GROUP THERAPY AND THE PSYCHIATRIC CLINIC By L, Copy Mars, MD. OF TUCSON, ARIZONA ‘Two previous communications ' described certain projects in an at- tempt to treat frankly psychotic individuals by the use of group therapy. In the latter communication on this subject, brief reference was made to group therapy projects with psychoneurotics in the open community. I now wish to give a more detailed description of these experiments and those which have been performed since the writing of that report. Private psychiatry is available to very few persons, principally on ac- ‘count of its necessarily high cost. Whereas physicians in other specialties see four or five and even more persons in an hour, a psychiatrist ordi- narily requires an hour for each patient. We are constantly being asked, “When are you going to develop a type of psychiatric therapy which is financially within the reach of the average patient with the average sized purse?” Those who cannot afford to pay the fees of a private psychiatrist have ordinarily but one alternative, and that is the Psychiatric Clinic, These ‘clinics leave much to be desired. Jn the first place, they have a morbid taste to them, a taste which has been built up in the mind of the com- munity and for which we psychiatrists are not entirely responsible, Then it is not always possible to have psychiatrists for these clinics who can give regular attention throughout the treatment history of all cases. To be sure there is the psychopathic ward of a growing number of general hospitals, but these suffer from unsavory reputations built up principally by the fact that the psychopathic ward is too often the place where the community's inebriates are sobered, What is far worse, it is the place where the criminals and ngau-criminals and other notorious ‘Characters are housed for “observation.” ‘Thanks to the energy of the press for morbid stories, the psychopathic ward of the general hospital is about as inviting to the twentieth.century public as the Bridge of Sighs was to the medieval: populace. !Another objection to the psychopathic ward is that it’ has the set up and general coloring of a typical hospital ward, and so called “nervous people” and others who require psychiatric 1The Group Treatment of the Psychoses, Mental Hygiene, April, 1931; An Experi- ‘ment in Group Therapy, Mental Hygiene, July, 1933. (38r] ol382 L. CODY MARSH care do not feel that they are sick and do not wish to be treated as such,, he private sanatorium for nervous diseases is also beyond the reach of the average purse, and very few of them have an Out Patient Depart- ment. i Lastly there is the State Hospital, and many of our large cities have these. To be sure, an all too few of them are becoming interested in maintaining an Out Patient Department, but the average citizen, no matter how pressing his emotional conflicts may be, certainly does not wish to admit to himself, much less to his friends, that he is going to the Out Patient Department of “Such and Such an Insane Asylum.” In psychiatry, we are dealing with a group of people who, consciously or unconsciously, cling to their maladies because they are serving a very definite purpose, whether they are aware of this or not. The result is that it is only with the greatest difficulty that they can be induced to take any form of treatment. Persons suffering from other maladies than those grouped under psychiatry generally seck treatment energetically and are more or less glad to codperate. For this reason it is all the more important that we, in psychiatry, offer not only a form of treatment which is financially accessible to patients, but which is so adroitly and cleverly presented that this therapy becomes attractive and disarms the sufferer of his forebodings. ‘Tur Group Approact Group Therapy is not a new thing. ‘The students who clustered about such ancients as Pythagoras, Socrates, Zoroaster, and probably most of the classic philosophers were partly seckers for knowledge, but they were also seekers for emotional help. Many of these early teachers con- ducted the so-called peripatetic schools, wherein the students walked about with the teacher as he taught. The physical effort involved in these walks, together with the interesting sights encountered, probably combined with the instructor's teachings, to make a form of group therapy as well as a form of education, Religion has utilized the forces bound up in crowd psychology to produce cures, both alleged and real. At the Boston Dispensary, Dr. Pratt has successfully treated psycho- neurotics in whom organic lesions could not be demonstrated, by the class method. [have reported certain values of this type of approach for those who are frankly psychotic. It is freely granted that there are types of psycho- neurotics whose sufferings are said to be made worse by being placed inGROUP THERAPY AND THE PSYCHIATRIC CLINIC 383 a group. However, I have found that where the class work is supple- mented with individual attention that this objection is overcome. ‘There is a compulsion at work in the group which is rarely at work with equal force when the physician meets the patient privately. Another advantage of the group treatment is that the transference