A Way to the Soul of the Mentally ill by Gertrude Schwing

Abstract

Despite the skepticism and indifference to group psychotherapy that existed in the 1950s and 1960s within the psychoanalytic community in general and among the staff and administration of the Menninger Clinic in Topeka, Kansas in particular, a few clinicians there forged ahead in pursuit of incorporating this modality as an accepted treatment. After gaining some acceptance first in the hospital, we experienced a slow rate of growth, except with our trainees who were generally enthusiastic about group work. Many of them were intrigued first by their exposure to the group dynamics seminars and later by the didactic courses and supervised group work that eventually came to be required by the accrediting body for residency programs of the American Psychiatric Association. Visiting senior consultants and teachers, mainly associated with the American Group Psychotherapy Association, as well as an esteemed clinician from the Tavistock Clinic, also lent credibility and legitimacy to our effort. When group treatment began to be adopted by units of the Menninger Hospital in the early 1970s, there was a significant sea change in the attitude of the organization and group psychotherapy became a well established modality.     

My life in testing

This autobiographical essay describes my career as a psychodiagnostician, which began at the City College of New York in 1941 and ended in the late 1970s when I became a full-time psychoanalyst in Manhattan. As a green, 20-year-old psychology undergraduate, I was picked by Gardner Murphy to assist David Rapaport at the Menninger Clinic in Topeka, Kansas, who was developing new methods for using psychological tests to diagnose and treat soldiers during World War II. Our findings were presented in the classic, two volume work, Diagnostic Psychological Testing, published in 1945-1946 (Rapaport, Gill, & Schafer, 1945-1946; 1968), to which I added two clinically enriched monographs: The Clinical Application of Psychological Tests, published in 1948 (Schafer, 1948/1995), and Psychoanalytic Interpretation in Rorschach Testing (Schafer, 1954), published in 1954. After the Menninger Clinic, I continued to hone my assessment expertise at the Austen Riggs Center and Yale University, but I also sought opportunities to develop psychotherapy skills. I completed psychoanalytic training in 1960 at the Western New England Institute for Psychoanalysis and thereafter sought positions that would offer more time for treating patients. A notable highpoint in my testing career was assessing Jack Ruby, killer of Lee Harvey Oswald. I look back fondly at my years as an assessment psychologist, which produced nearly 4 decades of great memories.     

Dynamically oriented group therapy with alcoholics: Making it work despite the prevailing bias

A bias exists in the psychiatric community against dynamically oriented group therapy with alcoholics. The basis for this bias lies primarily in negative experiences of practitioners who have attempted to use traditional therapy with alcoholic patients who continued to drink. At Appleton Outpatient Clinic, we have found that dynamically oriented group therapy is a highly suitable treatment modality for alcoholic patients when negative biases of treators can be addressed and when initial preparatory work is done with patients. This preparatory work includes: (a) building a working alliance around abstinence and providing adequate supports to make this possible; (b) explicit contracting that establishes clear treatment goals and consequences should the goals not be met; (c) preparatory short-termgroup experiences.This paper was presented at the 1988 annual meeting of the American Group Psychotherapy Association.     

Homogeneous group therapy of borderline personality disorder

The authors maintained a time-limited, diagnostically homogeneous psychotherapy group of borderline patients for one year. The group progressed through prototypical stages of group development, but each phase was marked by variations of the aggressive drive and defenses against aggression that are characteristic of this disorder. The group provided a well-suited forum for the exploration of suicidal and homicidal impulses and the development of an observing ego. Despite the limits on generalizability from this group, it appears that group psychotherapy can be a valuable adjunctive modality for some borderline patients.Paper presented at the American Psychiatric Association Conference, Montreal, May, 1988.     

On Preserving a Legacy: Paul Lerner and the Menninger Rorschach Tradition

Paul Lerner's contributions to the Rorschach test were rooted in a psychoanalytic approach to diagnostic testing that began with David Rapaport at the Menninger Clinic in the 1940s. This article reviews the work of Rapaport, Roy Schafer, and their heirs and shows how Lerner's career was devoted to advancing that tradition and assuring its continuing relevance.     

