Schizophrenia from a Group Perspective

Marvin Skolnick

This paper is an effort to acknowledge my appreciation to Wilfred Bion. His work on group dynamics and psychoanalysis of psychotic patients has inspired me throughout my work with chronically mentally ill patients in groups.

The schizophrenic disorder has as one of its most prominent features the estrangement of the inner world of the self from the social world of others. It would seem that dynamic group psychotherapy, which links the domains of the psychological and the social, would be a logical frame for its study and treatment. The hermit sitting alone in a cave or a hallucinating schizophrenic eschewing relationships with others cannot be helped without appreciation of the group context that spawned his isolation and in which he remains embedded. Schizophrenics are frequently grouped in programs called "psychosocial" that focus on delivery of medication, education and behavioral training. However, the use of the group as both a lens through which to explore the links between group process and the creation of schizophrenia and as a natural medium for treatment of the split between the schizophrenic and the group is increasingly neglected in mainstream psychiatry. Why?

An obvious reason is the resistance of the schizophrenic, whose way of life actively avoids emotional contact with the group. He repels others through the strangeness or menacing quality of his solipsistically created world of bad objects, or takes on a opossum-like stance that often convinces those around him that he is inert or non-human. He lives the conviction that his emotions are too toxic, shameful or destructive to be borne by himself or anyone else. Another less obvious reason is the resistance of normative groups to make emotional contact with an individual considered psychotic except in a quarantined stereotypical role as a diseased madman. Too often therapists and treatment systems consciously and unconsciously embrace the belief that emotional contact with the schizophrenic will be destructive or counter-therapeutic. An integration of the "madman" in the group requires not just an empathic understanding of the painful and strange inner world of the patient, but the development of a capacity not to recoil from what is stirred within by emotional contact with the schizophrenic.

Psychotic anxiety, the group, and clinical psychosis.

In the Kleinian world of the infant and young child the inevitable failures of the good breast to be unfailing present, stir rage, greed and envy that threaten the annihilation of the self or the breast (nurturing other). Unconscious fantasies involving the imagined contents of the mother's body such as poisonous penises, fecal babies, cavernous breasts utilizing evocative projective identification and splitting protect against paranoid schizoid anxiety or persecution and depressive anxiety about the destruction of the internalized good breast.

Klein(1959) and her followers including Bion gradually appreciated that these psychotic anxieties and paranoid schizoid processes that were inferred from the analysis of very young children were not mastered and left behind by entry into the depressive position. They intruded directly in the waking consciousness of clinically psychotic patients. They also persisted throughout adult life behind repressive barriers in the clinically non-psychotic. Analysis of adult dreams and material from analytic work with neurotics have revealed an ongoing mutually constituting dialectic between paranoid/schizoid and depressive modes of experience throughout the life cycle (Ogden, 1989). Bion also noted the power and ubiquitous nature of psychotic anxiety and the integral part it plays in stimulating the development of group basic assumptions that are constituted by the valences of group members to play part - object roles in unconsciously orchestrated symphonies of projective and introjective identifications. "Man is a group animal at war with his groupishness. ....The adult must establish emotional contact with the group in which he lives (or works). This task appears as formidable to the adult as the relationship with the breast is to the infant and the demands of the task are revealed in his regression." (Bion, 1961)

Bion was instrumental in developing an appreciation of the constructive use of projective and introjective identification, which serves as a bridge between the inchoate mind of the infant and the receptive mind of the mother. Projective identification enables the infant to transfer its nameless dread and beta elements into the receptive mother where it can be contained detoxified, alphabetized named and given back to the infant in a form that can be used for the development of thinking and the experience of being able to suffer one's own pain. The ability to suffer one's pain allows for the emergence of depressive organization with its capacity for reparation, gratitude and love of differentiated others. In Experiences In Groups, Bion emphasized the dialectic relationship between the basic assumption group steeped in paranoid schizoid dynamics and non-reflective instinctive reactivity (valence) of its members, and the work group created through use of the developed capacities of its members for differentiated cooperative behavior derived from what is learned from experience cohered into a more depressive organization. The capacity for a self/other differentiated, rational cooperation characteristic of a depressive mode of organization is essential for participation in the work activities of group life from child rearing to bridge building. However, at the same time at another level the group wrestles with the part-object irrationality of the paranoid/schizoid organization. Bion's penetrating insights revealed that the group at this unconscious level is experienced as the mother's body. The group thus becomes both the precipitator and container for psychotic anxiety after the actual symbiotic mother has receded into the background. Because a blissful reunion with the group as nurturing breast is impossible, destructive impulses and emotions such as envy, rage, hatred, greed, guilt, and shame are stirred and defended against as they were in infancy. Through complex unconscious communication mediated through projective and introjective identification these encounters and collisions are transformed into a coordinated dance of primal part-objects in the Basic Assumptions. In the level of the group unconscious members take on roles that personify good and bad breasts or creative and destructive penises that play out the basic assumptions as they did in infancy.

