselves.

The patients can see their own reactions and behaviors in others, know themselves through the others. They can see the effect of their behavior in the group. Each patient knows the images of themselves that the group members return to them. They see themselves from outside, with other eyes, other points of views and perspectives. Each patient benefits from the insight of others on him/her and begins to know himself/herself through the others. He/she confronts, questions, validates, confirms or rectifies with the others, with whom he/she reconstructs and redefines him/herself.

Mirroring favors cognitive decentering and mutual validation of reality, first in the others and then in oneself. The patient separates the psychotically undifferentiated duality of the objective and subjective realities of each one.

3). GROUP THERAPEUTIC FACTORS

The group therapeutic factors are basic or elemental components of the change phenomenon of the group therapy. The action of these mechanisms is not isolated, but combined in each group process stage.

Among the group therapeutic factors, the following can be distinguished: 1. support factors such as acceptation, cohesiveness, universality, hope and altruism; 2. self-revelation factors such as emotional catharsis and verbal self-revelation; 3. learning factors of other group members, such as imitation, identification, advice, information or education, and vicarious learning and finally 4.-insight factors, such as self-knowledge and interpersonal learning.

Some therapeutic factors are specific to group therapy, such as interpersonal learning, universality, cohesiveness and altruism, however, all the therapeutic factors are qualitatively different to the similar ones in other therapeutic modalities, because here they are horizontally multiplied and reciprocally potentiated.

The universality breaks the patient's isolation and feeling of uniqueness. The group cohesiveness facilitates identification and revelations of the psychotic and biographic experiences. Validation of the objective and subjective realities in each group member leads to acceptation and awareness of the disorder and makes the interpersonal learning and insight possible.

SOME ADVANTAGES OF GROUP PSYCHOTHERAPY IN THE TREATMENT OF SCHIZOPHRENIA

1.  The patient may desingularize or lose sense of uniqueness. He/she may know and communicate with other persons who have lived or are living similar experiences or disorders, in an egalitarian and safe setting, without mistrust, or fears about being discredited, but with attention, being listened to and respect. The patient may abandon the defensive withdrawal and the psychotic world, beginning to see reality from outside his/her perceptive egocentrism.

2.  The group functions by comparing and questioning the psychotic identities and blocking the development of delusional convictions or beliefs in the past “truth’s” veracity of the psychotic experiences lived.

3.  He/she may validate the objective reality and subjective experiences of each group member with agreement and question his/her subjective character of his/her psychotic experiences, accepting his/her psychopathological disorders and personal and biographical difficulties.

4.  He/she establishes therapeutic relationship more rapidly, with more confidence in a professional team, and can reveal his/her experiences to face and overcome them. The patient also has a reference group in the other group psychotherapy members, which provides him/her with a more objective vision of him/herself and of his/her progresses in the recovery process.

5.  The group is a socializing, motivating and altruistic support that permits the subject to analyze, approach and improve his/her problems in the interpersonal and familial relationships. Finally, the group helps the subject to fight against depression, demoralization and stigma and to achieve or continue a project of possible and realistic life.