Introduction

The treatment of major mental illness remains inadequate because many patients receive inappropriate treatment or no treatment. There are a number of reasons for this lack of treatment. In the U.S., not enough facilities are available, and funding by managed care is often insufficient. In addition, although neurobiology and psychopharmacology have made great strides, the major mental illnesses and their treatments remain poorly understood. Third, compliance with recommended treatment is often hard to maintain for many patients. Also, many patients remain refractory to current pharmacological treatments. It has been difficult to bring the latest treatments to many sick, poor, and isolated patients.
Poorly treated patients are most obvious in large cities, where deinstitutionalization policies, lack of facilities, and under-funded treatment programs contribute to the street presence of such patients. A large proportion of the homeless population suffers from mental illness (Lamb et al., 1992).
Because of the great number of such hard-to-treat patients, group treatment for medicated, seriously ill patients may be helpful. Such medication groups have been used successfully for a number of years. In this paper I will discuss the theory and techniques for the use of such groups.

Review of the Literature

Group therapy has been used to treat severely and chronically ill patients for many years (Hellerstein & Meehan, 1987; Kanas et al., 1980; Yalom, 1983). The use of increasingly effective medications has been an important factor in our growing ability to use a group format to treat such patients.
Clinicians in the 70's used medication groups to dispense food as well as medications in order to gratify all dependent needs, and to lessen isolation and increase communication (Payn, 1974). Groups were used to monitor the patients' compliance with medication regimens, while the groups discussed everyday problems (Malhotra &Olgiatf, 1977; O'Brien, 1977). These groups were somewhat unstructured and gradually evolved to use educational techniques and group support. In this way, self-identity would be enhanced and anxiety would be lessened. Sharing of experiences with medications was combined with reality testing and education (Diamond & Little, 1984).
Many authors have examined the combination of group therapy with psychopharmacotherapy (Beitman et al., 1984; Kymissis, 1978; Rodenhauser, 1989). Both benefits and difficulties of such a combined approach have been recognized.

Misconceptions About Medication Groups

A number of therapists in the past felt that medication groups were unsuccessful or too difficult to conduct. Often, the focus of the group remained on the group process or interactions, rather than on the medications which were given to patients in the groups. Because patients were often on different medications, it was difficult to use a group to enhance compliance for treatment to be more effective. Also, medication was mistakenly seen as an adjunct to the group therapy rather than as the primary or main method of treatment that it actually was for many patients. This view also had an adverse effect on compliance.
Some difficulties arose because patients with severe mental illnesses often find it difficult to take medications on a regular schedule. This may be attributed to the occurrence of uncomfortable side effects, such as parkinsonian symptoms or tardive dyskinesia. Many such patients feel neglected, and many paranoid patients include their doctors or group members or their medications in their paranoid delusions, believing that the group and the medications will harm them.

Goals of Medication Groups

1. To increase patient compliance with medications by combining group therapy with psychopharmacotherapy.
2. To carefully assess patients on medications.
3. To teach patients about the main effects and side effects of their medications.
4. To discuss mental illnesses and their treatments.
5. To focus on the use of medications as the primary means by which patients can control their lives.
6. To help patients learn to cope better with the stresses of daily life.
7. To increase socialization and decrease isolation through interactive participation in a group setting.
8. To provide a supportive environment for the expression of patients' feelings.
9. To provide a trial of group therapy for the possible transition of appropriate patients to more dynamic therapy groups.

Patient Selection and Treatment Planning

The treatment team evaluates each patient according to DSM-IV criteria to better understand each person's functional capacities and ability to benefit from a group treatment setting. All aspects of each patient's life are examined, including the social, familial, psychobiological, genetic, psychodynamic, and phenomenological aspects. Past history is evaluated, especially the history of prior treatment with medications and group therapy.
The treatment team should formulate a treatment plan for each patient. During the patients' individual sessions, decisions may be made about which group each patient should join. In addition to the group treatment and medication, other treatments may also be recommended, including individual treatment. In placing a patient in a particular group, the "fit" of each patient in a group should be considered, as well as the benefit of the group to each patient. Relevant aspects of each group's leaders should also be considered. If possible, it may be helpful to make up groups composed of diagnostically similar patients on similar medications. The results of such grouping awaits further study.

Organization of the Groups

Groups are usually long term, and require a critical mass of at least six to seven core patients. Patients usually attend every third or fourth week. The total number of patients in each group varies between 40 and 60, so each week's attendance comprises from 10 to 15 people, usually different from week to week. Groups contain men and women of varying ages. Each group is led by two or three co-leaders, including a psychiatrist, and a nurse or a social worker. The format is flexible and determined by the leaders, depending on the needs of the group members. Because the weekly membership of each group changes with time, the leaders must learn to deal with the strain on cohesion and group identity caused by the infrequent and irregular attendance of the members. Over time, all of the members of each group come to know one another, as they see each other not only in group sessions but also in the waiting room.
Contraindications for inclusion in medication groups include active suicidality, violent acts, severe substance abuse and/or dependence, acute psychosis, or an inability to provide self care. The knowledge that people with similar symptoms and illnesses are all being treated similarly is itself supportive. Behavior deviating greatly from the group norm could interfere with compliance and the group process.