is a group transference and a less impersonal one than is made in private treatment. The patient not only makes the transference to the physician but to the group. The transference is more readily broken. The patient comes to regard the proceeding as an educational one and takes a more sunny attitude toward it. Since he sees that others in the group whom he can respect do not differ greatly from himself, he concludes that he is not in a morbid situation. The class also takes on a certain enthusiasm which one rarely gets ina private contact. Because of this enthusiasm and the compulsion at work in the group, the case seems to move on more rapidly toward betterment, if not recovery. It is my experience that patients seem more willing to accept a new point of view in the group than they do when approached singly. In going over some five hundred private cases, I believe that most psychiatrists will agree with me, that something like seventy-five per cent of the material which is offered to the patient is material which could be embodied into a course of lectures. That being so, it occurred to me to devise a course of lectures which included this material and supple- ment this with individual work for the more intimate and specific mat- ters which persons naturally dislike to discuss in an open class. Tt has seemed to me that patients also liked the impersonality of the class situation. In spite of one’s success in developing the so-called ob- jective or psychiatric attitude in the task of psychiatric therapy, private consultation necessarily constitutes a very intimate and personal situa- tion. This very situation seems to act as a fearsome thing, against which the patients builds up a whole congerie of defenses. The descriptive matter following is drawn from the writer’s experi- ence with: (1) Mental Hygiene Classes Conducted at Worcester State Hospital — ‘These classes were primarily for the relatives of patients, but in time they came to include many others from the community, clergymen, school teachers, nurses, parents, and a various assortment of persons who could be classed as psychoneurotics and pre-psychotics. OF this last group, most of them sought the help of the Group Clinic of their own accord, although there were several who were referred to the Clinic by physi-384 L. CODY MARSH cians in the city of Worcester, social service agencies, Y. M. C. Ay Y.W.C. A, district nurses, clergymen, and others. Of course no charge was made, although I believe that one should have been made. In spite of the fact that most of these people had at some time taken a firm but silent vow that they would never enter the doors of what they called “the insane asylum,” they seemed to enjoy coming to the classes because of their educational accent and certain other features which they considered attractive. For one thing, the psychoneurotic and psy- chotic recognized at a glance many persons who occupied substantial places in the community and instantly he identified himself with them, so that membership in the class gave him a tone feeling of comfort and a certain degree of pride. In short it did not strike him as a clinic for queer people or “crazy” people. Furthermore it was never called a clinic. Many of the class members were given private attention and in most instances, they sought this private attention. (2) A Group Class for Normal and Psychoneurotic Persons in the City of Worcester-—This class had a membership of sixteen. All were school teachers, females, and of one religious faith. The religious and sex homogeneity seemed to have certain advantages. This was also an intelligent group and they were taken into the writer's confidence as to what he was trying to do. Because of their splendid codperation, much was learned about what to do and what not to do in the group approach. (3) The Re-educational Institute in Boston—This was founded by the author in June 1932. A large, high ceiled studio with two small entrance rooms was engaged for the purpose. The studio was fur- nished with chairs, blackboard, grand piano, and attractively decorated, and gave the atmosphere of a class room rather than of a cold treatment room. Twelve series of classes were held in this studio in the course of a year. Classes contained normal persons, physicians, clergymen, educa- tors, teachers, nurses, college students, etc, and also others who were frankly psychoneurotic, pre-psychotic, and others definitely psychotic. This particular experiment which I have called the Re-educational In- stitute gave very gratifying results. Certain social agencies referred cases, but only five physicians in Boston referred cases, although an- houncements were sent to some two thousand. In this connection I have often wondered what the average physician does with those cases which should be referred to a psychiatrist. In a previous paper I ‘once mentioned that of a long series of patients I had admitted to a State Hospital, and all of whom had family physicians, only in a scant half dozen had these physicians referred the case to a psychiatrist,GROUP THERAPY AND THE PSYCHIATRIC CLINIC 385 Certainly the Psychiatric Clinics are few and they also are not over- crowded, so I wonder again what the medical profession does about cases which are referable to a psychiatrist. Procepure (1) Enrollment—Patients were enrolled as students. In the case of some of the classes, these students signed a pledge to give their fullest codperation in the course, to do the assigned home-work, and to be regular and prompt in attendance. The pledge went into some detail as. to what was to be accomplished in the course and was, in fact, called the “Psychiatric Pledge.” Ordinarily tutition was payable in advance, the understanding being that time taken privately with the instructor was to be an additional cost. (2) The Lecture Course.