Introduction of the group psychotherapy program in the mental hygiene clinic, regional office, Veterans Administration, Los Angeles, California

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INTRODUCTION OF THE GROUP PSYCHOTHERAPY PROGRAM IN THE r r

MENTAL HYGIENE CLINIC, REGIONAL OFFICE, VETERANS ADMINISTRATION, LOS ANGELES, CALIFORNIA -1

9

A Thesis Presented to the Faculty of the School of Social Work The University of Southern California

In Partial Fulfillment of the Requirements for the Degree Master of Social Work

by Vernie McCann June 1950

UMI Number: EP66348

All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion.

UMI EP66348 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code

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T h i s the sis, w r i t t e n u n d e r th e d i r e c t i o n o f th e c a n d id a te ’ s F a c u l t y

C o m m itte e a n d a p p ro v e d

by a l l its m e m b e rs , has been p re s e n te d to a n d a c c e p te d by th e F a c u l t y o f th e G r a d u a t e S c h o o l o f S o c i a l W o r k in p a r t i a l f u l f i l m e n t o f the r e ­ q u ir e m e n t s f o r th e d e g re e o f

MASTER OF SOCIAL WORK

Dean

D a te .

Thesis

MCCANH........

F a c u lty C o m m itte e

Chairman

TABLE OF CONTENTS

CHAPTER I.

PAGE

THE PROBLEM AND THE SETTING . ............... . .

1

The problem.................................

1

Purpose of the study.

....................

2

Importance of the s t u d y ....................

3

The setting • • • • .........

3

Previous studies of the Veterans Administra­ ...........

tion.

5

Social work participation in group psycho­ therapy • • • • ....................... II.

METHODOLOGY, TERMINOLOGY, ANDORGANIZATION. . . . Methodology • Terminology

7 9

. . . . . . .

9

...........................

13

..............

13

......................

13

Deep therapy. • • • • • • • • Group psychotherapy Non-directive therapy Pre-psychotic

. . . . . . .

.........

13 I1*

Psychotic

lb

Psychoneurotic.............................

lb

Schizoid.........

15

Schizophrenic • • •

...........

Supportive didactic therapy .............. • Organization.............................

iii

15 15 15

iv CHAPTER III.

IV.

PAGE

REVIEW OF THE LITERATURE ON GROUP PSYCHOTHERAPY . .

17

Development of group psychotherapy..............

17

Review of literature on group psychotherapy . » *

18

Military use of group psychotherapy ..........

22

Trends in the use of group psychotherapy. • . •

25

PHILOSOPHIC BASIS OF THE GROUP PSYCHOTHERAPY PROGRAM IN THIS CLINIC. .

....................

30

Difference in ideas of approach ................

30

Administrative attitude ......................

31

Different experiences and background of the

V.

therapists.................................

32

Treatment objectives of the therapists. • • • •

31*

THE BEGINNING STRUCTURE .......................... Time. . . .....................................

35

Description of the first group. ................

35

Recording ...................................

38

Problems met. • •

M3

...........................

Description of the second group •

VI.

35

.......... .

4-2

Recording ...................................

4-5

Problems met................................

4-5

RESULTS AND CHANGE IN THINKING IN THE FIRST YEAR OF PRACTICE.......................................

4-7

Results to the patients.......................

4-7

Learning results to the therapists. • • ........

4-9

CHAPTER

PAGE Results for the C l i n i c .......................... 52

VII,

SUMMARY AND CONCLUSIONS...........................5k Summary of findings, • • ........ . ........... .

5^

Conclusions............. .. ................... 58 Progress........................................ 59 Suggestions for furtherstudy..................... 60 BIBLIOGRAPHY............................................. 63 APPENDIXES APPENDIX A— Closing Summaries on Four Patients of the First G r o u p .............................. 70 APPENDIX B— InterviewingSchedule. • • • « • • • •

?k

APPENDIX C— Personal Correspondence to the Author from V. C. Branham, Chief, Out-Patient Section, Psychiatry and Neurology Division, Veterans Administration, Washington,D.C .

. . . . . . .

77

CHAPTER I THE PROBLEM AND THE SETTING Group psychotherapy was introduced in the Mental Hygiene Clinic, Regional Office, Veterans Administration in Los Angeles, California, in June 19^6, one year after the Clinic itself was established.

Although the psychoanalyti-

cally oriented method of group psychotherapy had been used and studied rather widely in the last fifteen years, there was still great variation in practice.

A survey of the

literature reveals that it remains a subject of general study and there is continued effort to develop its fullest possi­ bilities even to date. The Clinic1 is constantly aware of this responsibility as a part of its function.

The awareness is expressed not

only in special training for staff members through bi-weekly group psychotherapy seminars, but through constant research and study. I.

THE PROBLEM

This is an historical study and covers only the first year of the group psychotherapy program from June 19^6 to

ttClinic11 will hereinafter refer to the Mental Hygiene Clinic, Regional Office, Veterans Administration, Los Angeles, California.

1

June 19*+7♦

It was limited to this specific area due to the

investigator’s interest in program development and the addi­ tional limit of time for this study.

Only two groups were in

operation on an experimental basis during this period.

They

represented a very small part of the Clinic’s total program. The introduction of the two groups did, however, demonstrate an effort to develop and provide an additional kind of ser­ vice to the patients.

The experiments were in keeping with

the general trend of the time to set up and improve services to the returning veteran. Since these early experiments the program has had a rapid development, not only in size but in defining its use­ fulness and refining its purpose.

Philosophy and thinking

have changed in many respects but these two original groups provided the basis for the expansion.of the program at this Clinic. Purpose of the study.

The purpose of this study was

(1) to determine the thinking, philosophy, and planning that went into the establishment of the group psychotherapy pro­ gram as it was introduced into the Clinic; (2) to review the literature written by leaders in the field of group psycho­ therapy for the purpose of gathering such criteria and facts as were applicable to the understanding of the approach taken by the two psychiatrists and two psychiatric social

workers in working with the first two groups at this Clinic; (3) to describe and examine these two groups from the stand­ point of structure, treatment approach, and results at the end of the first year; (*+) to present in summary any signifi­ cant conclusions including subjects for further study. Importance of the study. An examination of the Clinic resources revealed that there was no recording on the intro­ duction of the group psychotherapy program and the planning that went into it. ings were available.

Records of only a few of the group meet­ There had been an increased interest in

the use of group psychotherapy in the Veterans Administration Mental Hygiene Clinics since World War II, but only limited recording as to what had gone into the establishment of such programs.

A study of this kind is of value as a reference

source for other Clinics contemplating the introduction of group psychotherapy programs, as it illustrates some.of the difficulties as well as the possibilities inherent in experi­ mentation with a new form of treatment. II.

SETTING

The setting of the study is the Mental Hygiene Clinic, Regional Office, Veterans Administration, Los Angeles, California.

This is an adult outpatient clinic established

in 19^5 to meet the treatment needs of the emotionally

b disturbed veteran, to help him remain active in the community and prevent the necessity of hospitalization*

The Clinic is

a part of the Medical Division of the Veterans Administration Regional Office*

It is staffed by six full-time psychiatrists,

ten part-time psychiatrists, five resident psychiatrists; five full-time psychologists, seven psychology trainees; ten psychiatric social workers, one part-time psychiatric social worker and seven psychiatric social work second year graduate students. Veterans of World War II who have psychiatric service connected disabilities or who have service connected disabili­ ties of any nature and are in training under Public Law 16 are 2 eligible. The patients come to the Clinic on a voluntary basis through referrals from various departments of the Veterans Administration, schools, colleges, social agencies, private physicians or through their own initiative. At the time that the group psychotherapy program was introduced into the Clinic in June 1 9 ^ , the Clinic itself had been in operation only one year.

It was in the process

of developing, and extending its services in the most con­ structive ways to help the patients.

Inasmuch as it was an

^ Emanuel Newman, tfA Resource File of the Adult OutPatient Psychiatric Treatment Facilities in Metropolitan Los Angeles,*1 (Los Angeless Welfare Councils of Metropolitan Los Angeles, June 19*+7.)

entirely new project without traditional precedent or struc­ ture, there were many questions as to how it should be. organized most effectively to meet the demands made upon it* World War II had been over less than a year and due to the subsequent demobilization, the caseload was a large one con­ sisting of veterans struggling to make an adjustment to civilian life., Continued efforts were made to develop further service to the patients, as well as to organize and provide individual treatment. The patients who came to the Clinic at that time had recently had some kind of military experience and had been exposed to a group way of working and living.

Some of them

had been in hospitals where group treatment was given.

The

introduction of group psychotherapy in out-patient clinics seemed in keeping with the times. Previous studies of the Veterans Administration. Similar experiments were being made in other Mental Hygiene Clinics in the Regional Offices of the Veterans Administration as they too attempted to meet the treatment needs of the returning veteran.

For instance, in Boston, Massachusetts,

the Mental Hygiene Clinic, Regional Office, Veterans Adminis­ tration had introduced a group psychotherapy program when that Clinic was organized.

As a result of the early experi­

ments, this Clinic felt that group psychotherapy as a total treatment technique was of little value.

However, as a

preliminary or adjunct to individual treatment it was helpful in reducing stigmatization and isolation of the patients to the point that they became more accessible to individual treatment.

This was only a tentative conclusion and the

exploration of group psychotherapy as a treatment method was 3 continued. The Veterans Administration, in Washington, D. C. , is now in the process of writing an informational bulletin on the subject of group psychotherapy which will be available about September 1950.

According to V. C. Branham, M. D.,

Chief of the Out-Patient Section of Psychiatry and Neurology, Veterans Administration, Washington, D. C.: While there is a fair amount of group therapy being given somewhat sporadically by the various Mental Hygiene Clinics in the Regional Offices of the Veterans Administration, the subject has not been clarified and a good deal of variations in techniques exist.^ Two studies of group psychotherapy have been made in the Mental Hygiene Clinic, Regional Office, Veterans Adminis­ tration, Los Angeles, California.

