Integrative Group Therapy for Psychosis

An Evidence-Based Approach

Nick Kanas

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000171808
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Stemming from a series of outcome and process studies, this book presents an evidence-based, integrative group therapy treatment model that includes elements from psychodynamic, interpersonal, psychoeducational, and cognitive-behavioral approaches to address the needs of people suffering from psychosis.

Designed to help patients deal with delusions, hallucinations, disorganized thinking, interpersonal problems, mood changes, and the stigma of having a serious mental illness, the book chronicles the evolution of the integrative approach from research in inpatient and outpatient settings to theoretical and clinical issues that were derived from the empirical studies. Chapters also include information and vignettes to assist the reader in conducting therapy groups for patients suffering from psychosis, including schizophrenia spectrum and bipolar disorders.

Shown to be a safe and supportive adjunct to medications that is useful in both inpatient and outpatient settings, readers will find value in this unique, empirically driven model for groups that are long-term, short-term, and time-limited.

1 Nature of Psychotic Conditions

Introduction

People with psychosis have severe thinking and mood impairments that cause them to lose contact with external reality. These impairments may affect belief systems, perceptions, thought processes, behaviors, motivations, emotional states, and relationships with other people. Most psychotic individuals experience or sense reality differently from others, and they have an impaired ability to test the validity of their experiences.

Under certain conditions, anyone can experience a transient psychosis. For example, as a young medical student, who had been on-call with no sleep for 36 hours, I once had the experience of hearing someone call my name while walking down a long hallway. I looked around and didn’t see anyone. I laughed to myself and said: “Boy, I need to get some sleep” and went home for a nap. Although my reality sense was temporarily impaired by lack of sleep, my reality testing ability was intact, and I was able to dismiss the voices as due to sleep deprivation. In contrast, a psychotic individual would believe in the reality of his or her hallucinations and might even conjure up a delusional belief as an explanation rather than simply looking around and, not seeing anyone, pass them off as a production of the mind.

Etiology and Psychopathology of Psychosis

Genetic and developmental factors play a big role in psychotic conditions (Sadock, Sadock and Ruiz, 2009a). For example, in schizophrenia, monozygotic twins have a concordance rate of 50% for the disease, and in bipolar disorder, this jumps to about 70%. As worldwide problems, schizophrenia affects about 0.5% of the population at a given time. For the mood disorders, psychiatric researcher Hagop Akiskal believes that better detection of bipolar II disorder has raised the point prevalence number for these conditions. He has stated that

the conventional figure of 1 percent for bipolar disorders in the general population is being challenged, and there are now convincing data that this group of disorders may account for 5 percent of the population and up to 50 percent of all depressions.

(Sadock, Sadock and Ruiz, 2009a, p. 1629)

External stressors (e.g., lack of sleep, life-threatening events) and physiological factors (e.g., drugs, medications, medical illnesses) also may precipitate a psychotic episode.

Specific neurodevelopmental and neurocognitive deficits have been found to occur in psychotic patients, especially those suffering from schizophrenia (Sadock, Sadock and Ruiz, 2009a). Beck and Rector (2005) point to neuroimaging and other evidence to suggest that many people with schizophrenia have pathological changes in their brains, such as enlarged lateral ventricles and abnormalities in their hippocampus and prefrontal lobes. The resulting cognitive deficits may be found early in childhood and often precede the advent of other disease characteristics; they may be more significant determinants of functional outcome in work, school, and daily living than positive symptoms (e.g., hallucinations, delusions) or negative symptoms (e.g., decreased emotional responses, lack of motivation); and they usually do not improve during periods of remission (Hurford, Kalkstein and Hurford, 2011; Vinogradov, 2019). Cognitive and brain changes also have been found in psychological tests, leading to deficits in executive functions, attention, speed of processing auditory and visual information, learning (including socially relevant information), and memory (especially verbal memory) (Beck and Rector, 2005; Hurford, Kalkstein and Hurford, 2011; Nuechterlein and Dawson, 1984; Vinogradov, 2019).

