Group Therapy Approaches for Managing Mental Illness

Introduction: Mental Illness and the Challenge of Long-Term Management

Managing mental illness in such a way that realistic life expectations, self-identity, and long-term health and wellness are fostered is one of the most enduring problems associated with health care in society. Mental illness represents a significant health problem with long-standing personal and social implications for the individual, the family, and the community, as unresolved management issues can — and often do — create difficult and even destructive social situations for all (Pollio, North, Reid, Miletic & McClendon, 2006, p. 31; Accordino, Porter & Morse, 2001, p. 16).

Chronic mental illness has long been recognized as having an impact on an individual's sense of self (Bleuler, 1950; Freud, 1958; Kraepelin, 1904; Sullivan, 1940). Estroff (1981) writes that "the chronicity of mental illness involves more than just the persistent and recurrent nature of the illness; it also includes the relatively permanent shifting of expectations and definitions of self" (p. 223). Estroff (1989) further describes schizophrenia as an "I am illness — one that may overtake and redefine the identity of the person. Having schizophrenia results in a transformation of self as known inwardly, and of person or identity as known outwardly by others" (p. 189). Charmaz (1983) refers to the suffering of the chronically ill as loss of self. A more optimistic view allows that the self need not be permanently lost in chronic illness, but can be recovered or reconstructed (Czuchta & Johnson, 1998, p. 31).

The individual with a fractured sense of self is far more at risk for social difficulties than one with a solid sense of self. Self-identifying with the disease rather than as an individual with personal goals and life expectations is an essential process, and one that often cannot be achieved without social challenges. Social challenges encountered in a safe environment — such as well-directed and planned group therapy — provide a productive way to help patients resolve these issues and move toward more productive and fulfilling lives, in spite of a mental illness diagnosis.

One of the newer issues associated with the management of mental illness is the trend in health care toward a managed care context, where techniques and standards of care are assessed frequently to assist in the most effective manner, reducing costs and long-term burdens on individuals and systems of care. Mental illness has been left out of many managed care systems partly because many individuals and institutions do not feel compelled to tackle this difficult social issue, yet managed care is an essential and lasting context of care.

Managed care is here to stay, and social workers must rise to the challenge or cede leadership to others. Managed care has forced the profession to think more critically about how its members provide care and how they can deliver the best quality of services to the most people under increasing resource constraints. The practice wisdom gained through years of providing case management services to people with severe mental illness, combined with state-of-the-art efficacy information, is critical to the development of responsive, individualized, and cost-effective mental health services. The involvement of consumers as partners in the development of managed mental health care is also critical to its success. Social workers have a unique role and responsibility in ensuring that this vision of consumer involvement is realized (Shera, 1996, p. 196).

Group Therapy: Promise, Practice, and Controversy

It is for these and many other reasons that best practices must be adopted for the long-term management of mental illness. Without such standards of care and ethical considerations, mental illness can — and has — become a significant drain on the community. One of the best practices of the past, with regard to management of mental illness, has been group therapy — yet only when conducted with care, consideration, appropriate planning, and contextual development by skilled therapists and group leaders.

Group therapy techniques have been at the forefront of research and clinical application for the long-term treatment of mental illness for many decades. When done correctly and in the proper context, they result in substantial long-term gains for individuals and families managing mental illness within society. This is not to say that group therapy has been without its critics and controversies, as group therapy can and does create further difficulties when conducted incorrectly, in the wrong context, or without the appropriate controls (Corey, Williams & Moline, 1995, pp. 161–183).

Group therapy and various forms of personal-growth groups have sometimes been the object of attack by the public and mental health practitioners alike. Although the therapeutic power of group approaches is well recognized, organizing, planning, conducting, and evaluating groups demands considerable time and commitment on the group leader's part (Corey, Williams & Moline, 1995, p. 161).

Group therapy, when done correctly and with the proper outlay of coordination, planning, and evaluation, can serve as an outlet for individuals managing mental illness in the long term — and, by proxy, their communities. It provides an outlet for comparison of self to others and offers the individual the opportunity to ally and associate with others who face similar struggles when it comes to living with a different kind of mind in a society populated by neurotypical thinking individuals.

Risks Within the Group Dynamic: Scapegoating and Therapeutic Divergence

When individuals who think and sometimes behave differently are grouped with others similar to themselves — particularly at different levels of functional success — they may be given the opportunity to make the mind-body connection spoken of by Schoo in Reality Therapy and the Human Energy Field: Working with Needs that Influence Mind and Body, where the author stresses the need to think positively in order to act positively (Spring 2005, p. 15). If the desired behavior is positive and the individual is offered a point of comparison through group interaction — whether someone functioning at a lesser level than themselves or someone who is managing their mental illness rather well — the primary individual is given a model for increasing self-esteem and thereby deriving greater success from future possibilities.

As mentioned earlier, these interactions are not without risk and controversy. Clark warns that the individual who might be perceived as weak — the lower-functioning individual in the above scenario — may be unfairly and aggressively targeted by other group members as a scapegoat for their own feelings of inadequacy. This therapeutic divergence can take an extremely high toll on the target and eliminate genuine therapeutic self-reflection on the part of other group members (Clark, 2002, pp. 271–276).

In agreement with Corey, Williams, and Moline, Clark stresses the critical need for the therapist (group leader) to be adequately prepared to recognize when a group turns to scapegoating and not mistake such interactions for helpful therapeutic exchanges. The therapist must be capable of diverting attention away from the scapegoat toward therapeutic self-reflection that is more equally distributed among members, both within the therapeutic timeframe and in individual work (Clark, 2002, pp. 271–276).

Conclusion

Self-control and self-esteem cannot be learned in a vacuum, as individuals have little if any comparison models to give them hope for their own future if they are isolated from society. Group therapy settings can allow the individual to create a reasonable set of hopes that build social health and help them learn how to develop coping skills oriented toward a positive, rather than negative, future in the community where they live. Group therapy is an essential tool for this attainment, as the intense interaction within groups helps individuals see and feel what it might be like to confront the steps and stages of social growth, while commiserating with others who face the same or similar obstacles — namely, the management of mental illness.