—The course consisted of four lectures. The following is a brief outline of the lecture material: Family Situation-—~A constructive sociological study of one’s own family to obtain a sunny and sympathetic understanding of family relationships, and the r6le of each member in the family drama. ‘The meaning of “good family” and “good birth.” Foundations of Personality in Childhood.—Formation of habits of feeling and thinking which condition us throughout life. Beginnings of play life and dissipation trends. School life. Significance of the Intelligence Quotient. The orderly use of the mind. Economic Equipment-—Job integration, aptitudes, and ambitions. Job behavior. Production drive. Emotional Life—Understanding one’s emotional pattern, The conflict between love and fear. Emotional Agility, the measure of one’s modifiability. “Monkey Wrenches” in the emotionatmachinery, Emotional outlets. Social Life—Social assets and liabilities. The development of charm and “personality.” Sex attraction, Small talk. Free association. Religious Life-——The conflict between: religion and modern needs. ‘The new ethics. A psychiatric interpretation of sin, conscience, faith, etc. Sex Life-——A short history of the philosophies of sex. Influence of sex glands on behavior. Dangers of adolescent period. Values and dangers of sex repression and sex indulgence. Love life and marriage at the juvenile, adolescent, and adult levels. Abnormal People-—Beginnings of “mental trouble” in the rigid, shut-in and selfish personalities. Common types of nervousness, their meaning and management. Normal Adult Personality—Health without fads, control over environ- ment, healthy emotional mechanisms, thrift, happiness, the open ‘mind, integrated reaction to life, free association, fact facing, self-understanding, ability to play, articulatcy, social ease, success in small things, security fecling,treating. 386 L. CODY MARSH sense of freedom, satisfactory family and love life, independence without pugnacity, loveableness, push. In several instances students repeated the lecture course, a few of them three and four times. In the deeply seated neuroses, patients even in class work put up formidable resistances to instruction. However, this is not so marked in the class approach as in the individual ap- proach. The group compulsion tends to overcome these resistances. It may be said, parenthetically, that neurotics tend to put up resistances to any type of instruction. This accounts in part for the difficult time that most neurotics have in all educational institutions. (3) Questions and Answers-—When the lecture was concluded, op- portunities were given for asking questions. At first students had to be encouraged by writing out questions and leaving them on the instruc- tor’s desk. After the first session, however, few questions were written and, in general, students tended to become amazingly frank in asking the most intimate and personal questions which were clearly descriptive of their own difficulties. Oftentimes the instructor asked for answers from class members and occasionally a consensus of opinion would be taken. It was not long before each class developed a sound mental hygiene point of view. The class thus became a democratic, educational project wherein the instructor was rather a moderator than a lord. (4) Class Atmosphere—The instructor was always careful to main- tain an atmosphere of academic dignity. The language used was rarely scientific, that is, the writer rarely indulged in the “slang,” “lingo,” or “neologisms” of psychiatry. On the other hand; popular slang was not used, except rarely with apologies. On the other hand, the atmosphere was kept sunny and the-subject- matter was handled with a-certain Jightness oF touch. The writer believes that there are great dangers in presenting mental hygiene or the subject matter of psychiatry, unless an air of sunniness and lightness of touch is maintained. Students in this type of a set up must be impressed from the outset that they are not queer, that the subject is not queer, but that, on the other hand, they are people like any other group of persons and that the subject matter is just as normal, sunny, informative, and valuable as any other subject. ‘The emphasis in the class atmosphere is on ¢eaching rather than on uring the actual lecture period, the atmosphere was distinctly dignified, moderately formal and academic. But before and after class, the students were encouraged to be sociable, and if they showed a tend- ency here and there to be rowdyish, this was ignored. Flowers were always placed in the class room, and