One, under the title of

11Individual-Group Therapy,” was presented to the American

3

Morris H. Adler, Arthur Valenstein and J. J. Michaels, 11A Mental Hygiene Clinic— Its Organization and Operation,*1 (Mimeographed pamphlet of the Mental Hygiene Clinic, Regional Office, Veterans Administration of Boston, Massachusetts, 19W ) , p. lb.

19W.

** V. C. Branham, personal communication, November 28,

7 Orthopsychiatric Association in Atlantic City in February 1950.

5

Another study on the selection of patients for group

psychotherapy is in the process of being written. Social workers participation in group psychotherapy. During World War II and in the post-war period, along with the rapid development of interest in group psychotherapy, psychi­ atric social case workers and social group workers of neces­ sity were drawn into practice. professions had practiced.

Individuals of many different

Nurses, occupational therapists

and recreation workers sometimes took part in group psycho­ therapy, but those persons most frequently mentioned in the literature were physicians, psychologists and social workers.

6

The use of social group workers and psychiatric social case workers seemed logical in that at least some of them had had experience in a group approach to working with children.

Many

of them had also worked closely with psychiatrists in clinics and hospitals. In group psychotherapy, they sometimes worked in teams with a psychiatrist, participating as a mother-substitute

^ H. Michael Rosow and Lillian Kaplan, “IndividualGroup Therapy,11 (unpublished paper read before the American Orthopsychiatric Association, February 23, 1950)* 6 Edward Burchard, J. J. Michaels and B. Kotkov, “Criteria for the Evaluation of Group Therapy.11 Psychosomatic Medicine. 10: 262, September-October 19^8.

8 figure, much as they practiced in the first two groups that were started at this Clinic*

For instance, M. R. Friend and

W. F. Sullivan mentioned the use of psychiatric social work­ ers on their teams in treating groups at an army general hos7 pital. In other hospitals, where group psychotherapy was used as a method of treatment, some social group workers took part in the treatment groups hut more often carried on coordi­ nate activities in social group work, while the psychiatrist o

gave the group treatment. When group psychotherapy was introduced into the Mental Hygiene Clinic, Regional Office, Veterans Administration in Los Angeles, California, two psychiatric social caseworkers were active in both the beginning groups working in teams with the two psychiatrists.

Since that time more and more

psychiatric social caseworkers, some of whom have had some social group work experience, have been drawn into the prac­ tice of group psychotherapy at this Clinic.

It seems to be a

growing field for social case work and social group work par­ ticipation.

7

M. R. Friend and 1. F. Sullivan, “Group Psychother­ apy in an Army General Hospital in Relating to Civilian Re-ad .iustment.“ American Journals of Orthonsychiatry • 17: 256. April 19^7. ® Ethel B. Bellsmith and Joyce Edward, “The Role of a Social Group Worker at Central Islip State Hospital,“ Journal of Psychiatric Social Work. 1?: lto, Spring, 19^3.

CHAPTER II METHODOLOGY, TERMINOLOGY, AND ORGANIZATION I.

METHODOLOGY

It was necessary to develop material for this study* There was little recording as to what had gone into the plan­ ning and the introduction of the group psychotherapy program in this Clinic*

Through inquiry at the Clinic, the investi­

gator ascertained that three of the four persons directly involved in setting up the structure of the group psychother­ apy program were still in Los Angeles*

Two others, in addi­

tion to the Clinic Director, were currently employed by the Clinic and had been when, the group psychotherapy program was introduced in June The Clinic administration gave its approval for this research project and the utilization of Clinic resources to carry it out*

Individual consent for interviews was then

obtained from those persons interested and active in the establishment of the group psychotherapy program*

A schedule'*'

of specific questions to be answered was mailed to each person one week in advance of the appointment time*

The interviews

were conducted in an informal manner, but the focus held to

^ See Appendix, p* 71**

9

10 the factors listed In the schedule.

Verification by question

was made to ascertain that the information obtained was the product of the early group experiments and planning for it, rather than the result of later experience* In order to be able to conduct the interviews and evaluate the results, some knowledge of the historical .development of group psychotherapy, as well as the various approaches and methods was necessary. this area prior to the interviews.

Heading was done in

There were multiple pub­

lications on group psychotherapy between 19^3 and 1950 so it was impossible within the time limit to survey the entire field.

Selected reading, mainly in the area of the psycho-

analytically oriented approach to group psychotherapy, was of value in preparing to study the development of. the group psychotherapy program in the Mental Hygiene Clinic, Regional Office, Veterans Administration, Los Angeles, California. Records of only seventeen meetings of the first group were available for study and there were no records on the second group.

In order to clarify the results of treatment

to the patients it was necessary to examine the individual records as well.

In the first group, it was possible to trace

individual records through names from the group records.

For

the second, no listing was made of the patients receiving group treatment.

A search of individual records produced no

conclusive evidence though one case opened and closed during

11 this period indicated that the patient had made some progress in the group.

Due to lack of recording on this group it was

necessary to rely upon verbal communications with those per­ sons interviewed and a written report made by the Clinic Director on July 10, 19^7 for the results of treatment to the patients. In writing this study, notes_ from each of the inter­ views which were conducted in December 19^9 and January 1950, were compared.

The like opinions were used as a basis of

recording and the unlike opinions were included to bring out the variation in ideas present at the time that the group psychotherapy program began at this Clinic.

Problems met and

conclusions of other psychoanalytically oriented authorities practicing group psychotherapy during this time, were brought in to illustrate the generally experimental tone of the prac­ tice in this early post-war period. Those persons to whom the investigator is indebted for participating directly in providing material for this study are:

Miss Lillian Kaplan, now Psychiatric Casework Super­

visor, and formerly a psychiatric social worker at the Mental Hygiene Clinic, Regional Office, Veterans Administration, Los Angeles, California; John C. Mergener, M. D., private psychiatrist, *fl6 North Bedford Drive, Beverly Hills, California, formerly employed as a psychiatrist, and now a part-time consultant to the Mental Hygiene Clinic, Regional

12 Office, Veterans Administration, Los Angeles, California; Mortimer Meyers, Ph. D., Chief Psychologist, Mental Hygiene Clinic, Regional Office, Veterans Administration, Los Angeles, California; Mrs. Jean Livermore, formerly a psychiatric social worker at the Mental Hygiene Clinic, Regional Office, Veterans Administration, Los Angeles, California, and now Visiting Associate Professor in Psychiatric Social Work, University of California at Los Angeles; and Max Sherman, M. D., private Psychiatrist, 6333 Wilshire Boulevard, Los Angeles, California, who was formerly neurological psychi­ atric consultant at the Mental Hygiene Clinic, Regional Office, Veterans Administration, Los Angeles, California.

The

investigator is also indebted to Samuel Futterman, M. D., Chief Psychiatrist, Mental Hygiene Clinic, Regional Office, Veterans Administration, Los Angeles, California, for material on the results of the group form of treatment at the end of the first year of practice in this Clinic.

Letters written

by Dr. Futterman on July 10, 19^7 and April 12, 19^8 to Branch Medical Director, Branch Office 12, Veterans Administration, San Francisco, California, reporting on group psychotherapy were used as a resource in writing this thesis.

Personal com­

munication from V. C. Branham, M. D., Chief of the Out-Patient Section, Psychiatry and Neurology Division, Veterans Adminis­ tration, Washington, D. C. on November 28, 19^*9 and March 8, 1950 were of additional value in providing information on the

13 development of group psychotherapy studies on a national level.

The investigator is also indebted to the Research

Committee of the Mental Hygiene Clinic, Regional Office, Veterans Administration, Los Angeles, California, for assist­ ing in focusing and carrying out this study. II. Deep therapy.

TERMINOLOGY

In this study the term deep therapy will

refer to treatment aimed toward stimulating release of uncon­ scious urges and emotions and catalyzing new insight into the 2 meaning of deeper experiences. Group psychotherapy.

Group psychotherapy will be used

to refer to group treatment involving a systematic approach to the total personality including access to unconscious mechanisms, and bearing the potentialities of basic reorgani3 zation of personality. Non-directive therapy.

Non-directive therapy will

refer to treatment in which the therapistfs major activity is to clarify the subject content of the patient's verbalization

2 * Nathan W. Aeherman, "Some Theoretical Aspects of Group Psychotherapy," Group Psychotherapy (J. L. Moreno, editor; New York: Beacon House, 19*+!>) > P* 118.

3

Loc. cit.

l*f

in helping him to recognize and understand his own feelings b and reaction patterns. Pre-psychotic.

Pre-psychotic will he used to describe

a patient in whom all conditions for the development of a mental disorder exist and who is in a period of life prior 5 to the appearance of a psychotic break. Psychotic.

Psychotic will be used as a general term

to describe a patient with a severe mental disorder in the sense that all forms of adaption are disrupted and the disorganization of the personality is extensive. Psychoneurotic.

6

Psychoneurotic will describe a patient

with a psychiatric disorder resulting from the exclusion from consciousness of po\*erful emotional charges which in turn find expression in anxiety, phobias, compulsions, obsessions, and conversion phenomena.

Ordinarily a psychoneurotic individ­

ual possesses insight, that is he is aware that his symptoms 7 are manifestations of morbidity.' k

Carl Rogers, Counseling and Psychotherapy (Chicago: Houghton Mifflin Company, 19*+2), p. 125. Leland E. Hinsie and Jacob Shatzky, Psychiatric Dic­ tionary (Hew York: Oxford University Press, 19^-0). ^ Doc. cit. 7 "Nomenclature of Psychiatric Disorders and Reactions,11 Veterans Administration Technical Bulletin. TB 10A-78 (Washington, D. C., October 1, 1^47).