At first glance these formulations of what transpires in the unconscious dynamics of groups may seem more bizarre than the creations of the most florid psychotic. The correspondence between the mental content and process of clinically psychotic patients and the unconscious content and process of groups and organizations composed of "normals" is striking. The presence of Basic Assumption in all groups without regard to the mental health of its members again suggests the fine line that exists between the clinically psychotic individual and the psychotic like processes that pervade group life. As in the case of Nazi Germany, whole nations can be taken over by basic assumptions in their most paranoid primitive form leading to murderous enactments of part object dramas while members of the group when scrutinized as individuals reveal a "healthy" mental health profile by DSM standards. Menzies (1975) using Bion's formulations showed how the administration of a teaching hospital treating terminally ill patients impelled by basic assumption dynamics as defense against annihilation anxiety, developed a social system with an elaborate set of policies and procedures that walled off patients from meaningful personal and emotional contact with staff. Group Relations Conferences (Miller and Rice, 1967) offer opportunities to individuals in leadership positions for experiential study of interrelationship between group process, authority and leadership. Although participants in these conferences are screened to exclude persons with psychiatric disorders nevertheless members invariably play out primitive dramas enlisting members into starring part object roles that often take on the trappings of madness. With a few exceptions if the conference attends to its task to study the unconscious collaborative nature of the group process, these individuals are relieved of their roles as containers of madness or isolates and learn a great deal. In Bion's formulations the Basic Assumptions defend the collective against direct encounter with the primitive psychotic process latent in human relations. However, in groups that remained fixed in defensive patterns and don't work toward reowning projected parts, vulnerable individuals are at greater risk of being fixed in pathological roles.

The Schizophrenic and the Family Group

Much attention has been given to the failure of the contained / container relationship with the mother that skews the personality of the child toward dominance of the psychotic part of the personality in order to content with emotional pain. The psychotic personality as described by Bion (1967, 1977) with its excessive reliance on evacuative projective identification, subversion of the mental apparatus that generates and processes experience and attacks on emotional links with others may well be the psychological bedrock of schizophrenia. The vulnerable child's involvement in the group relations of the nuclear and extended family can serve to rectify this skew, or propel the child further down a path toward schizophrenia. In this respect the family can be seen as a primary training ground for both healthy group relations and schizophrenia (Lidz & Fleck, 1973; Wyne, Ryckoff, Day, & Hirsch, 1958; Robbins, 1993). The move from the symbiotic mother/infant relationship to the more complex psychology of the multiperson field of the family is crucial to become a feeling, thinking member of peer, school, family, community and work groups of adult life. If basic assumption subverts the work group function of the family in terms of child development the child with tendencies toward schizophrenia is likely to become fixed in roles that ill prepare him for group relations outside the family. He is likely to remain excessively dependent on the primary caretaker, without role flexibility and capacity to contend with competition, jealousy, envy, and other complex emotions inherent in group life.

The Psychotic Break and the Group

Studies like those that show a schizophrenic can be identified from early childhood family picture albums (Walker and Lewine, 1990) suggests that the schizophrenic process does not begin in late adolescence or early adulthood, but much earlier. Unable to adequately share the pains of experience with his primary caretakers throughout his development, he increasingly relies on more drastic measures to make going-on being bearable. He turns away from links of love and hate, accepting impoverished and constricted roles. With impaired capacity to differentiate between self and other, he often serves as a repository for split off projections of others. He handles his own emotional experience of group life by massive projection into distant non-human targets Bion termed "bizarre objects." His capacity to experience life is greatly diminished. He no longer suffers enough of the pain of relating to fuel development because it has proved too unbearable. However, as long as the potentially schizophrenic individual is nestled in his family group these difficulties can remain in the shadows. It is when the vulnerable individual makes attempts to move out of the family nest into college or work settings in which his inflexible roles in the group are not tenable that psychosis often blossoms into a clinical syndrome. With this stress on family symbiotic ties the containing world as known by the schizophrenic disintegrates. Delusions and hallucinations can be understood as attempts to reestablish a sustaining world that is cut off from the unreceptive world of others.