the writer generally saw to it that there was someone who could play the grand piano or sing before andGROUP THERAPY AND THE PSYCHIATRIC CLINIC 387 after class, but always in a spontaneous fashion. If the group or any part of it wanted to sing, they did so, but the initiative came from the students and not from the instructor who stood apart from all of these activities. It was remarkable, at times, how these spontaneous social activities socialized the whole group, including two incipient, paranoid praecox young men who looked quite hopeless on admission. This latter situation suggested that there may be great therapeutic values in hazing, for oftentimes students seem to have the ability, by means of hazing, of correcting situations which the “prof” would rarely reach. At least some mild hazing did great things for these two paranoid young men. It is suggested that in attempting to do or improve upon this experiment that this particular feature be encouraged, perhaps with some backstage instruction. Neither the psychiatrist nor the teacher can haze. But students may haze their fellows. (5) Organization —Students were assigned to various tasks, so that by the time the lecture course was completed, each one had done some- thing which gave him or her a sense of ownership in the project. They were assigned to such special tasks as being monitors, “greeters,” “in- troducers,” to arrange chairs, care for the flowers, clean the blackboard or write thereon the lecture outline, and in keeping the roll. These activities tended also to dispel the atmosphere of morbidity which is apt to cling to things psychiatric, especially the clinic. (6) Notes—Students were always asked to take notes, and whether they took them or not, they were always given pencils and paper, if they did not bring notebooks, The art of taking notes, like the art of study- ing, is something that very few people learn. It was observed that even college people would, oftentimes, prefer to listen without note taking. There should be some place in our education plan to teach students how to listen to a lecture, how to take notes, and how to study. After all, these are tokens of our powers of attention and concentration. Neuroses often develop from failures and failure may be due to an inability to listen, or to observe, or to take notes, or to study. Some attention was given to this with some of the groups, and with profit. However, the notes are not an end in themselves and it is granted that most of the notes should be taken in the head. (7) Grading—In certain of the courses, each student was given a grade on the following points: (a) Attendance (b) Punctuality (c) Attentiveness388 L. CODY MARSH (d) General codperation (e) Standing with class members (£) Evident improvement (g) Avowed improvement (h) Insight and judgment These grades were discussed with the student when he came for the private interview after the lecture course was completed, In one class the students were asked to grade each other on most of these points. In this one instance, it was valuable. (8) Outside Reading—At one time I was rather enthusiastic about giving outside reading to those who have so-called mental difficulties. 1am beginning to feel now, however, that it is like certain drugs which we use in medicine, that is, they are very valuable if given under the direction of a physician but never ought to be self-administered. It may be that we have not yet developed the right kind of mental hygiene litera- ture. At least my feelings are mingled about the advisability of giving outside reading in psychiatry or related subjects. Anyone familiar with the general type of person who registers for “Abnormal Psych” in our colleges must agree that study of these things is only an intellectual achievement and not an emotional one, Some of the best authorities I know on the subjects of mental hygiene and psychiatry are also the un- happiest people I know. I found it more valuable to send students to the library to work up a little outline on some cultural but unrelated subject as a test of their powers of attention and concentration. (9) Treating Each Other+}-1n most of the classes some of the stu- dents were asked to assist the instructor in “teaching” some classmate. In most of these cases the assistant so deputized was one of the out- standing class problems. But in helping a confrere, he was inspired to. make an effort which he would not otherwise make This also gave the instructor an opportunity to give experience to certin ones who were interested in the project. Of these, two were clergymen, a physician in general practice, a young psychiatrist, two social service workers, two mothers with problem children, and a Salvation Army official. Oftentimes when the instructor noted a flagging interest in a student, an assignment to assist “teaching” another student restored his interest. (10) Class Exercises—First of all there were the exercises which bore directly upon the subject matter. The first one was the preparation of the family case history. The class members were asked to make a family case study of their own families, but with the objective point ofGROUP THERAPY AND THE PSYCHIATRIC CLINIC 389 view rather than