15 Schizoid*

Schizoid will refer to a patient with a

personality maladjustment who is in such a border-line state that he cannot be classified in either the neurotic or in the psychotic group*

Such individuals react with unsociabil­

ity, seclusiveness, serious mindedness, nomadism, and often 8 with eccentricity. Schizophrenic*

Schizophrenic will describe a patient

with a type of mental disorder characterized by emotional withdrawal from the world of reality*

The basic symptoms are

those of delusions and hallucinations, substituting a universe of fantasy for a universe of fact.

9

Supportive didactic therapy*

Supportive didactic

therapy will refer to a class method of approach to group 10 psychotherapy • III*

ORGANIZATION

The first chapter has presented and validated the prob­ lem, as well as to describe the setting in which social workers participated in group psychotherapy. Q

The second

Loc* cit.

9 Hinsie and Shatzky, loc* cit*

10 J. I. Meiers, “Origins and Development of Group Psychotherapy,*1 Group Psychotherapy (J. L. Moreno, editor; New York: Beacon House, 19^5) V p* 268.

16 chapter has been devoted to the method of making this study and the terminology used in it.

The third chapter is a

review of the literature to present the facts applicable to the understanding of group psychotherapy, both at the time the Clinic group psychotherapy program was introduced and trends at the present time. «

The fourth chapter presents the thinking and planning that went into the group psychotherapy program, illustrated by the experience, philosophy and attitudes of the Clinic administration and staff toward such a program, before the groups were set up. The fifth chapter describes and analyzes the first two groups, from the standpoint of structure and method of treatment• The sixth chapter presents the results of the experi­ ment for the patients, the staff, and the Clinic as a whole, at the end of the first year. The seventh and final, chapter restates the problem, summarizes the findings and states the conclusion reached by the investigator, together with recommendations for further study. The Appendix includes case records on the first group, the interviewing schedule, and significant letters.

CHAPTER III REVIEW OF THE LITERATURE ON GROUP PSYCHOTHERAPY Much has been written concerning the development of group psychotherapy and its application as a method of treat­ ment •

Only a brief summary of its history and the various

methods will be given.

The emphasis will be on the psycho-

analytically oriented approach to treatment of adults, with which this study is concerned. I.

DEVELOPMENT OF GROUP PSYCHOTHERAPY

The earliest scientific experiments in group psycho­ therapy were done by two men in the early twentieth century. In 1906 Dr. J. H. Pratt of Boston, Massachusetts, gave mass instruction to his tuberculous patients, later called his Thought Control Method.

It involved a lecture method and

relied heavily on a repressive-inspirational approach to 1 treatment• In 1909 Dr. J. L. Moreno of Vienna, Austria, began experiments with psychodramatie work with children, letting 2 act out their problems and fantasies. He emphasized the 1

’ J. H. Pratt, "The Group Method of Treatment of Psycho somatic Disordersyft Group Psychotherapy (J. L. Moreno, editor; New York: Beacon House, 19*+p) 5 P* 9i« . 2 J. L. Meiers, "Origins and Development of Group Psychotherapy," Group Psychotherapy (J. L. Moreno, editor; New York: Beacon House, 19^^) * p« 265.

17

18 element of spontaneity and at times, planned role playing, as a means of correcting personality disturbances.

He has con­

tinued to develop this method at St. Elizabeth*s Hospital in Washington, D. C.

In addition, Dr. Moreno developed his

sociometric method of measuring group problems, developing leadership and personality growth through democratic control and self-help.

The approaches have been widely used with

adult patients since. Other methods, such as the use of music, dancing, motion pictures, and puppets have been used as a stimulus to group 3 treatment but to a lesser degree. II.

REVIEW OF LITERATURE OH GROUP PSYCHOTHERAPY

The analytically oriented method of group psychotherapy with which this study is concerned was used by a few men in the 1920*s but the first recording of organized interest appeared in the American Psychiatric Association meeting in if Philadelphia, Pennsylvania in 1932. In the last fifteen years there has been a tremendous increase in interest as to its use and a national association, the American Group Therapy Association, was established in 19^2.

3 Edward Burchard, J. J. Michaels, and B. Kptkov, “Criteria for the Evaluation of Group Psychotherapy,M Psycho­ somatic Medicine, 10: 261, September-Gctober, 19h-8. k ^ Meiers, op. cit., p. 263.

S. R. Slavson worked with children for many years and found some of his experience applicable to the group treat­ ment of adults.

He employed an activity method of group

psychotherapy with children, utilizing play, crafts and other mediums of expression.

Through activity the child found

release from internal conflicts and gained a derivative insight into his behavior in learning adaption to reality. The atmosphere created, was one of unconditional love and per­ missiveness, with the group itself exerting control. interpretation was rarely given.

Verbal

Dr. Slavson felt that

character formation through a group experience modified or eliminated "egocentricity or psychological insularity."

The

individual derived satisfaction from receiving support and response from others, conforming to the group through his desire to be accepted.

With adolescents, he used a discus­

sion method of treatment•

More direct insight was achieved

through verbal communication, and he felt that this method 5 was effective in treating adults. Paul Schilder, used the group discussion method of group psychotherapy with adult psychoneurotic patients in the out-patient department of Bellevue Psychiatric Hospital in New York City, New York.

He utilized written material from

^ S. R. Slavson, "The Field and Objectives of Group Therapy," Current Therapies of Personality.Disorders (Bernard Glueck, editor; New York: Grune and Stratton, 19w ) , p. 188.

20 the patients or disguised case histories to get the discus­ sion started.

He interpreted dreams and the patients1 reac­

tions to each other, pointing out that the therapist’s job was that of guiding the group toward insight.

Ho tended to

give concurrent individual psychotherapy only when a member met some difficulty he was unable to resolve in the group, but the patients were given individual interviews before entering the group.

He felt that group psychotherapy was

especially successful with a kind of social neurosis,

6

Louis Wender experimented with group psychotherapy in hospitals with mental patients, and utilized considerable individual, treatment in conjunction with group treatment.

He

usually began with a talk to give some understanding of the subconscious mechanisms over which the patients had no con­ trol,

Sometimes disguised case histories were used to illus­

trate the symbolic expression of conflicts.

The group

interaction was used to enable patients to live out some of their early fixations.

Dr. Wender acted as an arbitrator and

observer, interpreting and re-directing the discussion if a patient seemed to be particularly threatened.

He structured

his treatment pattern with himself as a father figure and a nurse as a mother substitute figure.

He came to the

Paul Schilder, "Results and Problems of Group Psycho­ therapy in Severe Neurosis,** Mental Hygiene. 23 s 89, January 1939.

21 conclusion that group treatment was not a time saver in that 7 it was often combined with individual treatment, Nathan Ackerman, in his use of group psychotherapy, did not use so much concurrent individual psychotherapy.

He began

his group treatment by outlining the method and aim, encour­ aging the patients to speak spontaneously of their conflicts and anxieties.

After the group got started he became an

active participant and stabilizer, encouraging the members to interpret the meaning of behavior to each other.

His role

was that of a father figure to a group of sons and he did not have a mother substitute figure in the group.

He felt that

the group helped individuals to externalize patterns of emo­ tional conflict more quickly than, individual treatment and heighten the expression of emotional drives.

In a group situa­

tion, each patient could test out his treatment gains. In choosing patients, he tried to combine those with similar conflict patterns and balanced the timid and aggres­ sive personalities.

Dr. Ackerman came to the conclusion that

group psychotherapy was neither a substitute or competitor of individual treatment, but an independent method with charac­ teristics of its own.

It seemed best for patients with a

chronic tendency toward failure, perfection, or emotional

^ Louis Wender, "Group Psychotherapy,** Group Psycho­ therapy (J. L. Moreno, editor; New Yorks Beacon House, 19^5)> p. 108.

isolation* J* W. Klapman had considerable experience with group psychotherapy in mental hospitals.

He used a class method of

treating groups bringing material* such as disguised case histories, to the patients.

These were discussed as the

characteristics applied to the group's problems.

The patients

were helped to find out why they reacted as they did to the material and to each other, with the therapist guiding them toward correct interpretations.

Dr. Klapman was of the

opinion that the group was an enemy of patients remaining self-centered and that the corrective experience was based on identification with the therapist and the other members.

He

felt that individual psychotherapy in conjunction with group 9 treatment seemed most effective. Military use of group psychotherapy.

Previous to

World War II there was some efforts to use group psychotherapy with adults in extra-mural clinics to help patients adjust after discharge from hospitals.

The major development of its

use outside of hospitals, however, was in working with

Q

Nathan Ackerman, "Some Theoretical Aspects of Group Psychotherapy," Group Psychotherapy (J. L. Moreno, editor; New York; Beacon House, 19^5), p. 121+. ^ J. W. Klapman, "Observations on the Inter-relation of Group and Individual Psychotherapy," Journal of Nervous and Mental Diseases. 101: 2*4-2, July 19*+P*

23 10

children, mothers, and youth. Group psychotherapy as a method of treatment gained real impetus during the war.

It was used as an expedient in

the early days, receiving official recognition by the War * *

11

Department in 19^-h-.

Its use spread rapidly in the military

hospitals where the limited number of psychiatrists were faced with an insurmountable number of patients. This form of treatment seemed to be fitting because of the group nature of the military organization.

There was an

awareness of the unifying quality and the security that developed through men facing common problems together.

The

setting was uncomplicated by the economic needs and different social environments met in civilian life.

Lectures, discus­

sion, psychodrama, motion pictures or a combination of these methods were used with varying degrees of success.

In the

evacuation hospitals, the treatment was primarily directed toward getting the patients well, enough to return to active service, or, when this was not possible, return them home for further treatment. In convalescent hospitals it had further application, and was widely used not only as a form of treatment but to

^

Burchard, Michaels, and Kotkov. op. cit., p. 259•

^ War Department Technical Bulletin. TB 103, cited by Meiers, op. cit., p. 272.

