Psychodynamically Oriented Supportive Group Therapy With Psychotic Patients

Abstract

This pilot study investigates the contribution of supportive psychodynamically oriented group psychotherapy to the clinical characteristics and functioning of psychotic patients. After a year of group psychotherapy using an intermediary object, the drawings of a number of psychotic patients were inspected separately so as to ascertain the improvement of psychopathological elements depicted. Two groups of 38 patients each, with similar psychopathology, clinical and demographic data were assessed before and after 1 year. One group participated in group psychotherapy, with or without an intermediary object; the other group received standard care. The study demonstrated improvement in functioning, quality of life, positive/negative symptoms, and relapses of hospitalizations for patients participating in group psychotherapy. Moreover, elements that indicate psychopathology declined in the drawings of the group in therapy with an intermediary object. Psychodynamically oriented group psychotherapy, with or without an intermediary object, could be an additional treatment option for psychotic patients.

Keywords

group therapeutic groups group process

Group psychotherapy is a well-established form of therapy for patients with major mental disorders. Four types of group psychotherapy are commonly used for patients with schizophrenia and bipolar disorder: (a) psychoeducation, (b) cognitive-behavioral focused on development of social and occupational skills, (c) psychodynamic, and (d) supportive. In regard to psychodynamic group psychotherapy of psychotic patients, few published studies were yielded (Cerbone, Mayo, Cuthbertson, & O’Connell, 1992; Gonzalez & Prihoda, 2007; Hallensleben, 1994; Kanas & Cox, 1998; Wode-Helgodt, Berg, Petterson, Rydelius, & Trollehed, 1988). Of these, most exhibited heterogeneous results, and most did not include a control group.

Psychotic individuals have great difficulty in verbalization of their thoughts and emotions and in the use of metonymy and metaphor. Especially in the acute phase of delirium, the psychotic patients cannot symbolize or do not need to symbolize. In psychotic patients, art therapy can contribute to restore orientation and structure within internal and external experiences and reinforce the function of reality testing (Montag et al., 2014).

The usage of intermediary techniques (such as drawings, presentation of personal items to the group, photography) is considered particularly useful when groups include patients with major deficits (i.e., psychotic patients or patients with alexithymia) because they assist development of abstract functioning, symbolization processes, and creative potentials. There were extremely few studies of groups with an intermediary object (i.e., drawing; Caddy, Crawford, & Page, 2012; Crawford et al., 2012; Montag et al., 2014; Steinbauer & Taucher, 2001; Teglbjaerg, 2011).

Aim of the Study

The aim of the current study was to investigate the potential efficacy of supportive group psychotherapy with psychodynamic orientation in psychotic patients. More specifically, the contribution of such therapy to clinical characteristics and functioning was investigated. Furthermore, the drawings of a number of psychotic patients were examined separately so as to ascertain the potential improvement of psychopathological elements depicted in these, after a year of group psychotherapy using an intermediary object.

Materials and Method

Sample

The study took place between February 2011 and December 2012, at the Attica Psychiatric Hospital (Dafni, Greece), and was authorized by the Scientific Council and the ethics committee of the hospital. All subjects gave written informed consent. Patients who were unable to consent were excluded. All ongoing and related trials for this intervention were registered. The Attica Psychiatric Hospital is a specialized tertiary care psychiatric hospital, the largest in the country, with 225 beds in the acute departments and 117 in the chronic illness departments. In addition, there are outpatient clinics, two community mental health centers, 86 staffed community boarding homes, and 21 units in the alcohol and drug rehabilitation departments.

The sample consists of 76 psychotic outpatients who were divided into two groups: the experimental group and the control group. The patients selected came from a group of 200 outpatients examined at the hospital outpatient unit. Patients for the experimental group were selected because firstly they met group-suitability criteria: ability to conform to group rules, desire to work with the therapists, low risk of violence, and willingness to participate in group psychotherapy. Patients of the experimental group (n = 38) underwent supportive group psychotherapy of psychodynamic orientation for 1 year. The patients were divided into four psychotherapy groups that were closed; that is, all members began the group at the same time. Seven patients ceased attendance of the group prematurely.

