When it comes to psychotherapy, the coin of the realm in our hospital is group treatment. If there’s a human malady or body of knowledge associated in any way with mental illness, we have a group where it can be discussed, taught, explored, contemplated in respectful silence or ignored. In bigger groups all of these things can happen at the same time.
Someone opens the discussion about how to handle the stigma of mental illness and a few people share their personal experiences and ideas on the topic. Others sit quietly, some following the speakers with their eyes, a few taking notes and one or two others struggling to stay awake. Or there is no response at all. As a therapist who by training and inclination is most at home in the individual encounter, I am always challenged by the complexity of group dynamics, fascinated by the process and not infrequently surprised by what gets said.
Sometimes I am not sure how we get from here to there. While it’s happening you can follow the links and it makes sense. A recent discussion of stigma, for example, started with the ways people with mental illness feel discounted by others and ended with our usually reserved bunch laughing about their elementary school teachers’ classic methods of discipline and their own ingenious efforts to subvert them. The sequence moved from discrimination against the mentally ill to an observation that there are people in the community who act less responsibly than many who are hospitalized. Was this because of an undiagnosed mental illness as someone suggested or were there other factors at work? Perhaps the problem was a failure of discipline. Mention of discipline provoked at least one voice of protest against the use of what the speaker could only imagine as harsh punishment to shape good behavior. But discipline can be kind as well as cruel and self-discipline can be the cornerstone of a well-ordered life.
The group process doesn’t always work this way. A group often moves like a new driver behind the wheel of a standard shift, lurching forward, stalling and then repeating the sequence until he has achieved fluid movement that continues for the length of the journey or comes to a jarring halt at every stop sign or traffic light. Then we sit in silence to start again when someone thinks out loud or responds to a question cast into the room by one of the group leaders.
Questions like this are readily available especially in groups where there is information to be taught about a specific topic related to recovery. In our Relapse Prevention Group, for example, we can ask if anyone can define the concept of trigger or give some examples of early warning signs of relapse. In this way, we can work our way through the different sections of a relapse prevention plan outlined on the white board, hoping to generate disclosure, discussion and the sharing of experiences and coping strategies that group members have found useful.
Sometimes the challenges are practical matters and the suggestions offered involve a simple but effective sharing of information. A group member who is ready for discharge expresses frustration about being stuck in the hospital because he can’t find an apartment and someone with experience in real estate suggests a Web site where he can find up-to-date, affordable listings.
Discussing challenges to recovery that involve managing behavior, emotions and relationships requires a deeper level of trust that, for most people, comes only gradually as the group develops a sense of cohesiveness over time. Yet time alone is not enough in an open group when patients who are transferred to different units are suddenly assigned to different groups and new faces take their places around the table. By limiting this practice of re-assignment, we have been able to stabilize group membership and develop a core group of participants. In this setting, someone may take the risk of sharing more personal issues and that disclosure may embolden another group member to offer validation, support, or a similar level of disclosure around a related issue.
Through this process, we sometimes hear about troubled family relationships, betrayals of trust by friends and encounters with the police and courts that resulted in what the speaker experiences as an unjustified hospitalization.
As the weeks turn into months, the group process develops in fits and starts, through silences and bursts of speech, and in the discussion of everyday annoyances, common challenges and intensely personal experiences. How can I convince my treatment team that I am ready for discharge or my doctor that he has prescribed too much or the wrong kind of medication? What does it mean to be incompetent to stand trial? What is a delusion and how can I tell if I have one? When will my family ever learn to take me and my opinions seriously? For group members, this is the stuff of real life. Some of the issues are specific to real life on a locked hospital unit; some are common to real life with a mental illness in any setting, and others speak simply to our shared human lot.
Alan Bodnar is a psychologist at the Worcester Recovery Center and Hospital.
By Alan Bodnar Ph.D.