2b

encourage cooperation and raise morale.

For instance, ward

members might be asked to join groups around some particular interest.

Mien a group member became uncooperative, the

group was asked to come to a common solution about him.

In

this way, they were confronted with the reality of the hos­ pital operation.

Dr. Foulkes in his experiments in Northfield

Hospital in England combined 'psychoanalytically, oriented group 12 psychotherapy with this group orientation. Drama therapy which has since seen further development by J. L. Moreno, was used with psychotic patients in Fitzsimmons General Hospital in Denver, Colorado.

Patients

were helped to ventilate fixed emotional attitudes either by discussing and then acting.out their ideas, or acting out traumatic.episodes encountered during military service.

Roles

assigned might include a patient who hated an officer taking the part of an officer to gain insight and understanding. Mien drama therapy was used, discussion of individual emo­ tional reactions followed, either within the group or individ13 ually, afterward, with the psychiatrist. Many different professions took part in group

J. D. Sutherland and G. A.. Fitzpatrick, "Some Approaches to Group Problems in the British Army ,*1 Group Psychotherapy (J. L. Moreno, editor; New York: Beacon House, 19*+5), p. 220. ^ Lev/is Barbato, "Drama Therapy," Group Psychotherapy (J. L. Moreno, editor; New York: Beacon House, 19^5)> P* 158.

25 psychotherapy during this period.

The success of the treat­

ment varied with the practitionerfs knowledge, skill, and training.

Some of the treatment was effective, but some of l*f it did little good, and in some instances harm. i

Trends in the use of group psychotherapy.

Some of the

more recent articles on group psychotherapy present a trend toward the use of the method in private practice, and by other social agencies, in addition to its use in hospitals and clinics. Alexander Wolf, who had discussed group psychotherapy with the therapists of the second group at this"Clinic, is at present using group psychotherapy in private practice.

He

believes that twenty to thirty individual sessions should be given to each patient before he is introduced into the group. He stresses feeling reactions of one group member to the other as the vital core of the treatment.

In selection the

patients should have some homogeneity of character structure, age, education, and intelligence.

His patients have the

opportunity of voting a disrupting patient out of the group, to receive individual treatment before returning.

The size

of the group, he believes, should be from eight to ten patients as fewer fail to provide the interpersonal

^

Burchard, Michaels, and Kotkov, op. cit., p. 258*

26 provocation and activity necessary.

An equal number of women

patients in the group tend to make available chances to pro­ ject more sibling rivalry as well as to provide mother sub­ stitute figures*

Dr* Wolf sees gi’oup psychotherapy as a

method applicable to private practice as well as in institutional and clinic settings. S. R. Foulkes had practiced group psychotherapy in hospitals, out-patient clinics and in private practice.

He

sees patients before they join the group, and gives individ­ ual treatment concurrently, only when an individual^ problem requires more intensive work than the group can give.

Like

Dr. Wolf, he accepts about eight patients as an average group, and believes they should have a similar range of intelligence and education.

He prefers to mix shy, aggressive, conscien­

tious and irresponsible patients.

He sees value in all com­

munications and analyzes resistance that interferes with free association.

He encourages the patients to create their own

topics for discussion out of their reaction to each other. Private patients, he feels, are more consistent in attendance, but otherwise, similar to other groups.

He concludes that

group psychotherapy is best in dealing, with, “present problems when sufficient inner mobility is left to make control over

15

Alexander Wolf, “The Psychoanalysis of Groups,*1 American Journal of Psychotherapy. 3* 525 > October 19^9*

present behavior possible.11 John C. Mergener who conducted the first group at this Clinic is at present using group psychotherapy in his private practice.

He does not give concurrent individual sessions,

but feels that group psychotherapy can develop into an unique instrument itself, doing much the same thing as individual psychotherapy but in a different way.

He sees the additional

socializing.experience as helping the patients translate treatment gains into the wider experience of living more quickly than in individual psychotherapy. Max Sherman, who conducted the second group at the Clinic is also using group psychotherapy in his private prac­ tice.

He does not encourage concurrent individual sessions,

and sees the patients only a few times before they are intro­ duced into the group.

He combines passive and aggressive

patients in groups of about six or eight.

His role is one of

drawing the patients out and helping them to develop a common ground.

The patients themselves, gradually participate and

take over their self-treating function, with the psychiatrist taking part only when the group does not see the meaning of an individual's behavior. In other social agencies, psychiatrist and psychiatric

l6

S. H. Foulkes, Introduction to Group Analvtic Therapy (Hew Yorks.. Grune and Stratton, 19^-9) 5 p. l£V.

28 social workers are beginning to view group psychotherapy as a prevention of disorders, in addition to its._use as a method 17 of treatment. One such experiment has been conducted at the Mother*s Health Center in Brooklyn, New York, where group premarital counseling has been given.

Two to six couples are gathered

together for short term treatment, with a class method of approach.

Some selection is made in that those whose problems

seem to be too deep-seated for group treatment, are referred to psychiatric clinics for individual treatment.

The experi­

ment has been sufficiently successful to be continued over a period of two years. Group psychotherapy has been increasingly used with mothers and parents.

One such experiment in connection with

a children*s court has recently been studied.

18

Another experiment was conducted at the University of California Student Health Center in Berkeley, California, by two second year graduate students in psychiatric social work. They were under psychiatric supervision.

Five women students

1'7 Lena Levine and Jeanne Brodsky, **Group Pre-marital Counseling,11 Mental Hygiene. 33• 577, October 19^9 • Huth Schram and Bill Haddock, **A Study of the Verba­ tim Recording of Six Group Sessions Conducted by a Psychia­ trist in the Children1s Court ,*1 Journal of Psychiatric Social Work. 19s 127, Winter 1950.

29

whose anxiety around their inability to relate to others were treated.

Individual psychotherapy was given concurrent with

the group treatment.

At the end of this experiment in brief

group treatment, it was felt that group psychotherapy reduced feelings of isolation and provided a testing ground of experi19 ence but did not change basic personality structure. Further exploration and study may see the development of new fields for its use with the merging of psychiatrists* clinical knowledge and social workers* rich mature skills. Group psychotherapy is in the process of growth and gaining increasing numbers of practitioners.

When used with skill and

the necessary scientific restraint, it can make a real con­ tribution as a method of both prevention and cure.

19 Pearl L. Axelrod, and others, "Group Treatment of Social Anxiety in College Women,11 Journal of Psychiatric Social WorkT 19* 115* Winter 1950.

CHAPTER IV PHILOSOPHIC BASIS OF THE GROUP PSYCHOTHERAPY PROGRAM IN THIS CLINIC The group psychotherapy program was introduced into the Mental Hygiene Clinic, Regional Office, .Veterans Adminis­ tration, Los Angeles, California, in June 1 9 ^ on an experi­ mental basis.

It grew out of the individual staff member's

interest in trying to study its use through actual practice. The possibilities of such a program were discussed in staff meetings at the Clinic in a general way.

In these early dis­

cussions there was some variation in ideas as to how group treatment might be approached.

The variation seemed to stem

from individual staff member*s previous observation and experi­ ence with group psychotherapy. I.

DIFFERENCE IN IDEAS OF APPROACH

The major difference seemed to be whether the therapist should give psycho therapy in a group. pointing the therapist's efforts toward needs of the individual in the group, or psycho­ therapy through a group, where the therapists leaned more heavily on the interacting relationship patterns of the group as a medium of treatment and of self help. The structural differences of the group form of treat­ ment were discussed but did not seem to have much emphasis at

30

31 that time*

Some of the staff felt that a father and mother

figure, represented by a male and female therapist, might give a family pattern to the group form of treatment*

There

was some question by the second group leader, as to whether a female therapist was necessary* The Clinic administration and staff recognized that the process of personality growth and character formation began, and was heavily influenced by early family relation­ ships.

There was some thought that by bringing the individual

patients into a similar treatment pattern with all the members facing the same or like problems, they might be able to work them out together*

There was an awareness that group partici­

pation modified consciously learned behavior and liberated unconscious emotionally motivated responses.

Group psycho­

therapy might, therefore, be a means of getting to the patient*s problems earlier than in individual treatment. Administrative attitude*

Those who were interested in

this group form of treatment, obtained permission from the administration and were encouraged to try group psychotherapy to see what its possibilities might be.

The Clinic administra­

tion felt in that it had been used in military service and in hospitals, an effort should be made to see if it could be used successfully in an out-patient clinic such as the Mental Hygiene Clinic, Regional Office, Veterans Administration,

32 Los Angeles, California.

Group psychotherapy seemed a possi­

bility of adding another kind of therapy to the Clinic pro­ gram.

Those persons interested in the program and with some

experience in group treatment, charted their own course of action.

They were not asked to follow a set form of procedure

and were able to put into practice their own ideas as to treat­ ment structure and activity. Different experiences and background of the therapists. Dr. J. C. Mergener, a psychiatrist, began the first group assisted by Miss Esther Wagner, a psychiatric social worker. Dr. Mergener had previously observed Dr. A. A. Loi^e treat groups at the Neuro-psychiatric Institute in Chicago, Illinois. He had also carried on some group treatment in army hospitals in connection with individual treatment of patients.

It was a

supportive, didactic kind of treatment rather than a deeper analytically oriented form that he hoped to try with this group.

Just before coming to this Clinic, both he and

Miss Wagner had conducted groups together at the Veterans Psychiatric Clinic in Los Angeles, California.

They carried

over some of their.ideas as to a structure and use of group psychotherapy into their practice at the Mental Hygiene Clinic, Regional Office, Veterans Administration, Los Angeles, California.