The control group (n = 35), which originally consisted of 38 psychotic patients, was treated with standard psychiatric care. The patients in this group were matched to those of the experimental group with regard to state of disease, sex, age, education, marital status, duration of disease, age of onset, number of episodes, and comorbidity with alcohol–drug use. Furthermore, criteria of low risk for violence and ability to conform to rules were also applied to this group. From this group, three members dropped out.

Standard psychiatric care is specified as psychiatric follow-up by a psychiatrist every 4 weeks for 15 to 30 min. Patients were followed up more often if their mental state changed. The psychiatrists who participated in the study had a minimum of 4 years of clinical and research experience with psychotic patients. All patients in the sample were on appropriate medication.

Patients taking part in the study were at least 18 years of age and had been diagnosed according to International Statistical Classification of Diseases and Related Health Problems (ICD)-10 criteria with a primary diagnosis of psychosis: schizophrenia, schizoaffective disorder, bipolar disorder type I with psychotic symptoms, and major depressive disorder with psychotic symptoms (see Table 1). ICD-10 diagnoses were made from case records by a consultant psychiatrist with training in general psychiatry. It was also considered important that no patient had been under any other kind of psychosocial treatment in the year preceding the study, had no physical problems that could lead to major cognitive deficits, and had not received electroconvulsive therapy (ECT) in the 6 months prior to the study. The diagnosis of the disease of each participant was established at least 2 years before this study.

Table 1.

Demographic and Clinical Characteristics of the Sample.

Characteristics	Experimental group (n = 31)		Control group (n = 35)		χ²	df	p
Characteristics	n	%	n	%	χ²	df	p
Gender
Male	24	77.40	28	80.00	0.06	1	ns
Female	7	22.60	7	20.00	0.06	1	ns
Age
20-30	5	16.10	3	8.60	2.75	1	ns
31-55	17	54.80	26	74.30
>56	9	29.00	6	17.10
Marital status
Unmarried	24	77.40	22	62.90	1.91	1	ns
Married	3	9.70	4	11.40
Other	4	12.90	9	25.70
Education
Obligatory	9	29.00	13	37.10	0.48	1	ns
Lyceum^a	15	48.40	15	42.90
University	7	22.60	7	20.00
Age of onset
<20	10	32.30	6	17.10	5.37	1	<.05
21-30	20	64.50	22	62.90
>31	1	3.20	7	20.00
Duration of disease (years)
1-5	2	6.50	3	8.60	0.17	1	ns
6-10	3	9.70	4	11.40
>11	26	83.90	28	80.00
Number of episodes
1-2	4	12.90	4	11.40	0.42	1	ns
3-5	10	32.30	14	40.00
>6	17	54.80	17	48.60
Months in hospital
0-6	10	32.30	15	42.90	1.13	1	ns
7-12	7	22.60	5	14.30
>13	14	45.20	15	42.90
Comorbidity with alcohol–drug
Yes	10	32.30	13	37.10	0.17	1	ns
No	21	67.70	22	62.90	0.17	1	ns
Psychiatric diagnosis (Axis I)
Schizophrenia	11	35.50	13	37.10	0.02	1	ns
Affective psychosis^b	10	32.30	9	25.70	0.34	1	ns
Comorbidity with alcohol–drug	10	32.30	13	37.10	0.12	1	ns

In the Greek educational system, the lyceum corresponds to the last 3 years of high school (16 to 18 years old approximately)

Schizoaffective disorder, bipolar disorder I, major depressive disorder with psychotic features.

Most patients were male, aged 31 to 55 years, not married, high school graduates, with age of illness onset 21 to 30 years, duration of illness above 11 years, more than six relapses, and without comorbidity with alcohol or drug abuse. Patients in the two groups did not differ in their demographic or clinical characteristics, only in the age of illness onset (see Table 1).

