GROUP THERAPY WITH SCHIZOPHRENIC AND PSYCHOTIC PATIENTS

    •    In general, the literature supports the value of group therapy for
    patients with schizophrenic and other psychotic conditions (Burlingame,
    McKenzie & Strauss, 2004; Burlingame, Strauss & Joyce, 2013; Kanas,
    1986, 1996).

    •    In controlled studies, both discussion-oriented and cognitive-
    behavioral approaches have been found to be effective (Burlingame,
    McKenzie & Strauss, 2004; Burlingame, Strauss & Joyce, 2013; Kanas
    1986, 1996).

    •    The best approach uses an integrative treatment model that addresses
    the specific needs of psychotic patients (Pearson & Burlingame, 2013;
    Kanas, 1996).

    •    Group goals should focus on helping patients learn ways to cope with
    psychotic symptoms and improve their interpersonal relationships (Kanas,
    1996; Pearson & Burlingame, 2013).

    •    The groups should be safe and supportive and should not deal with 
    issues that produce too much anxiety or negative affect (Kanas, 1986,
    1996).

    •    In managed care outpatient settings that permit only a limited number
    of visits per year, schizophrenic spectrum patients can be treated in a
    series of time-limited, short-term “repeater’s” groups over subsequent
    years (Kanas, 1996).

 Psychotic individuals have difficulty distinguishing reality from fantasy. Some psychotic patients primarily have mood disturbances (e.g., bipolar disorder), medical problems (e.g., thyroid disease), or more transient psychoses due to substances (e.g., stimulants) or personality vulnerabilities (e.g., borderline or schizotypal personalities). When the predominant deficiency is non-medical, chronic, and in the area of thinking, we are speaking of a schizophrenia spectrum disorder, such as schizophrenia itself, schizoaffective disorder, or delusional disorder (American Psychiatric Association, 2013). Such patients experience delusions, hallucinations, disorganized thinking, abnormal motor behavior, or negative symptoms for much of their lives. As a result, they have difficulties with interpersonal relationships, employment, self-care, and general quality of life. Treatment approaches generally have included antipsychotic medications, supportive individual therapy, and various social treatments, such as social skills training, occupational therapy, and family counseling (Kaplan & Sadock, 1989).

Group therapy has been shown to be an effective modality of treatment for patients with schizophrenia spectrum disorder.  In an extensive literature review of controlled studies spanning over 40 years from 1950 to 1991, a total of 46 studies were found where group therapy for schizophrenic patients was compared with a no group therapy control condition (Kanas, 1986,1996). Most of the groups were discussion-oriented and used psychodynamic, psychoeducation, or interpersonal techniques.  Overall, 70 per cent of the studies concluded that schizophrenic patients in the therapy groups did significantly better than their counterparts in the control conditions.  Group therapy was as effective as or more effective than individual therapy in those outpatient studies that made this comparison. There was a trend for long-term inpatient groups to be more effective than short- or intermediate-term groups. Significantly more groups using supportive, interaction-oriented approaches were found to be effective than groups using insight-oriented approaches that emphasized uncovering and psychoanalytic issues, especially in the inpatient setting. 

A more recent review has also supported the value of group therapy for schizophrenic spectrum patients (Burlingame, Strauss & Joyce, 2013). In a previous review from 2004, the authors described a number of studies that tested the efficacy of four group treatment models for schizophrenia: social skills, psychoeducation, cognitive-information processing and cognitive behavioral therapy, and multifamily groups (Burlingame, MacKenzie & Strauss, 2004). Over the next decade, 27 new studies were added to the review.  Overall, the 2013 review found that the group treatments had good to excellent support. Improvements were noted in psychopathological symptoms of schizophrenia (e.g., delusions and hallucinations), although there was also improvement in social and interpersonal functioning. Cognitive-behavioral group therapy was the most frequently used approach and shown to be effective.  The number of psychoeducation and multifamily groups decreased in number as compared with the 2004 sample, and traditional verbal therapies were infrequent in their literature review. The predominance of the cognitive-behavioral model reflects a general trend in recent group therapy research.  Since this approach is usually short-term, manualized, and has definable and easily measurable outcomes, it is especially amenable to research methodology and funding (Peters & Kanas, 2015). 

In terms of group process, it is important that the group goals help patients cope with psychotic symptoms and learn strategies of improving their interpersonal relationships.  Integrative models that serve these two goals by using techniques borrowed from other models are especially effective, whether the approach is more traditionally verbal and discussion-oriented (Kanas, 1996) or uses cognitive-behavioral strategies (Pearson & Burlingame, 2013). In either case, patients should learn ways to sense and test reality; cope with delusions, hallucinations, and disorganized thinking; and relate better with others, either through the discussion or by practicing interpersonal skills in the here-and-now of the sessions.  Psychotic patients do better in groups that are safe and supportive rather than focused on issues triggering anxiety or the expression of strong affect, such as anger between the group members (Kanas, 1986, 1996). Patients need to be manageable and responsive, so severely catatonic patients may not be good group candidates.

Time-limited, short-term groups in the 12-session range have been found to be safe and beneficial for schizophrenic patients using either discussion-oriented or cognitive-behavioral techniques (Kanas, 1986, 1996; Burlingame, Strauss & Joyce, 2013; Pearson & Burlingame, 2013). These groups are especially useful in the managed care outpatient setting where only a fixed number of therapy sessions are permitted per year, since patients can be discharged and re-enrolled in a series of short-term “repeater’s” groups over subsequent years (Kanas, 1996).

   

References

American Psychiatric Association (2013), Schizophrenia spectrum and other psychotic disorders. In Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).  Arlington, VA: American Psychiatric Association, pp. 87-122.        

Burlingame, G.M, Strauss, B. & Joyce, A.S. (2013). Change mechanisms and effectiveness of small group treatments. In M. J. Lambert (Ed.), Bergin & Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Ed. New York: Wiley & Sons, pp. 640-689

Burlingame, G.M., MacKenzie, K.R. & Strauss, B. (2004). Small group treatment: Evidence for effectiveness and mechanisms of change. In M. J. Lambert (Ed.), Bergin & Garfield’s Handbook of Psychotherapy and Behavior Change, 5th Ed. New York: Wiley & Sons, pp. 647-696.

Kanas, N. (1986) Group therapy with schizophrenics: A review of controlled studies. International Journal of Group Psychotherapy 36, 339-351.

Kanas, N. (1996) Group Therapy for Schizophrenic Patients. Washington, DC: American Psychiatric Press.

Kaplan, H.I. & Sadock, B.J. (1989) Comprehensive Textbook of Psychiatry/V.  Baltimore, MD: Williams & Wilkins, pp. 669-815. 647-696.

Pearson, M.J. & Burlingame, G.M. (2013). Interventions for schizophrenia: Integrative approaches to group therapy.  International Journal of Group Psychotherapy 63, 603-608.

Peters, T & Kanas, N (2015). Psychodynamic research in group therapy.  International Journal of Group Psychotherapy, 64, in press. 

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