Concurrent individual and individual-in-a-group psychoanalytic psychotherapy

This paper's thesis is that concurrent individual-in-a-group and individual psychoanalytic psychotherapy can be conducted in conformance with psychoanalytic principles of treatment as well as can individual psychoanalytic psychotherapy alone. American psychoanalysts have shown little interest in group psychotherapy, probably because of earlier criticism that transference is diluted by the greater reality of the therapist in group psychotherapy. This is a misconception extrapolated from the mirror model of dyadic analytic technique. The criticism was formulated during a period when that model was prominent and there was little awareness that the actual personal relationship between patient and analyst played an important facilitating role in the dyadic analytic process, including providing a basis for investiture of transference. Also, the criticism was based on one-session-per-week group psychotherapy, whereas concurrent individual-in-a-group and individual psychoanalytic psychotherapy utilizes two group sessions plus one or two individual sessions per week, enabling a more intensive patient-therapist relationship. Concurrent group and individual psychoanalytic psychotherapy constitutes a contribution to the widening scope of application of psychoanalytic treatment.     

AGAINST RECORDING SESSIONS FOR SUPERVISION

The American Psychological Association’s (APA) 2014 injunction that supervisors must listen to recorded sessions of their supervisees’ work is based on a rich and thorough body of research, and yet it entails a narrative of psychotherapy as a discipline of Science. If psychotherapy is understood as an endeavor also of the Humanities, recording sessions may be anathematic to supervision and training. Developing ideas from Greenberg’s (2015) theory of “controlling fiction,” the writer presents a narrative of psychotherapy in which it is not wise to review recorded sessions in supervision.

     

Psychotherapy: Definitions, Mechanisms of Action, and Relationship to Etiological Models

In this paper, we define psychotherapy as a modality of treatment in which the therapist and patient(s) work together to ameliorate psychopathologic conditions and functional impairment through focus on the therapeutic relationship; the patient's attitudes, thoughts, affect, and behavior; and social context and development. The possible mechanisms of action and active ingredients of psychotherapy in children and adolescents are discussed, with an emphasis on the above-noted domains. The adult psychotherapy literature strongly supports the central roles of the therapeutic relationship and therapeutic empathy; this has been much less intensively explored in the child and adolescent psychotherapy literature. Similarly, there have been few studies examining the mediation of treatment effects by impact on specific domains. Ideally, treatment studies should gather data that can be informative about the impact of putative mediating and moderating psychosocial and biological variables on outcome and course. The results of such studies can aid further refinements in both theories of etiology and improvement in treatments for children and adolescents.     

Transference focused psychotherapy: overview and update

This paper describes a specific psychoanalytic psychotherapy for patients with severe personality disorders, its technical approach and specific research projects establishing empirical evidence supporting its efficacy. This treatment derives from the findings of the Menninger Foundation Psychotherapy Research project, and applies a model of contemporary psychoanalytic object relations theory as its theoretical foundation. The paper differentiates this treatment from alternative psychoanalytic approaches, including other types of psychoanalytic psychotherapy as well as standard psychoanalysis, and from three alternative non-analytical treatments prevalent in the treatment of borderline patients, namely, dialectic behavior therapy, supportive psychotherapy based on psychoanalytic theory, and schema focused therapy. It concludes with indications and contraindications to this particular therapeutic approach derived from the clinical experience that evolved in the course of the sequence of research projects leading to the empirical establishment of its efficacy.     

The Hispanic Female Adolescent: A Group Therapy Model

This essay serves as an introduction to a collection of articles on group psychotherapy for children that appears in the following pages. These articles are an outgrowth of a symposium on children's group treatments presented at the 1990 Annual Conference of the American Group Psychotherapy Association. The present author provides a general overview of relevant literature and offers an orientation to the subsequent theoretical and practical integrations.     