The four experimental psychotherapy groups included two groups of 20 psychotic outpatients. These groups had four dropouts. The other two groups of 18 psychotic outpatients used an intermediary object (drawing). These groups had three dropouts. All patients of each group entered the program at the same time and were observed for 1 year for the purpose of this study.

Interventions

It is common for therapists working with psychotic patients to use cognitive behavior therapy (CBT) approaches (National Institute for Health and Clinical Excellence, 2009). In this study, the technique of group psychotherapy used was supportive with psychodynamic orientation. This type of supportive group therapy is inspired by psychodynamic theory that uses a psychodynamically grounded understanding of psychosis. Behind every symptom or pathological behavioral type in each patient, therapists sought to understand intrapsychic conflict, the unconscious mechanisms which led to this conflict, impulse correlations, and the dominant relation with the object. However, toward the members, therapists adopted a non-directive approach including the use of nonverbal mechanisms (e.g., eye contact, voice coloration), and encouraging patients to express feelings, especially in the here and now. Patients were not flooded with interpretations, and the therapists maintained a more supportive stance. The revelation of unconscious elements was avoided in vulnerable individuals. If particularly hostile or brutal unconscious material emerged, the therapist tried to conceal it, to strengthen the repression, to stay close to reality, and to comment on the positive elements and the healthy identifications of the members. Negative transference¹ was avoided. If it arose, the therapist remained neutral, noting the deepest motives of the patients’ aggression. When unconfessed thoughts of death concerning beloved ones or incestuous ideas were expressed, the therapist would not make comments (Hochmann, 1995; Sakellaropoulos, 2010; Sakellaropoulos & Krysilas, 2010). Group process was based on free associations. Members were encouraged to interact without the therapists assigning a specific topic.

The therapists of the groups included a trained group analyst, who participated in all groups, and a trainee therapist, who was different for each group. Frequency of sessions was once weekly, and the duration of sessions was 90 min.

In two of the experimental group, an intermediary technique was used (i.e., drawings). Two phases were involved. The first phase was nonverbal. The members of the group were given art materials to use as they chose on a piece of paper (drawings). The art materials included wax crayons, felt-tipped pens, and pencils that were usually available in a range of colors. The paper provided was white, size A4 (210 × 297 mm). Materials were set on the table from the start. The duration of this phase lasted 20 min. The second phase lasted 70 min and elaborated on the material brought to the group in the first phase. In this second phase, each group member presented his or her drawing and commented on it, and this was subsequently commented on by the group.

Measures

Global Assessment of Functioning Scale (GAF) was used to measure psychological, social, and occupational functioning of the person, and is rated on a hypothetical continuum of mental health to mental illness. Psychological, social, and occupational functioning were scored from 1 to 100 and divided into 10 levels per 10 grades; however, interim rating could also be used when required. For example, scores of 91 to 100 indicated superior functioning in a wide range of activities, with no symptoms present. Scores of 51 to 60 indicated moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores of 1 to 10 indicated persistent danger of severely hurting self or others (e.g., recurrent violence) or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.

The Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) is a widely used questionnaire designed to differentiate between positive and negative symptoms. It provides separate scores for general psychopathology and risk of aggressiveness. Both the Positive Syndrome and Negative Syndrome subscales consisted of seven parts; two are of interest here: general psychopathology and risk of violence, with 16 and three parameters, respectively.

The Quality of Life Scale (QLS; Heinrichs, Hanlon, & Carpenter, 1984) consists of 21 items that provide information on the symptoms and functioning of a patient in the last 4 weeks. It appraises more insidious dimensions of the psychopathology of psychosis, such as residual symptoms. The elements scored were divided into four categories: (a) the interpersonal relations, (b) instrumental role, (c) intrapsychic foundations, and (d) common objects and activities.