Dr. Mergener*s plan of conducting groups was

patterned somewhat after S. R. Slavson*s approach in working

33 with children,

although the adult patients might communicate

feelings through words rather than activity,

A father and

mother figure represented by a male and female therapist was used to help the patients express their emotional reaction patterns learned in early childhood#

Other members of the

group might represent siblings thus carrying out a complete family picture. Dr. Max Sherman, another psychiatrist who began the second group at the Clinic had a somewhat different viewpoint. He had been doing individual psychotherapy at the Clinic and became interested in group treatment so decided to set up a group of his own.

In 1939 he had sat in on some of Dr. Paul

Schilder*s group sessions with psychoneurotic patients at Bellevue Hospital in New York City.

Dr. Schilder had con­

ducted his groups without a female therapist so Dr. Sherman began his group in this way.

He had previously conducted some

groups in army hospitals during the war. Mrs. Jean Livermore, a psychiatric social worker, who later joined Dr. Sherman*s group as a female therapist had had experience with group therapy for children in a family agency in Cincinnati, Ohio.

She felt that it was so useful in deal­

ing with children*s problems that it might be equally as useful for adults.

From her previous experience she felt that a

^ J . C. M e rg e n e r, v e r b a l c o n v e rs a tio n .

31* father and mother figure present within the group might be an effective way of working with adults too* Treatment ob.iectives of the therapists*

In general

both the first and the second group were approached in an experimental way in an effort to develop more available and further service to the patients.

The therapists who began

the first group felt that this form of treatment might do the same thing as individual psychotherapy and consequently be a time saver, reaching more patients with a similar caliber of service.

It might on the other hand, be of value as a way of

introducing patients to what individual psychotherapy might involve.

They were uncertain as to what would result from

the experiment. The treatment was aimed toward personality and attitude change.

The primary aim did not include combining a socializ­

ing experience with working out individual problems in group sessions.

It was not directly geared to help patients adjust

to family or cultural settings either, even though it might be a resultant part of this group form of treatment.

CHAPTER V THE BEGINNING STRUCTURE I.

TIME

A psychiatrist, a diplomate of the American Board of Psychiatry and Neurology, and a psychiatric social worker, M. A . , a member of the American Association of Psychiatric Social Work, organized the first group in June 19^6. group met once a week for a period of nine months.

This Another

psychiatrist, also a diplomate of the American Board of Psychi atry and Neurology, began the second group in the fall of the same year.

The exact date could not be ascertained as no

record was kept.

This group was joined a little later by a

psychiatric social worker, M. A., a member of the American Association of Psychiatric SocialWorkers•

The second group

met once a week over a period of sixteen months, but the com­ position of the group had changed sufficiently_after seven months that it was evaluated from a treatment standpoint and results, in July 19^7 •

This evaluation was used as part of

the basis for this study. II.

DESCRIPTION OF THE FIRST GROUP

The patients were gathered together from the Clinic waiting list, primarily because no one was immediately avail­ able to give them individual treatment at the time.

35

Before

36 joining the group, each patient was given a few individual interviews with the therapists to prepare him for this group form of treatment.

This introductory process was not

recorded* The members of the first group were of a random selec­ tion consisting of four psychoneurotic patients and one prepsychotic patient.

Later the number varied from three to five

with at least three patients usually present at each group session. The recording on this group did not begin until September, 19^6 so that it was impossible to describe accu­ rately what had happened to the patients previous to that time. The group and individual records on the patients remaining, showed that two members of the original group, Jones, and Brown, continued until the group terminated.

A third member,

Doe, the pre-psychotic patient was dropped from the group for hospital referral before September 19^6, but the records did not reveal the exact time of leaving.. A few weeks after the group began, .a new patient, Smith, was added to the group and remained for a period of six months.

In January, 19^7

about the time that Smith, dropped but, four new patients came into the group but only one, V\lhite, remained until the group ended.1

The three others attended from two to four sessions

^ Fictitious names for patients, see Appendix.

37 terminating of their own accord. The group was composed entirely of males in the age range of the twenties and thirties.

Meeting periods were

once a week during the day and lasted about one and one-half hours.

Two therapists were present to conduct the group. The purpose of the treatment was deep therapy.

In the

early stages of the group the male therapist found himself taking an extremely active role and the female therapist a more passive one.

The group gathered around the male thera­

pist looking to him as children might to a father.

He dis­

covered himself doing a supportive didactic kind of therapy instead of the group utilizing him to guide them in a more inter-group self-treating way.

Some effort was made toward

direct interpretation of sibling rivalry; of their unconscious need of individual attention from the father figure.

As he

became increasingly aware of this problem through study of the group, he was able to use it in terms of a type of resistance to working out their problems with each other with the thera­ pist fs help.

The male therapist*s aim then became one of

helping the group to reach a working status where many of the usual social inhibitions were down and the patients might speak out to each other and obtain interpretation from coequals or 11siblingsH rather than, entirely from the male thera­ pist.

This, goal was not achieved though the male therapist’s

role did become more recessive.

He still symbolized the

38 authoritative figure to the patients and recognized that he was trying to do one thing, but was achieving the other, because he had not been fully aware of the difference in 2 approach to group and individual treatment. The presence of the female therapist in the group had a similar influence as a mother might have on a family.

The

patients were just as afraid to talk in rough language in front of her

as they might be before their mother.

However,

this did not

seem to keep them from discussing aspects of

their individual problems in any way. Recording. Recording of each group session was done by the female therapist.

There was some effort to take pro­

cess notes and then summarize the process after it was dis­ cussed.

The

success of this method varied as to how muchthe

female therapist was

drawn into the group discussion.

Indis­

cussing the notes, however, the two therapists found that in each individual's predominant defenses were consistently illustrated so that it was not so difficult to recall what had occurred even though complete notes were not taken.

The

recording had an additional value in that the therapists were able to discuss and study what had occurred in an effort to improve their skill.

The emphasis on the group rather than

J . C. M e rg e n e r, v e r b a l com m unication.

39 the individual was apparent in that the patients1 reactions to each other as well as to the therapist were recorded* following is an illustration of this early recordings 9-30-1+6. The group was led by a psychiatrist with a psychiatric social worker assisting# The patients present were Smith, Jones, and Brown#*^ The discussion today began around Doe, (a psychotic dropped from the group for hospitaliza­ tion and subsequently committed a violent crime) in whom the patients still expressed interest# Smith brought out that most of the patients had left the group and more or less directly, so he felt that it was because they weren't getting any good out of the group and had lost faith in the Clinic. He questioned what had happened to all the patients# The Psychiatrist went through the list of patients and it was brought out that some left because they felt too tense to stay in the group, or had left town or had gotten better and didn't feel the need of it any more# Jones began discussion about how it might be more helpful if doctors would tell a patient of the diagnosis so they would know where they stood. Jones told about some previous psychotherapy he had received in which he had a different schedule of things to do and to report on and the doctor gave him a good deal of suggestion# This resulted in Jones having a good deal of hope that things would improve# His difficulties were in the area of not haying a successful woman and some other ways# It turned out that in the end, although he had hoped, it seemed to be unfounded# Brown brought out the idea that maybe the doctors don't tell patients1 diagnosis and tell them what is wrong with them, because a patient might then become defensive and for every reason the doctor gave them, that there was something wrong with them, they could think up ten reasons why the doctor was wrong and

^ Fictitious names for patients, see Appendix

The

bo nobody would get anywhere. Brown at this point feels that the doctors are right in not telling patients what is wrong with them but letting them find out for themselves when they are able to take it. Smith in the meantime, had been striving for attention which the psychiatrist gave to him. It turned out that Smith is quite willing to acknowl­ edge that he always wants to be the center of attention and feels uncomfortable and left out if he isn't. In the course of the discussion, Jones raised the question as to whether he really wanted to get well or not. There was some discussion about the gain in not being well, that is the chance of avoiding work and responsibilities. Jones had a couple of examples of this which he contributed. Brown didn't think a person would want to avoid responsibility if it was for their own family. It was brought out though that many people remained ill because they feel certain types of responsibili­ ties. Smith brought the, subject back to the failure of doctors to cure patients. A discussion of this went on and the psychiatrist brought out the mechanism that Smith seems to want the doctors to do things for him and the general question was raised as to whether any doctor or institution can give a patient the full attention and care which infants enjoy from good parents. Brown brought out the opinion that perhaps Smith did not want to get well and came to the Clinic with the idea that he would not, which mitigated his becoming cured at the Clinic. Smith then wondered if this was his fault and the psychia­ trist said it was not a question of anybody's fault but just something that we had to look at and under­ stand. Smith wondered if he would ever get well if there was no hope and the idea was expressed that there was hope and he would change, that it would probably be Smith who changed rather than the doctors and environment from which he needed so much dependent help. Problems met.

It was apparent from this record that

in the first group, considerable difficulty was experienced

bl

in keeping it going. treatment.

The patients did tend to discontinue

The pre-psychotic patient in the group became*so

tense that it was necessary to drop him from the group because hospital referral seemed indicated. One factor which seemed to contribute to the insta­ bility of the group was that the patients were selected at random and hence there was a wide variation in background and types of illness.

S. R. Slavson felt that with a group of

adult male patients some homogeneity was important to prevent overstimulation and possible traumatization.

The members

should have some of the same psychological syndromes and some b degree of social and intellectual similarity. Another difficulty seemed to arise out of the small size of the group, although there were varying opinions on the subject at this time.

Some men who were experimenting

with group psychotherapy at the same time felt that too small a group failed to give the same therapeutic climate as a larger group of seven or eight, patients.

S. H. Foulkes

believed that at least two-thirds of the old members should 5 remain to give a group continuity of movement.