Preparation and First Group Session

Patients are prepared in two to three individual sessions before beginning in group, and the usual therapeutic contract is discussed individually with each patient, as well as in the group. Emphasis is placed on the importance of taking medications as prescribed.
The therapeutic contract includes prohibition against physical contact, an understanding of confidentiality, and the knowledge that individual sessions are available at any time as needed during the course of the group. Some patients may require further instruction about appropriate group participation and group norms.
Patients may be afraid of getting decreased attention because of the group setting, or that the leaders may not be helpful enough. Ambivalence towards medication compliance often is a group theme, and the group must help patients cope with such concerns.
During the first session, the group leader states to the group that the reason each member is in the group is in order to take medication as a primary part of each person's treatment. The leader should emphasize the effectiveness of medication in the treatment of the patients' illnesses; This emphasis helps increase group cohesion and focuses the group on the use of medications. Sometimes it is helpful for each patient to discuss their medications in the group session.

Techniques

Techniques in medication groups include behavioral, psychoeducational, and cognitive components. A knowledge and recognition of unconscious processes is useful to the therapist, and helps the therapist intervene with a proper mix of behavioral, educational, supportive, and dynamically-based interventions. It is important that the group leaders explain such group phenomena as denial, scapegoating, and rationalization in order to clarify the interactions in the group. Leaders may use a group-centered approach in order to assess both the group process and the individual group member's contribution to the group process. Patients should be actively involved in discussing their medications, and the use of medications should remain as a central focus of the group discussion. The group remains the main therapeutic tool to help group members use their medications effectively. The group leader may also focus on other group goals, such as achieving independence, social functioning, and work goals.
The group may show a great deal of resistance in focusing on issues concerning the use and effects of medications. Discussion of psychoeducational issues, particularly with relevance to patients' illnesses and medications, is often useful. The leader should avoid an excessive focus on individual psychodynamic issues. Any discussion that takes the focus of the group process away from the use of medications may be viewed as a resistance, and may be dealt with by the use of appropriate interventions.
Patients' difficulties in interactions in the group may be useful in helping members discuss difficulties in their daily lives. Such discussions may lead to a further discussion of difficulties with compliance with medication. As noted, the primary focus of the group should always be on medications. As the group progresses, other issues may be discussed, but the primary goal must remain helping patients use their medications effectively to improve their lives. The group is used as an aid to enhance the use of medications, and medications are the primary treatment for these very sick patients.
Institutional transference can sometimes be used by the group leader to enhance group cohesion and to help members get through difficult episodes of exacerbations of illness. Over time, the group members make reference to their common experience in the clinic. The leader highlights this discussion, in one way or another. In doing so, the leader encourages discussion of institutional experiences, thereby making a covert institutional transference into an overt one. Institutional transference can also enhance group interaction and modulate the attachment of members to the group leaders. The leader must remember that some of these patients need to remain dependent and attached to both the group and the leaders, and premature attempts to help them achieve independence may lead to psychotic decompensation or self-destructive acts.

Individual Sessions

Individual sessions may be used in addition to the regularly scheduled group sessions. Such sessions can help with the assessments of each patient's functioning and mental status, and may also be used to decrease resistance and treat recurrent psychotic episodes. Such episodes may be difficult to treat in the group, and individual sessions may be helpful for that purpose. Individual sessions may also be useful in furthering patients' interactions in the group as well as compliance with medication treatments. The therapist must ensure that individual sessions are not used to avoid group participation and interaction, and that they do not act as a resistance to treatment.

Conclusions

Medication group sessions may provide both an efficient use of time and effective treatment for chronically and severely ill patients. Such sessions may help patients avoid episodes of decompensation and enhance patient compliance with medication treatment. The group process can offer patients education, mutual support, practice in socialization, and a decrease in feelings of isolation. In medication group sessions, the therapist must focus on the use of medications as the primary goal of treatment. Patients can be mutually supportive and helpful to one another in medication compliance. A shift in group focus away from the use of medications into psychodynamic issues may be a resistance to treatment. The main purpose of the group is to enhance patients' compliance with medication treatment. Such groups may be useful for a wide range of chronically and severely ill psychiatric patients.

References

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Diamond, R. J., & Little, M. L. (1984). Utilization of patient expertise in medication groups. Psychiatric Quarterly, 56, 13-19.
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Kannas, N., Rogers M., Kreth, E., et al. (1980). The effectiveness of group psychotherapy during the first three weeks of hospitalization: A controlled study. Journal of Nervous and Mental Diseases, 168, 487-492.
Kymissis, P. (1978). Pharmacotherapy combined with analytically-oriented group therapy. In L. Walberg & M. Aronson (Eds.), Group therapy (pp. 131-139). New York: Stratton Intercontinental Book Corp.
Lamb, H. R., Bacharach, L. L., & Kass, F. I. (Eds.) (1992). Treating the homeless mentally ill: A task force report of the American Psychiatric Association. Washington, D. C.: American Psychiatric Association.
Malhotra, H. K., & Olgiatf, S. G. (1977). Fluthenaziane therapy in groups. Comprehensive Psychiatry, 18, 89-92.
O'Brien, C. P. (1977). Group therapy of schizophrenia. Current Psychiatric Therapies, 17, 149-154.
Payn, S. B. (1974). Reaching chronic schizophrenic patients with group pharmacotherapy. International Journal of Group Psychotherapy, 24, 25-31.
Rodenhauser, P. (1989). Group psychotherapy and pharmacotherapy: Psychodynamic considerations. International Journal of Group Psychotherapy, 39, 445-456.
Yalom, I. D. (1983) Inpatient group psychotherapy. New York: Basic Books.

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