the usual, carpingly critical point of view, which ordi- narily characterizes the family member. A form for these studies was put on the blackboard, discussed, and questions answered. Other and similar group tasks were: (a) My Earliest Memory (b) Ingredients of my Inferiority Complex (c) Things I am Afraid O£ (d) Emotional Monkey Wrenches (e) Disarmament Conference of the Human Heart (£) Social Assets and Liabilities (g) Sources of Inspiration and Happiness (h) Night and Day Dreams ‘These class room tasks, if one made contribution to them, gave an opportunity for a good deal of laughter and also for each one to see that most of the material in the secret recesses of his heart was not sinful, or morbid or abnormal, and that he was quite like anybody else, These tasks also assisted the class members in making out their own private tabulations under the above headings. In addition to this purely academic work and apart from the spon- taneous stunts in which students indulged before and after class, they were required to do certain socializing things under the direction of the instructor: (a) Class was required to organize within five minutes at the third lecture. (b) Occasionally the class was given tap dancing instruction en masse. This was found most valuable and would have been used more had the finances of the Institute permitted it. The writer knows of nothing that is better calculated to limber up an individual or a group. It served as an emotional stramonium. (c) In a few instances the class was conducted as an informal dramatic group. This is also very helpful. ‘The shyest person, for example, is willing “to play” the part of the gayest social lion, and this eventually gives him the courage to live something approaching that. (11) Home Work-—Each student was asked to write out and hand in his own personal tabulations under the headings listed in paragraph (10) above. ‘In addition he wrote a mood history, so that I could ascertain what his favored emotional mechanisms were and thus help him make a better selection of these mechanisms, if necessary, planning and developing new and better ones. He was also asked to make a list of his problems, first of all to find out what they were. They are ordi- narily profound secrets to most people. In some instances, class members390 L. CODY MARSH were asked to make a brief outline of their love life history, their job history, and a simple description of their physical development and illnesses. (12) “Private Consultation.’ —The writer believes it is highly impor- tant in psychiatric work to rid ourselves of this expression for reasons which have been given. The expression was not used at the Institute, and this particular task was always referred to as “tutoring” or “coach- ing.” As a rule, the students sought this, and this was a valuable bit of psychology. If the instructor suggested to the student that he had better have some private tutoring, he was quite apt to put up defenses which had to be overcome. If he asked the instructor for it, he brought to the task a genuine interest and at least some enthusiasm. However, he was not given the tutoring until he had completed the lecture course. In most cases, he came to this private hour with a definite list of questions and problems written out. He knew most of his needs and was ready to receive suggestions about them. Most of this did not require more than two or three hours of private consultation. They were charged a reduced coaching fee, where they had limited finances. Cases referred by welfare organizations were charged $5.00 an hour. In several in- stances my assistants took over this task, and with credit to themselves. Certain agencies advised me that, whereas they had been lugging along for months at considerable expense problem people referred to the In- stitute, that the work we had done at very slight expense had relieved the welfare agency of any further responsibility and cost. Doubtless the great majority of people who are ordinarily being carried on the backs of our welfare agencies are people who need a constructive job in mental hygiene, rather than food, clothing, and money allowances. (13) Physical Examination-—In most cases, the physical examination was included “among the privileges for which tuition was paid.” ‘The examination given was rather thorough and disclosed many things which needed correction, mostly mistaken ideas. The outstanding need here was to reassure the student that he did not have a bad heart, that he was not about to die of tuberculosis, that she did nor have cancer of the breast, or that the snapping feeling felt in the head was not disin- tegrating nerves in the brain. Thus the value of the physical examina- tion was more for reassurance than as an excuse for some medical treatment. (14) The Progress Card-—Students were asked to keep a record of their progress or lack of progress, and show this frequently to the in- structor. It was a single card, ruled into three columns. The first oneGROUP THERAPY AND THE PSYCHIATRIC CLINIC 391 named briefly a life situation which was a source of discomfort or unhappiness. The second column listed, quite as briefly, the usual response of the individual to this situation. In the