Book review: Group Therapy for Psychoses

Urlić and González de Chávez Eds. Group Therapy for Psychoses (Routledge 2019)

Looking back at my NHS experience in the UK, I was privileged to have worked at a time and place where it was encouraged and expected to work with unwell psychotic patients in an eclectic manner, combining psychodynamic and group approaches to conventional psychiatric care in one of the few hospitals adopting therapeutic community philosophies (Claybury Hospital, now no longer in existence). Sadly, it is now rare in the NHS to find teams prepared to offer psychological groups to patients with psychotic presentations, mainly due to pressure on services, scarce opportunities to train staff in psychodynamic understanding of their patients , and the mistaken belief that offering groups is a waste of time and effort. Certainly this was not my impression, as I found that having groups of this nature in acute wards had a profound effect on the prevailing atmosphere of the unit, as well as reducing the needs for unnecessarily high levels of medication, and engaging users to gain some mastery over their symptoms and distress. (Fagin, 2001)

So it was with pleasure I was asked to review this collection of contributions from various enthusiastic  clinicians who are not only keeping the therapeutic flame alive, but are also systematically reflecting on how psychotherapeutic groups can enhance recovery in patients suffering from psychosis. They describe groups taking place in various settings (acute general psychiatric wards, forensic units, out-patients, community services) with diverse therapeutic models, although psychodynamic and group analytic approaches predominate. They explore with realistic aplomb the requirements that need to be put in place for such efforts to have a measurable impact: adequate training of staff, support from the institution, incorporation of evaluative measures, timing and pace of interventions at different stages of the user’s illness, and possible contra-indications.

Albeit with some exceptions, (to be expected in multi-authored collections) the accounts do not rely on dogmatic theoretical pre-conceptions and challenge prevailing resistance to work psychotherapeutically with users.

I found the conceptualisation proffered by the Spanish group (Cabezas, González de Chávez) to be particularly helpful, highlighting support factors (hope, universality – especially desingularisation -, altruism and acceptance), self-disclosure (catharsis, communicating feelings), learning factors (education, information, modelling, imitation, identification, advice), psychological work (self-understanding, interpersonal learning and insight, feedback, cohesion and safe climate). Underlined are those factors most valued in patients with psychotic symptoms, especially those with a worse prognosis. Self understanding-mediated by the interaction with others- was valued more in out-patient groups, especially when there was a degree of insight, high ego functioning, better prognosis and long-duration groups. However, the conclusion is that all these factors act synergistically, prompting each other, making the group a therapeutic tool in itself. They attempt an understanding of how and why these groups work and provide ground rules for in-patient and out-patient groups, emphasizing the need for training of staff, supervision, screening and evaluation. In terms of the role of the therapist or mediator the authors suggest they should lead the group from questioning the reality of the experience to accepting their subjective character, this objective is the  ’, and facilitates members to question how they came to believe in this subjective reality, experience it in a different way to others. The group moves from the seeking of veracity to causality.

The Croatian group (Urlić et al) puts forward suggestions on how to improve the therapeutic alliance between psychiatric staff and patients on admission wards with support of the institution – unfortunately this is difficult to achieve in the UK, for a combination of various factors – rapid discharges, chaotic ambience on the wards, poor training of personnel, forceful practices, staff pressures and movements, importation of illicit drugs, among some of the factors (Fagin , 2010). Illustrative vignettes give a flavour of interventions in various chapters, focusing on how users benefit from sharing their experiences and learn from each other, confronting isolation and stigma, and taking on board the impact of intimacy, trust, and sexuality in these encounters.

Different group settings  are also described, such as therapeutic communities, early intervention services, forensic units as well as different models, including  psycho-education, multi-family,  CBT, creative arts , hearing voices, peer-led and self-help groups, not ignoring the contextual and political issues such as the impact of wars or migration on people who experience psychotic symptoms, all contributing to a panoply of possible interventions which should whet the appetite of readers and practitioners  who wish to embark in the effort of offering a range of services that can flexibly meet the needs of a long suffering, and often neglected community. My experience is that younger clinicians are thirsting for approaches that maintain a human, sensitive contact with psychotic patients and develop their understanding of the underlying psychosocial foundations of their distress.

References

FAGIN, L. (2001) ‘Therapeutic and countertherapeutic factors in acute ward settings’. Psychoanalytic Psychotherapy, 15, 2, 99-120.

FAGIN, L. (2010) ‘Is it possible to make acute wards into therapeutic communities?’ In Radcliffe J, Hajek K, Carson J, Manor O (Eds.), Psychological Work with Acute Psychiatric Inpatients (Whiting & Birch, London).

Leonard Fagin