^ S. R. Slavson, “The Field and Objectives of Group Therapy,tf Current Therapies of Personality Disorders (Bernard Glueck, editor5 New Yorks Grune and Stratton, 19*+6), p. 175. ^ S. H. Foulkes, "Principles and Practice of Group Therapy," Bulletin of the Menninger Clinicf 10: 871, May 19*+6.

k-2

A third difficulty was that the therapists trained in working with individuals in a one-to-one relationship, were not fully aware of the different factors operating within a group, and automatically utilized their familiar skills in the new setting until they learned the different approach

6 required in group treatment* III.

DESCRIPTION OF THE SECOND GROUP

The second group began on a more selective basis.

More

time was taken in choosing individual patients through individ­ ual sessions.

All of the patients were intellectually or

educationally within the high school and college level.

No

particular attention was paid to cultural background although through accident rather than intent, they were all of the Caucasian race.

Marital status or previous service rank had

no particular bearing on the choice of patients so that there was actually considerable divergence in social background and experience.

The group was composed entirely of psychoneurotic

patients with no psychotic or pre-psychotic patients, nor were there any overt homosexuals.

There was some effort to balance 7 the passive and aggressive members in the group. During the time that the group were receiving group

6

J. C. Mergener, verbal communication.

7 Max Sherman, v e r b a l com m unication.

h3

treatment, the therapists had an opportunity to discuss selec­ tion with Dr, Alexander Wolf who felt that the addition of a schizophrenic patient might bring out material, mainly uncon­ scious to the other patients and therefore provoke a deeper

8

discussion in the group.

Such a patient was, therefore, added

to the group, but it was found that he was too “scattered11 a talker.

He became overwhelmed by some of the other members.

When one woman patient was added, there- was a similar result in that the male patients1 reactions toward women appeared too pointed at the one isolated female patient in the group.

In

both experiments these patients were dropped from the group to receive other treatment. Except for this brief period, the members were all male veterans between the ages of twenty-three and thirty-five, conforming with the general age span that came to the Clinic for treatment.

It was felt that it might be difficult for an

older man to be treated with such a group, but there was no rigid age limit.

This second group averaged from six to eight

patients in number.

They met together once a week during the

day, the sessions lasting from one and a half to two hours each time.

At first only one therapist was present, a male

psychiatrist, but later a female therapist who was a psychiatric social worker joined the group.

O

Jean L iv e rm o re , v e r b a l com m unication.

The beginning pattern was with the male therapist sym­ bolizing an authoritative or father figure to a group of sons. Mhen a female therapist was added to the group, it was done in the belief that although a group of women find a mother figure among themselves, there was some question as to whether men were likely to do this. The method of the treatment was non-directive therapy. In the early stages of this group, the male therapist found that he too, had carried over his previous analytical attitude to the group as a group of individuals.

The patients competed

for his individual attention instead of using him to help develop the potential of the group itself.

After some experi­

ence and recognition of the problem he learned something of using himself more as a balancer and director of group ener­ gies toward self treatment, intentionally taking a less active role.

He began looking at the. whole group and their inter­

action, applying himself to furthering it as well as guiding the treatment process, but felt he had only limited success because of his own inexperience in this form of approach. When a female therapist was added to the group she took a passive role, but participated in the discussions.

Her

presence proved to have a controlling effect upon the men in that it did tend to keep them from getting rough and aggres­ sive, yet did not seem to hamper the subject matter in any way.

It also had another effect.

In the female therapist's

^5 absence, the patients were able to express some of the hatred man has toward woman and relate it to their own individual experience.

Similarly in the male therapist*s absence such

reactions toward his authoritative figure appeared in varying degrees of intensity. Recording. recording.

In the second group there was little actual

The female therapist took notes while she was also

participating in the group, and they were used as a basis of discussion between the therapists after the session. manent records were kept.

No per­

There was some thought that a

stenographer might be necessary in order to develop an accurate record of what went on.

When the female therapist took part in

the discussion, she might visualize she was playing one role to the patient, while he might be reacting to her in an entirely different way and this factor could be missed without process recording. Problems met.

In the second group, as in the first,

there were similar signs of instability.

It was felt that,

especially in the early stages of the group, part of the turn­ over in patients was due to the lack of skill in developing a unity of spirit and helping them establish emotional and intellectual contact.

The patients, sensed this and competed

for individual analysis rather than turn toward each other for support and help in an inter-group way.

Another factor which seemed to effect the stability of the group was inexperience in selection of the patients for treatment, rather than lack of selection* A third difficulty seemed to be that the group met only once a week during the day.

This involved some reality

factors such as employment demands on patients, as they became more able to take or hold jobs.

CHAPTER VI RESULTS AND CHANGE IN THINKING IN THE FIRST YEAR OF PRACTICE At the end of the first year of experimentation with group psychotherapy the program was reviewed by the adminis­ tration and by the practicing therapists.

Only tentative

conclusions could be drawn as to the results of the treatment but the therapists had learned much from the year's experi­ ence. . I.

RESULTS TO THE PATIENTS

Direct results to the patients were difficult to esti­ mate not only because of the paucity of records, but because many of the patients in the first group, received individual 1 treatment concurrent with the group treatment. Because of this factor, it was difficult to discern how much the group treatment had directly effected the patients. Most of the patients of the first group dropped out in the early phases, before any records of the meetings were kept. Some became more anxious and were referred for individual

See Appendix, p. 70* (Four of the cases are described by means of disguised closing summaries from the individual records under the names of Jones, Brown, Smith, and $hite.)

*7

b8

treatment alone, and others dropped out after a few meetings with no appreciable change.

Only two patients of the origi­

nal group remained for the full nine months, and one of these showed slight progress.

A third member who entered the group

soon after it began, remained for a period of six months, until he was referred for individual psychotherapy because he proved to be a disturbing influence in the group.

A fourth

member who attended the group for the last three months of its 2 existence also showed some progress. Three other patients who entered about the same time as the fourth member, remained for only two to four sessions and an examination of the records indicated no clear reactions or effect from the group. The major results of the group treatment seemed to be in the area of maintaining the patients* current adjustment with some increase in feelings of support and in freedom of expression. In the second group, many of the patients also received individual treatment concurrent with the group treatment. Lack of any recording of the second group meetings made it impossible to ascertain which patients active at the Clinic from June 19^6 to June 19^7> received concurrent group and individual treatment, and which ones received group treatment alone.

It was, therefore, necessary to rely on verbal

^ Loc. cit.

**9 communications with the therapists of the second group for an estimate of the results. In the second group there were some changes and improvements in the patients who entered the group after it was well started, and remained until it ended.

Physical

symptoms particularly disappeared and some of the patients 3 were able to hold jobs or planned to marry. The socializing factor of the group treatment proved to emerge as one of the possibilities of the new approach.

The patients expressed

their feelings about the group form of treatment as reassur­ ance gained in being with persons who had problems similar or as bad as their own.

Some, however, thought they could

express themselves more freely in individual interviews. Dr. Futterman reported: The patients who receive maximum benefits from group psychotherapy are those with a kind of social neurosis in which the group acts as a kind of reality testing where they not only participate in the group but, are able to verbalize their feel­ ings in a group.4, II.

LEARNING RESULTS TG THE THERAPISTS

Although the first yearfs experience in group treatment

Max Sherman, verbal communication. h Samuel Futterman, Letter to Branch Medical Director, Branch Office 12, Veterans Administration, San Francisco, California, July 10, 19*+7•

5o

was rather a "shaky time,11 the therapists learned much from actual practice.

They studied their own experiences with

the groups as they went along.

In both groups it was

believed that treatment through the group was the most effec­ tive approach.

In the transition period the therapists

recognized the need of, and attempted to develop the vital factor of group interaction and unity as a medium of treat­ ment.

Through this they thought that the group itself could

provide the function of support and share in treating one another so that the therapists1 roles could be ones of guid­ ance and interpretation.

For instance, a member of the group

might interpret the meaning of individual reactions to one another.

The male therapist might break silences by some

additional information about the cause of emotional difficulties, but never in a lecturing or authoritative manner.

6

In choosing patients for the group it was felt that some homogeneity in education, intelligence, and experience was advisable and it was best not to have excessive age differences.

The various diagnostic categories in the neuro­

ses appeared to be compatible but there should be some balance between passive withdrawn and aggressive out-going individuals.

Mortimer Meyers, verbal communication. Futterman, loc. cit.

51

Psychotic patients should not be included in a group with psychoneurotic patients.

It seemed unwise to place an

extremely infantile schizoid patient in a group with overaggressive patients unless the group was limited to two or three members.

Patients too laden with anxiety seemed to be

disturbing to the group.

If female patients were in the group

they should be in a sufficient number to balance the males. The group form of treatment did not seem to be a time saver for the staff in that part of the patients received individual treatment during the period they were in the group. At the same time it was felt that perhaps it was unwise to attempt to continue individual psychotherapy while the patients were seen in the group, as they tended to save their difficul­ ties for the individual sessions rather than express them in the group.

One therapist felt that in a way, the group treat­

ment supplemented individual treatment.

Much came out in the

group sessions that had not in the individual interviews.

The

patients* resistance broke down sooner; each stimulated the other and the group sessions seemed more free-flowing than the 7 individual ones. The majority opinion, at the end of the first year of treatment, was that concurrent individual treat­ ment should be used only when a patient had a specific problem

Jean L iv e rm o re , v e r b a l com m unication.

52

he could not seem to resolve in the group.

8

Group psycho­

therapy did not prove to be useful in introducing patients to individual treatment. The general conclusion regarding group psychotherapy was that it played a role only secondary to individual treat­ ment and there was a question as to whether it was a time saver.

The therapists felt that the groups would profit by

meeting more than once a week but even in the evening hours it was difficult to get the patients together all at once, III.

RESULTS FOR THE CLINIC

In these early group experiments, it was apparent that only a tentative conclusion could be drawn as to the clinical value of group psychotherapy at the end of the first year of practice.

The experiments were too limited and tentative to

effect the Clinic as a whole.