Treatment and the Group

Meaningful treatment should include an emotional reconnection with a group--a world of others--that individual psychotherapy alone cannot usually provide. The psychotic break is not just a tragedy, but as R. D. Laing (1968) has suggested, it can also be a breakthrough. It is an opportunity through treatment to find a group that can cultivate and appreciate strengths and be empathically nurturing in respect to weaknesses. The conventional school and workplace groups usually demand too much of the schizophrenic. After his break the schizophrenic usually finds himself in a mental hospital, a halfway house, a day program, or aftercare clinics -- society's social holding environments. These groups usually stress medication compliance and behavioral conformity. The promise of neuroleptics to cure schizophrenia, particularly the negative symptoms, has not been realized and there is some evidence that negative symptoms like emotional flatness, lack of initiative and social estrangement are exacerbated by medication and lack of social stimulation. Even the most enthusiastic advocates of behavioral social skill training and other behavioral approaches which minimize emotional engagement in favor of acceptance of illness have acknowledged that these interventions seldom generalize to other settings (Lieberman). These approaches often mirror the schizophrenic's belief that emotional connection and expression is toxic. In the enthusiastic embrace of biological explanations that dismiss meaning, the links between the schizophrenic person, other persons, and the social context are attacked in ways that reiterate the pathological symbiosis. It is here that a group that is receptive to emotional connection, finds meaning in experience and believes in the possibility of development can offer the patient a chance to revive a social self.

While Bion viewed contact with the group as vital in sustaining one's status as a viable human being, he did not explicitly propose the psychotherapy group as a container and development agent of psychotic anxiety as he did the mother/infant or the psychoanalytic dyad--that it could serve as a container not just defensive in nature but also for the development use of projective identification leading to transformations. Rather, In Experiences in Groups his accounts of his work in therapy groups suggest that he was less ambitious about the group's use aside from providing opportunities for its members to become acquainted with the phenomena of basic assumption and its hazards. By becoming more aware of these primitive processes, the individual would be better equipped to hear the siren songs of group life without so innocently crashing on the rocks, and better able to use his energy for participation in the more sophisticated activities of the work group. The psychotherapy group would thus only indirectly encounter and treat the neurotic and psychotic core of the individual. I suspect that Bion did not pursue his insights toward greater therapeutic use of the group for complicated reasons, one of which may have been discouragement by Melanie Klein.

However, Bion did not stop thinking about the group nature of being as reflected in Attention and Interpretation and Memoirs to the Future. His thoughts about the mystic and the establishment delineate the two edged nature of the relationship of the group and the disturbing individual. The relationship can be parasitic and mutually destructive or it can be symbiotic and mutually enhancing in which disruptive thoughts can be contained and tamed in the group in a way that expands possibilities for constructive use for the society. For example, the group that formed around Freud was able to contain the creative but disruptive thoughts about the power of the unconscious in human affairs to muddle reason, thus making disturbing truths more available for use by the society as a whole. I would like to suggest that the schizophrenic can be viewed in the Bionic sense as a mystic carrying into the group in raw form what has not yet been transformed and integrated from the real into symbolic register of the mother/infant relationship, the family or the wider culture. The schizophrenic and the group have the potential for either a parasitic destructive, commensal or mutually enhancing symbiotic relationship. Too often the relationship devolves toward the parasitic or commensal relationship in which in chronic schizophrenia and the established group either damage each other or are like ships passing in the night. The result is that the schizophrenic is shut out of the use of the basic assumption level of the group that non-schizogenic individuals are able to use as both a shelter from the chaotic and potentially overwhelming aspects of the human condition and as a transitional space in which in Winnecott's sense the frightening aspects of the subjective part object world can be encountered with others in play allowing for higher levels of integration and differentiation. In the Northfield experiment Bion used the group as the primary therapeutic agent for individuals encumbered and isolated as carriers of the uncontained traumas of war (Bridger, 1985). Why not use the group as a therapeutic agent for the schizophrenic who can also be seen as a carrier of the uncontained unmetabolized traumas of failed relationships.

Most treatment programs for schizophrenics are based on the notion that schizophrenia is primarily a brain disorder in which medication, education, behavioral techniques and the reduction of stress are the standards of treatment as they are in most chronic medical conditions. However, a careful review of the science of schizophrenia which is beyond the scope of this paper suggests that the role attributed to biology in schizophrenia is open to serious question (Breggin, 1991; Mender, 1994; Robbins, 1993; Sass, 1992). Science is not infrequently used to rationalize social systems that are less oriented to meaningful work than defense against anxiety generated by the task. This seems to be particularly true in the case of the task of managing the schizophrenic. Scientifically justified barriers against emotional engagement sequester the clinically psychotic patients into one dimensional roles that ignore the non-psychotic parts of their personality, their potential for growth, and buffer families and treatment staff from more direct contact with the psychosis of everyday life.