A scale to measure pathological elements of the sketch and the color in the drawings of psychotic patients was designed ad hoc, by one of the authors, based on the doctorate thesis of Melissinou (1979). This scale scores 24 pathological elements that one encounters in drawings of psychotic patients (i.e., elements of vagueness, disorganization, repetition, writing-in, disorganized color synthesis, and topic selection). Scoring of pathological elements ranged from 0 to 4, 0 = not observed, 1 = few, 2 = average, 3 = above average, 4 = many (see Table 2). The criteria for the selection of these tools were the following: The PANSS rating scale has been standardized for Greek populations (Donias, Manavis, Delapaschou, Garyfallos, & Paraschos, 1996), and the GAF and QLS rating scales have been widely used in studies concerning the Greek population. The administered tools were in Greek. The QLS rating scale is included in many Greek manuals of clinical psychiatry (Manos, 1997).

Table 2.

Rating Scale of Pathological Elements in the Use of Drawing and Color in the Drawings of Psychotic Patients.

1. Vagueness: The sketch is vague and blurred

2. Disorganization: The sketch is disorganized

3. Distortion: Persons or objects are distorted, proportion and volume distortion

4. Mutilation: Depiction of mutilated bodies

5. Multiplication: Multiplication of the same object. Many objects of the same kind, but in a different way

6. Repetition: Repetition of the exact same pattern, or with small differences, or repetition of the same object. The exact same object depicted in exactly the same way

7. Stereotypy: The sketch is the same in a stereotypical way

8. Overproduction: Overproduction of sketches, which due to the feverish pressure of production of many sketches, result in half-done or incomplete sketches

9. Decorativeness: The sketch itself is super-decorated or decoration and occupancy of every empty space of the paper

10. Micrography: The patient is fond of tiny sketches, which at times are set only in a corner of the paper

11. Gigantism and exceeding the limits of the paper: The opposite of micrography. A gigantic subject or object compared with others in the same picture, or a gigantic body member

12. Splitting: A tendency to split faces, objects, or body members

13. Writing-in: The patient writes phrases over his sketches, which are often incomprehensible, or names, dates, numbers. One may just be noting the title of the picture or some kind of explanatory remark

14. Perfectionism: A tendency for perfectionism, usually in patients with obsessive traits

15. Poverty of aesthetic result

16. Paradoxicalness

17. Disorganized chromatic composition

18. Monotony of color

19. Use of the same color repeatedly in a series of pictures

20. Poverty of color

21. Use of incompatible colors, with no coherence, which appear as a repulsive, vulgar, colored orgy

22. Use of dark, melancholic, faint, and cold colors

23. Themes of mourning

24. Aggressive elements

Process

The members of the experimental group were clinically evaluated twice by independent interviewers, or psychiatrists or psychologists, at which time they completed the tools, once prior to their entering the group and a second time at 1 year of group attendance. The same procedure was followed with the control group. Patients were evaluated twice with a year’s difference between the two appraisals. The drawings of the patients in the two psychotherapy groups, using the intermediary object of drawings, were photographed or scanned and filed electronically. They were subsequently rated according to a rating scale created by one of the authors (see Table 2) based on the work of Melissinou (1979). This scale rated pathological elements of drawing and color in the drawings of psychotic patients (see the appendix). Each drawing was rated separately by three psychologists who were blind to the dates at which each drawing had been created. This was done to ensure that the assessors stayed independent as far as the existence or the absence of improvement in the psychopathological elements in the drawings of the members. Once the appraisal was complete, the material was sorted and matched to the dates of creation. Of the three scores, per drawing, an average was calculated. At the end of the study, there were two separate sets of average scores. The first score corresponded to the evaluation of the drawings at the first trimester of group psychotherapy with an intermediary object, and the second corresponded to the last trimester.

The study kept record of (a) hospitalization of patients in the two groups: 1 year prior to initiation of the study and also during the following year (during the study), and (b) relapses of patients in both groups throughout the duration of the study. Relapses were defined as the need for increase or change in medication of a patient due to deterioration of affect, mental state, or behavior according to the attending psychiatrist.

Statistics

The initial and final scores of each group were compared for each separate rating scale according to the following methods: (a) Wilcoxon matched-pairs signed-ranks test (non-parametric tests for related samples) to evaluate the GAF, PANSS, and QLS scales; and (b) sign test (non-parametric test for related samples for ordinal data) to evaluate pathological elements in the use of drawing and color in the drawings of the psychotic patients and to compare hospitalizations/relapses during the 1 year prior to the study and during the year that the study was conducted.