In addition, the therapists

did not have enough previous training and experience in the use of group psychotherapy to produce the best results*

These

factors were taken into consideration in estimating its value to the Clinic.

The administration considered the possibility

of using it as an adjunct to individual treatment but no study was focused on this aspect of its use at the time. The program was retained on an experimental basis.

Q

F u tte rm a n , l o c .

c it*

It

gave indications of having unlimited possibilities as an approach to attitude change through the group, in addition to the socializing experience.

Because it did hold promise

through further study and experience, another full-timo psychiatrist began training in the method in an effort to get other groups started.

A new service was added at the Clinic

and a new program began. ^

CHAPTER VII SUMMARY AND CONCLUSIONS The purpose of this study has been to investigate the roots of the group psychotherapy program as it was introduced in the Mental Hygiene Clinic, Regional Office, Veterans Admin­ istration in Los Angeles, California,

This included recording

of the thinking and planning behind the establishment of the program, its early structure, and results at the end of the first year of practice. I.

SUMMARY OF FINDINGS

Examination of the theories and thinking on group psychotherapy at the time the program was introduced in the Clinic in June 19^6 revealed a wide variety of practice, but a great development of interest in learning more about its use. In keeping with this trend, the Mental Hygiene Clinic began an experiment in group psychotherapy with adult patients.

This

was only one year after the Clinic itself was established, and while it was still in the process of structuring its service to meet the increasing demands of the returning veteran, attempting to readjust to civilian life* The staff was primarily trained in giving treatment through a one-to-one relationship and there was some variation in ideas as to how to carry out a group psychotherapy program.

55 The major difference seemed to be whether to give treatment to a group of individuals, or give treatment through a group of individuals* Two staff members expressed their interest in trying the new method of treatment and the administration encouraged them to do so to see what treatment value it might have for an out-patient clinic*

Group psychotherapy was considered a

possibility of providing a further service to the patients. There was some thought that it might be a time saver reaching more patients with a similar caliber of service as individual treatment.

A few months later two other staff members

developed further interest and a second group began.

These

two groups were each conducted by teams consisting of a psychiatrist and a psychiatric social worker.

The teams had

to draw upon their previous experience with group treatment as a guide, and this experience was limited. The beginning philosophy of the new approach as a treat­ ment method was that personality and attitude change might be achieved by giving treatment to a group of individuals.

It

was not primarily aimed to eombine a socializing experience with working out individual problems.

Neither was it directed

toward helping patients test out treatment gains or adjust better to family or cultural settings, though this might be a resultant part of the treatment. The beginning structural pattern of the groups varied

56 only a little.

In both groups the male therapist, a psychi­

atrist, was to represent the father figure, and the patients the siblings so that they might be able to re-enact emotional patterns learned in childhood.

In this permissive non-

judgmental setting the patient might gain insight to reinte­ grate new patterns of emotional response.

In the first group,

a female therapist, a psychiatric social worker, was present from the beginning, to represent a mother figure to the patients.

In the second group another psychiatric social

worker, joined it for the same purpose soon after the group started. The number of patients varied from five in the first group, to eight in the second one.

In the first group patients

were chosen at random but in the second one, there was a more careful selection.

Meeting periods were once a week lasting

from one and one-half to two hours.

The first group met for

nine months and the second group for sixteen months.

Note-

taking was done by the female therapist in both groups.

It

was used as a basis for the therapists1 discussion after the sessions.

In the first group a summary record was then made

by the male therapists, but in the second group no permanent record was kept. The three major problems met in conducting the groups were felt to be:

(1) Inexperience in selecting patients who

might be able to work together and benefit by this form of

57 treatment.

(2) The therapists1 failure to recognize and

understand the importance of an inter-group Mcommunity of spirit,11 as the medium of group treatment.

(3) Their lack of

experience and skill in developing it when the need was recog­ nized. At the end of the first year of practice there was some change in thinking as to the application and use of group psychotherapy.

The therapists concluded that treatment

through the group was nlost effective and learned something of the need for and skill in developing interaction within the group.

In the selection of patients it was definitely felt

that psychoneurotic patients and psychotic and pre-psychotic patients should not be combined in one group.

In the first

year many of the patients received concurrent individual treatment with the group treatment but this did not seem to be advisable.

Some individual treatment before entering the

group seemed more desirable. Even though it was felt that the method had not been fully explored, it was considered only secondary to individual treatment and there was considerable question as to whether it would save time.

It was felt that the socializing factor of

group treatment had emerged as one of the important possibili­ ties of the new method of approach.

For this reason the possi­

bility of its use as an adjunct to individual treatment was considered for further exploration.

II.

CONCLUSIONS

Evaluation of the first year*s experiments with group psychotherapy can be made from two different aspects.

One

might be from the treatment standpoint and the other from the standpoint of program development. From the treatment standpoint, the first year*s experi­ ments did not prove too successful but an examination of the limited number of records available gave inconclusive evidence• The experimental aspects of group psychotherapy was reflected here as elsewhere during this period. The major difficulty in applying the group form of treatment seemed to arise from the therapists1 inexperience in selection of patients and their lack of understanding and training in the treatment of groups.

Their experience and

education had been primarily in treating individuals through a one-to-one relationship.

The therapists were not fully aware

of the different forces operating in a group, nor did they recognize the importance of and need to develop interaction and unity in the group.

When the importance and need was

recognized, they found themselves lacking in skill to help it happen. From the standpoint of program development, the experi­ ments were successful.

Psychiatrists and psychiatric social

workers, became aware of a need and showed individual interest in meeting the need.

They collaborated in recruiting support

and interest from other members of the staff, and from the administration.

With approval and encouragement of the admin­

istration, they set up a structure for group psychotherapy on an experimental basis.

Insufficient recording of the early

experiments reflects the pioneering nature of the plans.

At

the end of the first year, group psychotherapy showed suffi­ cient possibilities so that another full-time psychiatrist began training to carry on further experiments and an effort was made to get more groups started.

A new program was added

to the Clinic. III.

PROGRESS

Since that time there has been a continued expansion of the program.

There are seven groups receiving treatment at

the Clinic at the present time and a psychiatrist and psychi­ atric social worker practice in teams in each of the groups. They study and try to develop the quality of treatment.

For

instance, Dr. H. Michael Rosow, psychiatric consultant to this Clinic, and Miss Lillian Kaplan, psychiatric casework super­ visor, have been working with concurrent group and individual psychotherapy.

The result was reported before the American

Grthopsychiatric Association in Atlantic City in February 1950 under the title of ftIndividual-Group Therapy.”

This paper

demonstrated some of the value of the two way interchange of material, in group and individual sessions, and the advantages

60 of the multiple transference situation.

1

Staff education in group psychotherapy is provided through a bi-weekly seminar since the summer of 19^8.

A

psychiatric social worker has been active in planning these meetings since its inception.

The seminar gives staff members,

either interested or active in group psychotherapy an oppor­ tunity to discuss their reactions and ideas about this form of treatment.

Speakers selected from the staff or outside

speakers who have had experience in, or are now practicing group psychotherapy, attend.

In this way the Clinic staff is

able to develop or improve skill in the application of group psychotherapy• IV.

SUGGESTIONS FOR FURTHER STUDY

One question that arose out of this study was a com­ parative one concerning the amount and kind of previous train­ ing of group psychotherapists during this period, from 19^6 to 19^7*

When new groups were started in other clinics, how

did their experience and training compare or differ from the experience and training of the therapists in these groups? Another study that might be of considerable value in facilitating group treatment, would be a survey of what

H. Michael Rosow and Lillian Kaplan, 11IndividualGroup Therapy,11 (unpublished paper read before the American Orthopsychiatric-Association, Atlantic City, Georgia, February 23, 1950).

analytically oriented practitioners of group psychotherapy see as training requirements for the practice of group psycho­ therapy at the present time, A thix*d one of equal interest would be a survey opinion as to what psychiatric social workers* knowledge and skills contribute to group psychotherapy, A further study might be one of the development of group psychotherapy at this Clinic since the first year of experimentation.

BIBLIOGRAPHY

BIBLIOGRAPHY A.

BOOKS

Foulkes, S. H . , Introduction to Gr oup-Analytic Psychotherapy, New York: Beacon House, 19*4-9• 28l pp. Freud, Sigmund, Group Psychology and the Analysis of the Ego. London: Hogarth Press, 194*8* 127 pp. Hinsie, Leland E . , and Jacob Shatsky, Psychiatric Dictionary. New York: Oxford University Press, 19^0. Moreno, J. L., editor, Group Psychotherapy. House, 19^5* 26l pp.

New York:

Rogers, Carl, Counseling and Psychotherapy. Mifflin Company, 19h*2. Ppl 115-128,

Chicago:

Slavson, S. R . , An Introduction to Group Therapy. The Commonwealth Fund, 19^3* Pp. 1-2!?. B.

Beacon Houghton

New York:

ESSAYS

Ackerman, Nathan W . , “Some Theoretical Aspect of Group Psycho­ therapy,“ Group Psychotherapy. J. L. Moreno, editor; New Yorks Beacon House, I9V 5. Pp. 117-12>+. Bar bat o, Lewis, “Drama Therapy,11 Group Psychotherapy. J. L. Moreno, editor; New York: Beacon House, 19^5* Pp. 158-160. Meiers, Joseph I., “Origins and Development of Group Psychotherapy,** Group Psychotherapy. J. L. Moreno, editor; New York: Beacon House, 19^5* Pp* 261-281. Pratt, J. H . , “The Group Method of Treatment of Psychosomatic Disorders,11 Group Psychotherapy. J. L. Moreno, editor; New York: Beacon House, 19*+ Pp* 85-93* Slavson, S. R . , “The Field and Objectives of Group Therapy,1* Current Therapies of Personality Disorders. Bernard Glueck, editor; New York: Grune U. Stratton, 19*4-6. Pp. 166-193*

63

6b Sutherland, J* D., and G. A. Fitzpatrick, “Some Approaches to Group Problems in the British Army ,11 Group Psychotherapy* J. L. Moreno, editor; New York: Beacon House, 1 9 ^ 5 . Pp. 205- 22$. Wender, Louis, “Group Psychotherapy,11 Group Psychotherapy. J. L. Moreno, editor; New York: Beacon House, 19*+5» Pp. 108-111. ______, “Group Psychotherapy in a Psychiatric Hospital,” Current Therapies of Personality Disorders. Bernard Glueck, editor; New York: Gruene and Stratton, 19*+6. Pp. 1+6-58. C.