Ethical and Legal Issues Addressing the Use of Mobile Health (mHealth) as an Adjunct to Psychotherapy

mHealth refers to the rapidly evolving use of mobile devices for health care treatment purposes, particularly the use of apps and texting as adjuncts to psychotherapy. Although there is currently an extensive literature on issues related to telehealth, to date little guidance has been developed to help professionals function ethically in the rapidly emerging area of mHealth. This article identifies the major ethical considerations that need attention and proposes several recommendations to address mHealth use as an adjunct to psychotherapy, including the pressing need for relevant American Psychological Association practice guidelines to assist mental health providers in the ethical implementation of mHealth.     

Individual psychotherapy as an adjunct to group psychotherapy

This paper describes a form of combined psychotherapy in which the individual sessions are used as an adjunct to group therapy. Each group member is seen regularly in individual sessions to focus primarily on the member's ongoing group work. The individual sessions are scheduled on a rotating basis. Typically, each group member is seen in an individual session once every four weeks. Additional individual sessions are available only when immediate attention is appropriate and necessary. The group is viewed as the primary therapeutic component. A cost-effective therapeutic approach that uses both individual and group methods, this modality lends itself well to a clinic and to a private practice setting.     

Confidentiality and privileged communication in group psychotherapy

The concept of confidentiality is fundamental to all forms of psychotherapy. The idea of protecting confidential material goes as far back as the Hippocratic Oath in ancient Greek history. Centuries later, authors continue to assert that "only by maintaining confidentiality can the essential groundwork of trust in treatment be developed" (Hough, 1992, p. 106). Others have even argued that without confidentiality, psychotherapy has no value (Epstein, Steingarten, Weinstein, & Nashel, 1977). Confidentiality in group psychotherapy is more complicated than in individual therapy because self-disclosure is at the core of group therapy and there are numerous people hearing the disclosures. Confidentiality in group therapy, once ignored in the literature on ethics, is gaining more attention as this modality becomes more widely practiced; so too is an acknowledgement that ethical dilemmas surrounding confidentiality in groups are commonplace. This article discusses the major considerations and dilemmas on confidentiality in group psychotherapy. We first review confidentiality broadly and discuss the ethical principles that are related to confidentiality. In the next section, we discuss the complexities of confidentiality in group psychotherapy. Finally, we review research on confidentiality in groups and describe common ethical dilemmas.     

The Lonely Crowd: A Study of Changing American Character by David Riesman; in collaboration with Reule Denny and Nathan Glazer

This paper describes a form of combined psychotherapy in which the individual sessions are used as an adjunct to group therapy. Each group member is seen regularly in individual sessions to focus primarily on the member's ongoing group work. The individual sessions are scheduled on a rotating basis. Typically, each group member is seen in an individual session once every four weeks. Additional individual sessions are available only when immediate attention is appropriate and necessary. The group is viewed as the primary therapeutic component. A cost-effective therapeutic approach that uses both individual and group methods, this modality lends itself well to a clinic and to a private practice setting.     

Ethical Considerations for Providing In-Home Mental Health Services for Homebound Individuals

The number of homebound individuals in the United States is on the rise, causing health-care professionals to expand in-home health services to help meet the increased demand. Due to the prevalence of feelings of isolation and depression in this population, it is imperative that mental health professionals join this effort to increase access to mental health services. Delivering psychotherapy in clients’ homes presents many advantages to these homebound individuals, but there is a dearth of literature addressing how therapists should handle unique ethical issues that arise in this type of setting. This article addresses ethical considerations and guidelines for in-home provision of mental health services. General ethical issues related to home-based psychotherapy include boundaries, confidentiality and privacy, competency, insurance coverage, and autonomy. Issues pertaining to different categories of homebound individuals, including persons with agoraphobia, chronic illnesses, and older adults, are then discussed in turn. Recommendations on how to best manage these issues by applying the American Psychological Association’s, the American Counseling Association’s, and the National Association of Social Workers’ Ethics Codes are provided.     

Reflections on a developing body of group-as-a-whole theory for children's therapy groups: an introduction.