third column the student indicated a newly planned but improved response to the situa- tion described in the first column. Unfortunately the finances of the Institute did not permit of a staff of social service workers, occupational therapists, and many others the writer could name who would be most helpful in the project. In a few instances, volunteer workers helped with some of these special activities, but only enough to demonstrate the great need of well-trained workers. _We indulged in one type of follow-up which was pleasurable and helpful, and that was the student reunion. These were held occasionally, and all past students were invited. They were allowed to indulge their own spontaneous activities, compare notes about progress, show each other their cards, to tell proudly of achievements of which they had previously despaired, and otherwise renew auld acquaintance. The in- structor gave a brief lecture on some mental hygiene topic, suggested by what was being reported in the press, for example, “The Psychiatric Slant of the New Deal.” Sometimes we had simple refreshments. Casts Trearep (1) Psychoneuroses (2) Pre-psychotic conditions (3) Psychoses (a) Epilepsy with schizoid behavior (b) Post-encephalitic psychoses (c) Involutional melancholia (a) Hypo-manic state (€) Dementia praecox, simple type (£) Dementia praecox, hebephrenic type (g) Dementia praccox, paranoid type (h) Traumatic psychoses (4) Organic states with neuroses (a) Cardiac states (b) Gastric ulcer (c) Hay fever (d) Asthma (e) Orthopedic conditions (5) Stammerers Occasionally there were persons in the class who spoke little English, Italians, Russians, e.g., but they seemed to derive as much benefit as the others. The classes generally represented varying social strata and vary-392 L. CODY MARSH ing intellectual levels. However the lecture material was presented in the simplest language and even those not well favored intellectually seemed to grasp nearly all of the material. The psychology of the group levels off human distinctions, and very shortly the group takes on a uniformity of interests as well as of progress. The writer is especially enthusiastic however about “teaching” special and homogeiicous groups. It is suggested that physicians dealing with Such groups as cardiac, orthopedic, asthmatic, and hay fever, gastric ulcer, and diabetic cases, have them taught by a consulting psychiatrist or mental hygienist in groups. This will make more certain the purely medical task of the respective specialist. _A. group of stammerers, consisting of fourteen men and two women, was a special case in point. One of the secrets of the group psychology is ‘that the group share somie One gieat and common need. This was cer- tainly true of the stammerers and they were helped a great deal by the group work. Already specialists dealing with diabetes and tuberculosis, to mention but two examples, have found the value of teaching their patients in groups. Here, however, they have, for the most part, dealt with purely medical aspects of the situation. The class has been found to be not only a time saver but a progress maker. Resuits It is most difficult to appraise results in the field of psychiatry. We do not have the palpable evidences of improvement or failure of im- provement which other branches of medicine enjoy. However, both the writer and those students who attended the classes feel that psychiatric patients may be treated successfully by the class method, followed by individual consultation. It is certain that this method cuts down the expense to the patient considerably, and the method is offered as a contribution toward the solution of the problem:—How shall we offer an acceptable plan for psychiatric treatment which is within reach of the average purse? SUMMARY 1. Attention is called to the fact that facilities for private treatment of psychiatric cases, at the present time, are quite limited. 2. Attention is called to some of the short-comings of our present facilities for psychiatric treatment. 3, Very few persons can afford the services of a private psychiatrist. 4. The group treatment of psychiatric patients has certain special advantages over individual treatment, particularly in providing a thera-GROUP THERAPY AND THE PSYCHIATRIC CLINIC 393 peutic compulsion; a helpful transference which is easily broken; an educational and attractive setup; resistances of patients are more easily overcome; enthusiasms are engendered which are not so prominent in private treatment; and the impersonality of the situation makes the patient more amenable to treatment. 5, It has been found, by experience, that at least seventy-five per cent of the material covered in private treatment of patients could be em- bodied in a course of lectures. 6. The author’s experience with the group treatment of psychiatric patients is described. >. It is believed that the plan, as described, is superior to the psy- chiatric or mental hygiene clinic, and would enable us, with present facilities, to handle a great many more patients. 8. Emphasis is placed on the belief that patients should be regarded rather as students, than patients, and the process should be an educational one rather than a medical procedure.