PERIODICAL ARTICLES

Ackerman, Nathan W., “Dynamic Patterns in Group Psychotherapy,” Psychiatry. ?• November 19^. ______ , ”Group Therapy from the Viewpoint of a Psychiatrist,” The American Journal of Orthopsychiatry. 13: 667-681, October 19?3. , “Group Psychotherapy with Veterans.” Psychosomatic Medicine, 2: 118-119, March-April 19bo. Axelrod, Pearl, Ann K. Baerwald, Flora M. Finney, Hubert S. Coffey, “Group Treatment of Social Anxiety in College Women,” Journal of Psychiatric Social Work. 19*. 107-115, Winter 1950. Bellsmithr^ "Ethel B., and Joyce Edwards, “The Role of a Social Group Worker at Central Islip State Hospital,” Journal of Psychiatric Social Work. 17: 139-1^6, Spring 19^-8. Burchard, Edward M. L., Joseph J. Michaels and Benjamin Kotkov, “Criteria for the Evaluation of Group Therapy.” Psychoso­ matic Medicine. 10: 257-271*-* Sept ember-0 ctober 19^S. Cohen, Robert A., “Military Group Psychotherapy,” Mental Hygiene. 31: M+-102, January 19^7* Foulkes, S* H . , “Principles and Practice of Group Therapy,” Bulletin of the Menninger Clinic. 10: 89-93* January

wwi

______ , “On Group Analysis .“ The International Journal of Psychoanalysis. 27* w-5l, Parts 1 and 2, 19^6.

65 Friend, M. B . ,' and W. F. Sullivan, “Group Psychotherapy in an Army General Hospital Relating to Civilian Readjustment,11 The American Journal of Orthopsychiatry. 17s 25*+-265? April 19Li-7. Grot John, Martin, “Experience with Group Psychotherapy as a Method of Treatment for Veterans,*1 The American Journal of Psychiatry. 103 s 637-61+3? March 19?7. Hadden, Samuel B . , “Post Military Group Psychotherapy with Psychoneurotics,“ Mental Hygiene. 31s 89-93? January 19^7. Health, Robert G., “Group Psychotherapy,“ Psychosomatic Medicine, 2: 118, March-April 19*+o. Klapman, J* W*, “Some Impressions of Group Psychotherapy,11 Psychoanalytic Review, 31s 322-328, July 19M+. ______ , “Group Psychotherapy in Private Practice a Prospectus,*1 Journal of Nervous and Mental Diseases ? 103 s 383-388, April 19^. “Observations on the Inter-relation of Group and Individual Psychotherapy,*1 Journal of Nervous and Mental Diseases, 101s 2^ 2-2^+6, 19*+5 • Levine, Lena, and Jeanne Brodsky, “Group Pre-marital Counsel­ ing,*1 Mental Hygiene, 33s 577-587? October 19*+9* Paster, Samuel, “Group Psychotherapy for Combat Neurosis.“ The American Journal of OrthopsychiatryT 15s 322-32o, July 19^+5. Redl, Fritz, “Diagnostic Group ¥oi%k.“ The American Journal of~ Orthopsychiatry, 1*+: 53-07? January 19W. ■, “Group Emotion and Leadership,11 Psychiatry. 5s 39o, January 19l+2*

573-

Schilder, Paul, “Results and Problems of Group Psychotherapy in Severe Neurosis,“ Mental Hygiene. 23s 87-98, January 1939* Schram, Ruth and Bill Haddock, “A Study of the Verbatim Record­ ing of Six Group Sessions Conducted by a Psychiatrist in the Children*s Court Clinic,11 Journal of Psychiatric Social Work, 19s 127-128, Winter 1950.

66 Shaskan, D. A., “Must Individual and Group Psychotherapy Be Opposed,11 The American Journal of Orthopsychiatry. 17s 290-292, April 1947. Slavson, S. R . , “Differential Dynamics in Activity and Inter­ view Group Therapy,11 The American Journal of Orthopsvchiatry. 17 : 293-302, April 19l 19^7 is as follows: "Patient felt he had made an ally of me when the entire world and himself might frown upon his indecision about his relationship with his fiance. He seemed to get considerable support from my suggestions and a more realistic attitude toward marriage (which he had discussed in the group.) and in taking a more active part in trying to understand his feelings. There has, however, been only a little improvement in his school work.11

APPENDIX B INTERVIEWING SCHEDULE

TO;

Mrs. Jean Livermore Dr. J. G. Mergener Dr. Max Sherman Miss Lillian Kaplan Dr. Mortimer Meyers Re:

Our Telephone Conversation

I hope to be able to answer the following questions in relation to the introduction of the group psychotherapy pro­ gram in the Mental Hygiene Clinic, Regional Office, Veterans Administration in Los Angeles, California. (Behind the experi­ mental aspect of it, there were undoubtedly certain philoso­ phies and theories as to why such a program might be useful, even though they were not recorded at the time.) 1. HOW WAS THE PROGRAM SUGGESTED; WHAT EXPERIMENTS IN THIS AREA INFLUENCED THE ESTABLISHMENT OF THE PROGRAM?

2.

A.

Did the Clinic as a whole decide upon such a program or did one or two persons suggest it, obtain permission and set up a demonstration group with others following later?

B.

Was there a difference in ideas as to how the plan should be carried out?

C.

What previous experience and knowledge did those persons active in the early group treat­ ment, bring to the Clinic that influenced their thinking as to how such a program should be set up and conducted?

HOW WAS THE PROGRAM STRUCTURE SET UP? A.

How many therapists began? What was their plan of conducting the group meetings?

B.

What was the structural characteristics of the groups as to size, sex, age and meeting periods?

C.

What kind of recording was done?

3. HOW WAS GROUP PSYCHOTHERAPY TO BE USED--IN PLACE OF INDIVIDUAL OR IN ADDITION TO INDIVIDUAL? A.

Was it to provide a testing of individual adjust­ ment, or for training to function more comfort­ ably as a community member?

7^

75 If. HOW DID THE THERAPISTS BELIEVE IT WOULD BE USEFUL TO THE PATIENTS? A*

Was it to meet some specific needs in person­ ality or attitude change?

B.

Was it focused more on helping the patient adjust to family or cultural setting?

HOW DID THE THERAPISTS FEEL IT WOULD BE USEFUL TO THE CLINIC? A.

Was it to meet some specific Clinic need such as the time element, staff limits 9 or program expansion?

6. HOW DID THE PHILOSOPHY CHANGE AS THE PROGRAM WAS PUT INTO PRACTICE AND AT THE END OF THE FIRST YEAR? A.

What needs did it seem to meet?

B.

Did it seem useful to the Clinic from the aspects of time, staff, program expansion and service to the patient?

I sincerely appreciate assist me with this study and tions will help in conserving a guide for the information I

Not to meet?

the time you are taking to hope that this outline of ques­ your time as well as to act as am trying to gather. Sincerely, (Miss) Vernie McCann Graduate Social Work Student The University of Southern California

APPENDIX G PERSONAL CORRESPONDENCE TO THE AUTHOR FROM V. C. BRANHAM, CHIEF, OUT-PATIENT SECTION, PSYCHIATRY AND NEUROLOGY DIVISION, VETERANS ADMINISTRATION, WASHINGTON, D. C.

VETERANS ADMINISTRATION WASHINGTON 25, D. C. March 8, 1950 Department of Medicine and Surgery

Your File Reference: In Reply Refer tot 10EDE

Miss Vernie McCann 680 Witmer Los Angeles, California Dear Miss McCann: A contemplated bulletin on Group Therapy, as indicated in your communication of March 1, has not developed, because of the larger aspects of the whole matter which will be taken up in a special Round Table on the subject at the Annual Meeting of the American Psychiatric Association May 2* A number of the topic leaders are submitting papers on selected topics, and it was thought that material might be made available in this way which should be included in any kind of Technical Bulletin or informal bulletin which will finally be prepared by Veterans Administration for field consumption. At the present writing it looks as if it might be about the first of September that distribution of this material will be made. Your interest is much appreciated. Very truly yours., V. C. BRANHAM, M*D. Chief. Outpatient Section Psychiatry and Neurology Division

77

78 VETERANS ADMINISTRATION WASHINGTON 25, D. C. November 28, 19^9 Department of Medicine and Surgery

Your File Reference: In Reply Refer to: 10EDE

Miss Vernie McCann 680 Witmer Los Angeles, California Dear Miss McCann: Your communication of recent date addressed to the Veterans Administration Office of Publications, on the subject of group psychotherapy programs in Veterans Administration Mental * Hygiene Clinics, has been referred to this Section for reply, I would advise that this Section is in process of writing an informational bulletin on the subject of group therapy and that a considerable number of sources have been tapped for information. While there is a fair amount of group therapy being given somewhat sporadically by the various Mental Hygiene Clinics in the Regional Offices of Veterans Adminis­ tration, the subject has not been clarified and a good deal of variations in techniques exist, I do not believe I could tell you offhand the amount of this work that is being done, since it is all at field level. If your studies will permit you to wait a few months, I believe that this office will have some very interesting information to impart to you on this subject. Very truly yours,

V. C. BRANHAM, M.D. Chief, Outpatient Section Psychiatry and Neurology Division