There is strong evidence that negative symptoms especially are related to structural changes in the brains of schizophrenic patients. For example, the results from one study concluded that patients with schizophrenia who had especially large ventricles suffered from diffuse brain abnormalities (mainly atrophic), impaired cognitive functioning, and a preponderance of negative symptoms, while patients with the smallest ventricles were characterized by more focal brain dysfunction (primarily neurochemical), a normal sensorium, and a preponderance of positive symptoms (Andreasen et al., 1982). Negative symptoms have shown a higher concordance rate in monozygotic twins than positive symptoms, suggesting a greater genetic influence (Dworkin and Lenzenweger, 1984). These findings point to a strong biological predisposition to the development of negative symptoms that may begin premorbidly with cognitive beliefs of low expectancies for pleasure and success, a perception of having limited resources, and negative attitudes toward social affiliation and acceptance by others. This may account for the high prevalence of premorbid avoidant, schizoid, paranoid, dependent, and schizotypal personality disorders found in schizophrenia (Solano and De Chavez, 2000). Some negative symptoms also may be a secondary reaction to positive symptoms. For example, persecutory delusions may lead to avoidance of other people who may be a threat, or unbidden auditory hallucinations may lead to a sense of not having control over one’s thoughts and a need to withdraw and conserve resources.

Early on, the psychotic state may be latent, and people with this condition may simply be seen as odd or eccentric. Later on, a life event or no apparent cause may result in an acute psychotic episode that requires hospitalization. Sometimes, psychotic symptoms may simmer into a more chronic pattern that becomes worse over time. In all cases, psychosis may negatively affect a person’s ability to work, care for him- or herself, and relate with other people. When the predominant deficiency is in the area of thinking, we speak of a thought disorder, such as schizophrenia or delusional disorder. When the predominant deficiency is in the area of emotions, we speak of a mood disorder, such as bipolar disorder or major depression.

Treatment of Psychosis

The treatment for psychosis includes biological, psychological, and social components.

In the biological realm, this usually means medications. These range from antipsychotic medications for people with thought disorders (such as schizophrenia spectrum disorders) to antidepressants for people with depression to lithium and mood stabilizers for people with bipolar disorder (Preston and Johnson, 2019; Preston, O’Neal and Talaga, 2017). Electroconvulsive therapy also may be used to treat medication-resistant patients with a mood disorder.

Medications usually are prescribed by physicians in an office, a separate clinic, or a medication group (Stone, 1996). Sometimes, they are prescribed after a psychotherapy session by the therapist if he or she happens to be a psychiatrist. In such a case, it is important to not overlap the therapy and prescribing activities during the same session.

Although medications are very important in treating psychosis, they are not enough. As Stone has stated:

A schizophrenic adult, who because of peculiarities as a child was shunned or ridiculed and as a consequence did not develop the interpersonal relationships either inside or outside of the family that might sustain or support him or her, will not have problems solved with medications, even those that hold promise to improve negative symptoms of the illness.

(Stone, 1996, p. vii)

Supportive individual and family therapy may be indicated for psychological issues, and there is evidence that psychotic individuals spend less time in the hospital when psychotherapy is added to medications in the treatment plan (Martindale et al., 2000).

In the social realm, adequate housing, financial support, and recreational and occupational therapy may be indicated. For acutely disturbed patients, hospitalization may be necessary until they can be stabilized and prepared for outpatient treatment. Many psychotic patients have a co-occurring substance use disorder, which complicates their treatment (Horsfall et al., 2009).

What about group therapy? While beneficial for people suffering from non-psychotic conditions, how useful is it for people suffering from psychosis? At first thought, it would seem that a talk-oriented therapy would not be terribly helpful for people with breaks in reality. However, as we shall see in the next two chapters, the literature suggests otherwise and supports group therapy as part of a biopsychosocial treatment plan. But first, let’s examine the characteristics of psychosis more fully.

DSM-5 Criteria for the Psychoses

Formal diagnosis is a useful way to set up therapy groups with psychotic patients. In this book, I will use the standardized criteria described in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, commonly abbreviated as DSM-5 (2013). In this system, psychosis is characterized by abnormalities in one or more of the five domains shown in Table 1.1. These will be described in the sections below.