The two groups were compared for differences in initial and final scoring (ANOVA).

Results

Statistically significant improvement was found in all psychometric test scales for the experimental group (GAF, PANSS, QLS); in the control group, there was only statistically significant improvement in the PANSS subscale that evaluates positive symptoms (Table 3). Improvement on scores between initial and final measurements in all evaluated parameters is greater for the experimental group compared with those of the control group, with the exception of dGAF (difference between initial and final GAF measurement) where the Levene statistic criterion was marginally statistically significant (Table 4).

Table 3.

Comparisons Between First (Initial) and Second (Final) Evaluation of the Two Groups in Various Psychometric Tests.^a

	Experimental group					Control group
	First evaluation		Second evaluation		Comparisons	First evaluation		Second evaluation		Comparisons
	M	SD	M	SD	Z p ^a	M	SD	M	SD	Z p ^a
GAF	38.71	7.73	51.26	9.55	−4.86^b	48.14	12.07	50.20	12.94	−1.83^b
GAF					<.001					.06
PANSS total	96.26	18.62	74.68	19.05	−4.78^b	91.29	17.54	89.66	24.56	−1.63^b
					<.001					.10
PANSS-PS	19.77	5.37	15.32	6.22	−4.25^b	18.11	5.29	17.43	6.46	−1.99^b
					<.001					.046
PANSS-NS	21.52	7.02	15.94	6.07	−4.79^b	22.6	5.32	22.14	6.71	−1.47^b
					<.001					.14
PANSS-GP	46.13	8.02	36.16	7.69	−4.70^b	42.97	9.43	42.43	12.00	−1.07^b
					<.001					.28
PANSS-RA	9.00	1.65	7.10	1.92	−4.44^b	7.60	2.78	7.66	3.13	−.80^b
					<.001					.41
QLS	59.35	11.07	82.26	12.63	−4.86^b	59.06	17.93	61.80	18.49	−1.46^b
					<.001					.14

Note. GAF = Global Assessment of Functioning Scale; PANSS = Positive and Negative Syndrome Scale; PS = positive symptoms; NS = negative symptoms; GP = general psychopathology; RA = risk of aggression; QLS = Quality of Life Scale.

Non-parametric tests to related samples, Wilcoxon Signed Ranks Test.

Based on negative ranks.

Table 4.

Comparison of the Two Sample Groups for Differences Between Initial and Final Score on Each Psychometric Test.

	Descriptives				Levene statistic	ANOVA
	Experimental group		Control group		Levene statistic	ANOVA
	M	SD	M	SD	Significance	F	Significance
dQLS	−22.90	11.31	−2.74	10.35	.86	57.08	<.001
dGAF	−12.54	4.69	−2.05	9.05	.04	33.55	<.001
dPANSS total	22.35	11.17	1.62	23.35	.13	20.28	<.001
dPANSS-PS	5.22	2.84	.68	6.11	.13	14.31	<.001
dPANSS-NS	9.96	5.38	.54	10.68	.09	19.65	<.001
dPANSS-GP	9.96	5.38	.54	10.68	.09	19.65	<.001
dPANSS-RA	1.90	1.19	−.05	2.79	.20	13.10	.001

Note. df1 = 1 (between groups), df2 = 64 (within groups). QLS = Quality of Life Scale; GAF = Global Assessment of Functioning Scale; PANSS = Positive and Negative Syndrome Scale; PS = positive symptoms; NS = negative symptoms; GP = general psychopathology; RA = risk of aggression; dQLS, dGAF, dPANSS = difference between initial and final measurements.

Hospitalizations and relapses significantly decreased for patients in the experimental group during the period of the research and in the prior year. Hospitalizations and relapses of the experimental group were also found to be significantly lower when compared with the control group (Tables 5 and 6).

Table 5.

Hospitalizations–Relapses 1 Year Before and During the Research for the Experimental Group.