This essay serves as an introduction to a collection of articles on group psychotherapy for children that appears in the following pages. These articles are an outgrowth of a symposium on children's group treatments presented at the 1990 Annual Conference of the American Group Psychotherapy Association. The present author provides a general overview of relevant literature and offers an orientation to the subsequent theoretical and practical integrations.     

The differential effect of psychotherapy and psychoanalysis with anaclitic and introjective patients: the Menninger Psychotherapy Research Project revisited.

Analyses of the data from the Menninger Psychotherapy Research Project (MPRP) have consistently indicated little difference in the therapeutic outcome between patients seen in psychoanalysis and those seen in psychotherapy. Reanalysis of the data from the MPRP, utilizing a distinction between two broad configurations of psychopathology (Blatt, 1974, 1990a; Blatt and Shichman, 1983), however, indicates that patients whose pathology focuses primarily on disruptions of interpersonal relatedness and who use primarily avoidant defenses (anaclitic patients), and patients whose pathology focuses primarily on issues of self-definition, autonomy, and selfworth and who use primarily counteractive defenses (introjective patients) differ in their responsiveness to psychotherapy and psycho-analysis. Based on recently developed procedures for systematically evaluating the quality of object representation on the Rorschach, reanalysis of the Menninger data reveals that anaclitic patients have significantly greater positive change in psychotherapy, while introjective patients have significantly greater positive change in psychoanalysis. These statistically significant patient-by-treatment interactions are discussed in terms of their clinical implications as well as the importance of differentiating among types of patients in studies of therapeutic outcome and of therapeutic process.     

The Development,Process, and Evaluation of Group Psychotherapy With Sexually Abused Preschool Girls

The development, process, and evolution of group psychotherapy specifically designed for sexually abused preschool aged females is presented. Utilization of male and female cotherapists, group structure, individual and family dynamics, the role of children's mothers in treatment, and process of treatment are examined. Issues regarding countertransference phenomena, cotherapy relations, in-depth involvement of the children's mothers, and specifics related to structuring of a time-limited group are beyond the initial intent and scope of this paper, and are not discussed here.

The cotherapists conclude that group psychotherapy for children of this age group is both clearly valuable and highly indicated as an adjunct treatment modality. In future group psychotherapy with sexually abused preschool aged children, based upon clinical experience and evaluation, the cotherapists advocate a time-limited approach whereby each session would focus upon specific issues as illustrated in Table 1, and include structured and purposeful involvement of the girls' caretakers.     

Group psychotherapy with alcoholics: Interface with self-help groups

This paper addresses recovering alcoholics' concurrent involvement in psychotherapy groups and self-help groups. A developmental model of alcoholism group psychotherapy is presented, differentiating between early and advanced sobriety. Psychotherapy and self-help groups are compared and contrasted. Multiple group membership entails various areas of compatibility. Divergence and conflict result from differences in underlying conceptual framework and approach. Clinical implications of members' involvement in partially discrepant group settings are explored with an emphasis on transference and countertransference reactions. Multiple group membership is identified as a salient factor in alcoholism group psychotherapy at all levels of recovery.She is also in private practice.This paper was presented at the American Group Psychotherapy Association Annual Conference, Boston, February 1990.     

Potentiating group psychotherapy for bulimia with ancillary rational-emotive-hypnotherapy

A rational-emotive-hypnotherapy (REH) treatment was administered to five bulimic females who were concurrently participating in electic group psychotherapy. A within-group time series analysis design was employed to examine subjects' binge and purge symptoms. The combined treatments produced a declining frequency in symptoms for four subjects across three phases of the study. REH was responsible for 4 out of 8 possible treatment effects and appeared to potentiate the group psychotherapy. A theoretical explanation is offered for the REH effects along with recommendations for future REH with bulimics. This study was presented as a paper to the annual meeting of the American Psychological Association, 1982, Washington, DC. Appreciation is extended to Don W. Ball, Ph.D. for editorial and technical assistance in the preparation of this article.