Table 1.1 Characteristics of psychosis

Domain	Definition
Delusions	Fixed, unrealistic beliefs not amenable to change in light of conflicting evidence
Hallucinations	Perception-like experiences that occur in the absence of an external stimulus
Disorganized thinking/speech	Confused thought associations that are severe enough to impair communications
Disorganized or abnormal motor behavior	Bizarre physical movements or marked decreased reactivity to the environment (catatonia)
Negative symptoms	Decreased emotional responses to people or lack of motivation to engage in purposeful activity

To enliven these descriptions, I will insert some excerpts from a remarkable book entitled On Conquering Schizophrenia: From the Desk of a Therapist and Survivor, with Purview on Metaphysics, Philosophy, and Theology by Robert Francis. As the first part of the subtitle indicates, Mr. Francis (a pen name) is a person suffering from chronic schizophrenia and also licensed and employed as a social worker. In college, he received a B.A. in communications with a minor in philosophy, which accounts for the second part of the subtitle. In fact, the beginning and ending chapters of the book contain his musings on philosophy and religion. But the central chapters contain vivid descriptions of his psychotic symptoms. He began experiencing these symptoms at about age 21 and was subsequently diagnosed as having “schizophrenia, paranoid type.” After some rough years, he managed to learn strategies of coping with his symptoms, and in his early 30s, he went back to school and obtained his master’s degree in social work. Now in his 40s, he has worked as a Licensed Clinical Social Worker conducting therapy in the fields of mental health and in substance abuse. Quotes from his book are given below.

According to the DSM-5 (2013), delusions are fixed beliefs that have little or no basis in reality. There are several kinds: persecutory (beliefs that one is going to be harmed by an individual or group), referential (beliefs that certain gestures, comments, etc. are directed at oneself), somatic (beliefs about unsupportable physical problems), religious (beliefs not supported by an organized religious group), grandiose (beliefs that one has exceptional abilities or fame), jealousy (irrational beliefs that a spouse or lover is unfaithful), erotomanic (beliefs that another person is in love with you with no basis in fact), and nihilistic (beliefs that a major catastrophe is imminent). In addition, the DSM-5 recognizes certain clearly implausible delusions as bizarre (e.g., beliefs that someone has removed or altered one’s internal organs, or that one’s thoughts have been removed or inserted by an outside force, or that one’s actions are controlled by an external agency).

Francis (2019) says this about some of his delusions:

When I am under the influence or persuasion of a delusion, clinically speaking, I am experiencing and projecting a current belief about the specific situation, myself, or others that is in stark contrast to the larger tacitly agreed upon mutually socially constructed reality of the masses…A specific grandiose delusion I once experienced was that I was in a friendship with the then President of the United States. This delusion was recurrent over time and was intermittent over a period of many years…such delusions have been far more infrequent compared to other types of delusions, especially the type known as persecutory delusions…These types of delusions can be brief in time, can last minutes to hours, or can be more perseverative spanning days, weeks, months, or even years…Persecutory delusions are marked by beliefs that others are deliberately trying to cause pain, suffering, humiliation, fear, and harm to me…Oftentimes, in my experience, the delusions are perceptions of a pure form of evil intent.

(Francis, 2019, pp. 40–41)

He goes on to describe the various types of persecutory delusions he has had, such as:

…being used by the federal government in a manipulative ploy, having a microchip implanted in my brain when sleeping in order to control me, lobotomized while asleep, being abducted by aliens and physically transplanted onto a different planet, being rejected by all other people including family as well as being rejected by God, believing others know all of my thoughts…, contemplations of actually being present in “Hell,” the belief of being captured on live video for the rest of humanity to observe, and the belief tha...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of Tables
• List of Figures
• Author Biography
• Preface
• Acknowledgement
• 1 Nature of Psychotic Conditions
• 2 Historical and Clinical Issues
• 3 Research Issues
• 4 Clinical Issues of the Integrative Model: The Basics
• 5 Clinical Issues of the Integrative Model: Special Topics
• 6 Evaluation of the Integrative Model
• 7 Integrative Groups for Non-Psychotic Bipolar Patients
• 8 Conclusions
• Index