What are your recommendations for managing discussion of child abuse in group therapy with severely mentally ill clients? I work in a day treatment setting where many group members struggle with histories of incest, as well as positive symptoms of schizophrenia, dissociative identity disorder, borderline personality disorder and/or chronic suicidal feelings. Members frequently disclose that they were abused but generally do not process this with much depth. To what extent should I explore or encourage patients to verbalize more about their abuse on these occasions? How should I respond to the members who dissociate during discussions of abuse? I try to balance discussions of trauma with discussions on coping skills, and I do wind-down sessions. I would welcome your suggestions on addressing abuse issues with this difficult population.
Worried and Wary
Dear Worried and Wary:
Severely mentally ill people who also suffered child abuse routinely present serious challenges to clinicians. Beyond legal reporting stipulations, managing discussions of child abuse in group therapy depends on membersí ego strength, therapistsí experience, and the groupís goals. Letís look at two examples: a medication-support group (MSG) with modest, focused goals and a trauma group with ambitious goals but heterogeneous membership.
Medication-support groups provide medication management and support. They have flexible boundaries and are not meant for in depth trauma work. In such a group, an in depth discussion of childhood sexual abuse is unwise. However, a memberís suffering and symptoms of PTSD are clinically relevant for medication management and the provision of support. Therefore, a memberís history of child abuse may become part of the discussion but in a limited goal-focused way. The leaders should acknowledge the broad outlines of the patientís trauma (ďOh, youíre having bad dreams of traumatic events that really happened to you. Has anyone else suffered from traumatic dreams?Ē) and make referrals to other settings for additional treatment.
A trauma group with the explicit goal of addressing childhood abuse can be derailed if one member does not have the requisite ego strength to participate in the healing process. During group screening and pre-group preparation, the group leaders try to identify and refer such vulnerable individuals to other treatment settings. When group leaders fail to catch a
mismatch of memberís needs and groupís goals, then the group leaders must do what is best for all the members and transfer the person in question to another treatment setting.
The ideal clinical program has a wide variety of groups that can be stratified into different layers of intensity. The group program coordinator should ensure that each group has clear goals and inclusion and exclusion criteria. Day treatment settings often have a heterogeneous clientele. Some tolerate anxiety and strong affect much better than others. In a group setting, one must take into account the member with the least ego strength before aggressively exploring sensitive material with other members. Dissociating members present yet another challenge. One of my former supervisors noted ďpatients wonít benefit from group if they stop coming.Ē Dissociating members wonít benefit from group either until they stop dissociating. Techniques for helping such patients stay in their bodies are worthwhile if not essential. This approach could be incorporated into the groupís goals if it fell within the interests and skills of the therapists and if the members were able to use it.
Paul Cox, MD, CGP
Chair, AGPA Severe and Persistent Mentally Ill SIG
Dear Worried and Wary:
Working with trauma in any population can be challenging and is even more so with severely ill patients. Space limitations leave me wishing to know more about your group. For instance, do members enter and leave the group fairly frequently, or is the membership more stable? Where is the group developmentally? Are they saying hello or have they moved into a later stage of work? The more stable the membership and the more mature the group is developmentally, the safer the container is for difficult work. Your question seems to me to be about safety, although you did not use this word. How safe is it to discuss dangerous feelings, when the very talk of abuse may be experienced by some members as traumatic?
It sounds as though you have cautiously proceeded to explore the trauma issues in the group. You mention that some members have responded by dissociating during these discussions. How have other members reacted? Are the dissociating members able to talk about the feelings and experience of dissociation? Is trauma talk followed by physical absence in the group as well? Group members always find some way to communicate their feelings, and I encourage you to keep that third ear open to hear the membersí responses to discussion of trauma. You can then use these observations to begin a conversation with the members about the process of trauma work in the group.
You may also find it helpful to ask the group directly: ďHow do we decide what is safe to discuss here? How do we balance the needs of those who wish to process traumatic experiences with those who feel these discussions are too disturbing?Ē Allowing the group to participate in this decision can empower the members to speak up when they feel unsafe and to take ownership of the group in a very therapeutic way. I find it helpful to remember that the experience of trauma can lead to a powerful ambivalence, which can be displayed in the group as a split: some members will voice the wish to keep trauma silent, while others believe it is best to process these experiences as much as possible. If you can help the group to realize there is no one right answer all of the time, then the group has a better chance of working with trauma productively.
Alicia Powell, MD
Dear Worried and Wary:
Your questions raise the profound issue of finding the level of discussion that keeps the group as therapeutically productive as possible. It is essential to keep in mind the therapeutic goal for the specific group. For a mixed group of severely ill patients, including schizophrenics with positive symptoms, the goal is achievement and maintenance of the highest levels of function and quality of life possible. The purpose of anxiety in psychotherapy is to promote regression that will facilitate change. These patients are not aided in their therapeutic task by increased anxiety. In our eagerness to do good work, we must remember the injunction: first do no harm. In working with the group described, I would not encourage the pursuit of greater depth or stronger emotion in the discussion of these threatening issues. I would respect the group membersí needs and rights to process this material at a level that does not generate excessive discomfort. The best work will be done close to the psychological surface. Dissociation is a primitive defense against anxiety generated by the material. If this arises, the focus should be on the anxiety being experienced in the moment and not on the historical trauma.
Our senior colleague, Dr. Murray Itzkowitz, has had decades of successful experience in working with this patient population. He has pointed out that groups may raise issues to test the safety provided by the leader, and that in working with these patients, wisdom often lies in knowing which paths not to take. He suggests that supplementary individual sessions may be helpful for the severely ill group member struggling with a history of abuse or incest.
Keep in mind that this is not a group of non-psychotic or dissociative identity disorder patients set up with the goal of addressing the trauma of incest or sexual abuse. In such a group, if members have been selected carefully, a memberís struggle with these traumata may be expected to benefit other group members. A mixed group of chronically ill has as its goal the achievement and maintenance of the highest level of function possible. Most of the work should be done in the present and with the material of every-day life. You are to be commended for approaching work with these vulnerable patients in such a thoughtful manner.
Hillel Swiller, MD, CGP, FAGPA
New York, New York
This Consultation, Please column was published in the October/November 2001 issue of The Group Circle.