Psychiatry: Strength in Numbers

If all the 15,000 M.D.s in the U.S. who are psychiatrists, plus all the psychiatric social workers and all the psychologists trained as therapists, spent all their working hours with individual patients, they would still be able to treat only one in ten of the Americans who need help for emotional ills. For both psychiatry and nonmedical therapy (especially analytic forms) traditionally work on a one-to-one basis, with the reassurance that it’s all confidential. The 750 members of the American Group Psychotherapy Association who met a fortnight ago in Washington exchanged reports on a diametrically opposed theory: that for many patients, in many circumstances, treatment in groups is better than solo therapy. In most cases, it is at least better than no treatment at all.

Readymade Group. Perhaps because Americans are notorious joiners, group psychotherapy is the most distinctively American contribution to treatment of the mentally ill. The system had a false dawn as far back as 1905, when a tuberculosis specialist found that his patients benefited from regular meetings. But the emotional aspects of TB were not then understood, and a quarter-century passed before a few pioneers began to reason that some people get sick from their reactions to other people, and that when they get better they still have to live with other people. In the meantime, said the theorists, why not treat the patients along with other people?

One of the natural areas for group therapy is juvenile misbehavior or delinquency. A psychiatric social worker told the Washington meeting how his service, on the frayed edge of New York City, had handled a group of boys, aged 13 to 15, who were doing poorly in school and heading into trouble. The boys insisted on being treated together. They showed up in flashy clothes, laughing too loudly in the hope of appearing casual, and tensely chain-smoking. They ridiculed the therapist for wearing “square” clothes and not being hip. They complained of being persecuted by parents and police. When sex was discussed, the therapist found that the boys were utterly ignorant of the subject, and, despite their bravado, they were all virgins. The group sessions on sex became tense, often punctuated by uncontrollable laughter used to cover up doubts and fears. Within a year, though, the boys toned down in both dress and behavior. The self-constituted group, the therapists decided, had been readymade for treatment.

For 20 older and definitely delinquent youths, New York State set up a special center at Middletown. It was no plush country cottage, and the regimen was deliberately kept rugged to make sure the boys would not get too relaxed or get to like it. They met five times a week in groups of ten. “It became almost a matter of course,” reported Dr. Girard H. Franklin, “for them to discuss a mother’s prostitution, a father’s failures, their own homosexual fantasies or experiences. Their ability to accept and understand these highly anxiety-provoking phenomena was greatly aided by their being able to share their experiences, and their insights into them, with each other.”

So far, of 29 delinquents who have completed the treatment, only two have been haled into court again. And START (Short-Term Adolescent Resident Training) programs are being extended to seven more centers in the state.

Husband v. Wife. Many different types of people fit readily into group therapy if they have at least one major problem in common. One of the first and clearest examples of the method’s value was in the treatment of World War II victims of combat fatigue or “war neurosis.” Since these reactions could be traced ultimately to fear, shame and guilt, the soldiers who could see and talk with others in the same plight got better more quickly. Obese patients get mutual support from other fatties and bolster one another’s will power. At a Brooklyn home for the aged, patients thought to be hopelessly senile are showing new talents after group sessions, and a few feel such a quickening of youth that they want to get married.

Couples already married but about to break up are more of a problem. Dr. Philip R. Hastings of Iowa’s Black Hawk County Mental Health Center worked with four couples who spent most of their weekly sessions for the first few months arguing among themselves. Three of the wives kept assailing their husbands with accusations but would not let them get in a word of answer. It was just like home. But in couple No. 4, the husband was the verbal aggressor, and eventually the group turned on him. Gradually, the long-hidden, unconscious bases of marital difficulties were brought out in the open and discussed. Sometimes the patients vented their hostility on the therapist. In almost all cases, the husbands and wives also had private, individual therapy as well. But their ability to benefit from this, said Dr. Hastings, was largely the result of the group therapy.

Group psychotherapy is booming, and Manhattan Analyst Hyman Spotnitz calls it the “Third Psychiatric Revolution”—after the unshackling of mental patients around 1800 and the Freudian revolution a century later. But nobody at the Washington conference offered the technique as a total answer to mental health problems. In unofficial self-analysis within their own group, some of the therapists pointed to the danger that the group movement may become an uncontrolled fad.

But before that can happen it seems certain to pay off. Simply by enabling a therapist to deal with several patients at once, the group system reduces the number who must go untreated. And it cuts costs from an average of $20 a session for a psychiatrist or psychologist in private practice to as little as 50¢ for the needy and $4 or $5 for those of middle income.