As a psychiatrist working in a community mental health center in 1971, I was confronted with the task of caring for psychotic patients who were either not being admitted or were being ushered out of mental hospitals during a high tide of deinstitutionalization. Out of the necessity of providing treatment for numbers of patients who far exceeded our capacity for meaningful individual treatment, I began a day treatment therapeutic community that used the group as the primary treatment and holding agent. Inspired by experiences in Group Relations conferences, the work of Bion and Winnecott, I proceeded with the faith that schizophrenics could profit from emotional involvement in a group that respected their autonomy and their capacity to learn from experience. After twenty six years of work in this crucible, my faith has been tested but strengthened by my experience. However, I now more fully appreciate the enormity of the task and the resistance in everyone to such projects -- in the patients, the families, the staff, and the institutions involved.

In the time allotted I can only summarize some of what I have come to believe are crucial factors in developing and sustaining a community that works for schizophrenics. From an economic standpoint it can be done cheaply, requiring only a place to meet and a few staff, but the challenge resides in learning how to function as a group that contains the uncontained.

The schizophrenic brings to the group what was not adequately contained or metabolized in his family group, school or other social contexts. For the group to be therapeutic, it must become a home for what have been homeless thoughts and feelings. This requires of the group the development of a negative capability or reverie -- that is with the staff leading the way an ability to be "to live in mystery and doubt without irritable reaching after fact or reason (Keats)." Patients are encouraged from the beginning to express themselves fully including what has been previously responded to as symptoms of brain disease. Delusions, for example, are treated as concrete metaphor asking for loosening so that they can be used symbolically as reflecting something about the real world that needs to be included in the social discourse. Forms of extra verbal expression such as art, dance, movement, and psychodrama help patients who have not yet developed speaking but who can often communicate poignantly using other channels. Group enactments in which primitive affects of hate and love, envy, jealousy are made available for interpersonal and group processing rather than left to subvert the psyche of the patient. As members begin to trust that the emergence of their hate and love will not destroy themselves or others, the group can be used increasingly as a stage for improvisational theater. With the sense that the group as container is good enough, rigid defenses loosen. Many of the most damaging traumas of childhood cannot be remembered or worked with until they are experienced in action. Group members can now enlist each other as characters in their respective tragic paranoid and depressive inner world dramas as an alternative to schizoid slumber or entanglement with bizarre objects outside the room.

It is here that the dynamics of the families of origin are revisited. Unconscious maneuvering places group members into familiar straight-jacketed roles of scapegoat, identified crazy, sadistic bully, sacrificing masochist, pervert, and the greedy monopolist, playing out primal versions of Group Basic Assumptions. The flow between the group dynamics and the unintegrated part of the personalities of the members fills a transitional group space. If the basic assumption dramas can be contained within the group and worked on interpretatively, it becomes possible for members to develop empathic understanding for the scapegoat in their midst and an appreciation of how they maneuver each other into pathological roles that condemn individuals for what should be shared responsibility. This understanding and empathy facilitates the reintrojection of what has been projected in less toxic form with movement toward an integrative depressive capacity to experience oneself and others as whole objects.

The therapists' skill in negotiating the basic assumption world of projective and introjective identification in which he is also often an unwitting player can make the difference between a group that is therapeutic and one that traps its members in pathological roles and deepens despair (Hinslewood). The therapist needs to strike an artful balance between a permissiveness that allows the dramas to unfold and a willingness to intervene to protect members at risk of becoming casualties. Groups which are conducted on strict rules prohibiting disruptive behavior or hostility, or impede the emergence of psychotic material by reactive reality checks may foster normative behavior at the cost of leaving the disturbed affect-laden inner worlds of members relatively untouched. However, it is important that the community develop a consensus on limiting action so that it does not escalate into violence or create an atmosphere too frightening to permit creative work. In the development of the group culture it is often the staff sub-group who must be available at first to suffer the pain without retaliating or withdrawing, that heretofore has overwhelmed the capacities of the schizophrenic and their families. This requires a great deal of countertransference staff work to not only recover from counterprojective identification but also to survive the chaos of encountering one's own psychotic core and brushes with what Lacan has defined as the Real. When staff are able to experience psychotic anxiety as not just within the "other", deeper links can be established with patients as fellow human beings. Patients can then use these relationships as models to form emotional links with each other as an alternative to use of others as only objects. In this way the group culture can move beyond the normative culture toward a deeper integration of subjects that is closer to the ideal expressed by Dostovesky in which everyone is linked and everyone is responsible for everything to everybody.