	Before	During	χ²	df	p
	n (%)	n (%)	χ²	df	p
Hospitalizations	21 (67.70)	1 (3.20)	16.40^a	1	<.001
Relapses	26 (83.80)	9 (29.00)	8.25^b	1	<.01

With Yates’s correction.

Without Yates’s correction.

Table 6.

Hospitalizations–Relapses During the Research for the Experimental Group and Control Group.

	Control group	Experimental group	χ²	df	p
	n (%)	n (%)	χ²	df	p
Hospitalizations	8 (22.90)	1 (3.20)	3.84^a	1	.05
Relapses	23 (65.70)	9 (29.00)	8.85^b	1	<.01

With Yates’s correction.

Without Yates’s correction.

From the analysis and processing of the research data of pathological features in the drawings of the psychotic patients, there was a statistically significant improvement in vagueness, disorganization, distortion, mutilation, multiplication, repetition, stereotypy, decorativeness, gigantism, fragmentation, writing-in, poverty of aesthetic result, paradoxicalness, disorganized chromatic composition, monotony of color, repetitious use of the same color, poverty of color, use of cold colors, elements of mourning, and aggressiveness. There was no obvious improvement in overproduction, miniaturism, and unlimited use of incompatible colors, and there was only marginal improvement in perfectionism (Table 7).

Table 7.

Evaluation of Initial and Final Drawings of Patients Who Participated in Group Psychotherapy With Transitional Object.

	Initial drawings		Final drawings		Comparison
	M	SD	M	SD	p
Vagueness	3.20	0.94	1.27	1.10	.001
Disorganization	3.20	1.14	1.47	1.06	.001
Distortion	2.53	1.40	1.27	0.96	<.01
Mutilation	1.40	1.68	0.33	0.61	.02
Multiplication	2.73	0.70	1.27	1.10	.001
Repetition	2.47	1.24	1.33	1.29	<.01
Stereotypy	1.73	1.58	0.93	1.28	.01
Overproduction	0.20	0.56	0.07	0.25	.15
Decorativeness	1.07	1.43	.60	0.91	.03
Micrography	0.80	0.94	0.40	0.82	.15
Gigantism	2.13	1.18	0.73	0.79	.001
Splitting	2.00	1.55	0.47	0.74	<.01
Writing-in	2.20	1.32	1.33	1.17	<.01
Perfectionism	0.87	1.12	0.67	1.17	.08
Poverty of aesthetic result	3.00	1.19	1.67	1.04	<.01
Paradoxicalness	3.20	0.86	1.80	0.77	.001
Disorganized chromatic composition	1.40	1.40	0.93	0.96	.03
Monotony of color	3.07	1.38	1.67	1.34	<.01
Repetitious use of same color	2.67	1.44	1.33	1.11	<.01
Poverty of color	3.13	1.30	1.53	1.24	<.01
Unlimited use of incompatible colors	0.80	1.26	0.47	0.83	.16
Cold colors	3.07	1.10	1.13	0.64	.001
Elements of mourning	2.07	1.38	0.67	1.11	<.01
Aggressive elements	2.20	1.32	1.00	1.00	<.01

Note. Sign test.

Discussion

The present study supports the usefulness of group psychotherapy for psychotic patients. Results demonstrate definite improvement for the psychotic individuals who took part in the experimental group’s group psychotherapy when compared with the psychotic patients in the control group treated with standard care (i.e., psychiatric follow-up once a month).

Group Psychotherapy Research and Review

In the current research, attending group psychotherapy was associated with statistically significant improvement on all studied parameters (i.e., functioning, positive and negative symptoms, quality of life, reentrance, relapses, and appearance of psychopathological elements in the drawings-paintings of psychotic patients). For the control group, statistically significant improvement only occurred on the PANSS Positive Symptom subscale, and for marginal improvement in functioning.