At the same time that linkages are experienced and the power of the unconscious group process to buffet everyone about is grappled with, it is also important to underscore somewhat paradoxically that each individual is also ultimately responsible for self. To contend otherwise is bad faith in Sartre's sense. This principle is vital in countering a pull toward the use of the medical model as a rational for the perpetuation of a pathological undifferniented symbiosis in which it is the illness that exonerates everyone from responsibility and choice. The role of patient as responsible contributing agent is underlined by such things as patient government. To be able to help another in the group is an entree into life beyond abject dependence on literal mother toward an appreciation that one must participate in maintaining the mothering function of the group in order to be adequately mothered.

In order to maintain the community as a good enough container much work must be done to preserve the culture against social dynamics which tend to reinforce the schizophrenic as madman. In the grip of a need/fear dilemma, the schizophrenic radically renounces bonds with others, yet at the same time relies on others for the basics of existence. It seems eminently understandable that despite conscious intentions to treat, institutions mandated to minimize and control social disturbance and burdened with inadequate resources have little time or energy to contend creatively or therapeutically with this paradox. The critical element in addressing it is to provide an environment that is containing and holding which also allows space for autonomy and learning through experience. However, often the pressures of the primary task of social control leads mental health institutions to bypass interaction with the patient's autonomous self to settle for false-self compliance, reinforce regressive adaptations that echo the family of origin and impose order. Group programs based on the principle that some chaos and turbulence is inherent in the developmental process is likely to be experienced as unruly and subversive by the larger system. Tensions and conflicts at the boundaries of such programs and their institutional and social environment must be managed so that necessary connections are not severed while the integrity of the therapeutic culture is maintained.

Like the developmentally creative transitional world of mother and infant described by Winnecott, the effective psychotherapy group for schizophrenics should not be deadened by a solemnity and over concern with proprietary but allowed to become a transitional space for creative play in which fixed delusions can become the stuff of creative illusion. This allows for a play between the inner and outer worlds in which it need not be so clear what is inner and what is outer. The opportunity for play in the good enough container is not just play with mother group but the opportunity to play with peers.

When they entered the Day Program, Ray was occupied with being the Buddha who loves without attachment; Eileen with living as inconspicuously as possible amid a torrent of black things that swarmed around her; Carol with living on the street and living out a mission for God to give to others by self denial and suffering; and Alice with filling up a cavernous emptiness by stealing as much as she could as an alternative to depending on other human beings. At the first meeting these individuals had little interest in each other except as audience for each other's tales of grandeur or woe. With time they became bad part-objects for each other. Carol, who literally tried to feed the community with good works while dominating the kitchen, became a bad breast (at one point she was accused of flashing an ugly breast). Ray threatened to pull out his "bad penis" in retaliation against Alice who taunted him by calling him a "sucker" for believing that she would every pay back "borrowed" money; Alice, who believed herself under constant attack from devils, was targeted as a child molester by Eileen, while Eileen identified Alice as the devil incarnate. Each tried to provoke behavior that would confirm the badness of the other. Some of the community dramas pushed individuals close to the edge of violence.

The therapeutic community can be compared to a group of characters in search of a stage for dramatizations of trauma about victimizing and victimization, guilt and innocence, goodness and badness. Unlike many of society's dramas, this therapeutic theater struggles against ending its plays with the sacrifice of individuals as bad objects whose expulsion will cure what ails the community. The plays are repeated as often as necessary to allow for transformations of plot and character. While feelings are injured, windows and furniture broken, the community needs to be committed to keep all the players in the play until they are ready to leave. Ray, Eileen, Alice and Carol, at first indifferent to each other, then developed disgust and hate, followed by empathy. Later they come to see themselves in each other. At moments even love becomes possible.

Like all other perspectives and modalities of treatment, the group perspective and group therapies are no panacea for schizophrenia. All group programs and approaches, including the program I have described, experience failures.

I have tried to make the case that an understanding group dynamics and enabling the schizophrenic to rejoin the group as an emotionally alive contributing person rather than an objectified thing to be repaired is essential to all meaningful treatment. It may be that schizophrenia as a modern form of madness will always defy cure since madness and sanity constitute each other. However, when treatment consists too much of a clash of the dogmatism of sanity versus the dogmatism of insanity everyone loses and the tragedy for vulnerable individuals is exacerbated rather than ameliorated.


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Marvin R. Skolnick


©1997 - Copyright by Marvin Skolnick