In the literature, we often encounter the benefits of group psychotherapy in the functioning of patients (Granholm, Ben-Zeev, & Link, 2009; Michalak, Yatham, Wan, & Lam, 2005; Wallace, Liberman, MacKain, Blackwell, & Eckman, 1992). The literature finds improvement of symptomatology (negative and/or positive) with group psychotherapy (Andres, Pfammatter, Garst, Teschner, & Brenner, 2000; Penadés et al., 2002; Schaub, Behrendt, Brenner, Mueser, & Liberman, 1998; Shin & Lukens, 2002). Kanas, Deri, Ketter, and Fein (1989) reported an improvement only at the 4-month follow-up, whereas Buccheri, Trygstad, Kanas, Waldron, and Dowling (1996); Daniels (1998); and Liberman et al. (1998) found no improvement.

In terms of group psychotherapy improving the quality of life for psychotic patients, there are mixed results. Participants in Hayes, Halford, and Varghese (1995) showed improvement, but improvement was not demonstrated at the follow-up. Participants in the McCay et al. (2006) study showed improvement at the follow-up, whereas participants in the Daniels (1998) and Liberman et al. (1998) showed no improvement.

Finally, there was a statistically significant decrease in hospitalizations–relapses of patients in the experimental group during the time of the present research. In the literature, there are mixed results concerning decrease in the number of hospitalizations and relapses of patients undergoing group psychotherapy. The studies of Wode-Helgodt et al. (1988) and Dobson, McDougall, Busheikin, and Aldous (1995) observe no improvement, whereas the studies of Andres et al. (2000), Herz et al. (2000; relapses included), and Pitschel-Walz et al. (2006) observe improvement.

Art Research

There are a number of studies that support the fact that drawing and color comprise particular means of expression in psychosis (Gajić, 2013; Guttmann & Maclay, 1937; Reznikoff & Nicholas, 1958). Some studies show that features of a drawing suggest a patient’s effort to reveal emotion and also distinctive characteristics of the patient’s pathology, both of which can indicate patient progress. These features are: choice of theme and depicted objects in the art of psychotic patients; the way objects are placed in space; their symbolic meaning; the synthesis and choice or not of color. The literature contains very few studies that scored psychopathological features in the drawings of psychotic patients in therapy, especially on distinctions among two-dimensional artwork from different groups of patients (e.g., Gantt, 1990; Hacking & Foreman, 2000; Hacking, Foreman, & Belcher, 1996). No study was found that compared improvement/evolution in the drawings of patients according to change in clinical characteristics.

The rating scale of pathological elements in the use of drawing and color in the drawings of psychotic patients contains formal characteristics (i.e., how the picture is made, for example, color, color intensity, and space used in the picture) and content measures (i.e., what is represented; for example, themes of mourning, aggressive elements, and splitting or poverty of aesthetic result). There are recognized dangers in the interpretation of content without reference to a patient’s associations (Gantt, 1990; Wadeson, 1980). However, a patient may be unable or unwilling to explain his or her drawing (Hacking et al., 1996).

Limitations and Recommendations for Further Research

It is particularly difficult to find psychotic patients, especially outpatients, who fulfill the necessary requirements to participate in group psychotherapy. For the same reasons, the sample of patients included in the study group was not randomly selected from the total population of psychotic patients. As psychotherapy research always has to consider personal preferences and setting, group psychotherapy might have particularly appealed to a subgroup of patients with a better a priori prognosis. The fact that the current study revealed more positive results could be attributed to the patients who were chosen to undergo group psychotherapy (patients who were suited and open to therapeutic help, and had motivation). We are aware of the fact that data on efficacy and effectiveness from such a small non-randomized trial are biased and might overestimate the impact of the intervention.

Another limitation of this study is the lack of long-term patient follow-up. The main reason of this lack of reevaluation of the patients is the fact that most of the members of the experimental group continued psychotherapy even after the end of this study.

Subjectivity in the evaluation of the psychopathological elements in the drawings is a significant limitation for the rating scale of pathological elements in the use of drawing and color for psychotic patients. This is especially true in items such as themes of mourning or aggressive elements. For this reason, three individuals evaluated these themes, applying the average of their grades. Standardization of the rating scale of pathological elements in the use of drawing and color in the drawings of psychotic patients is currently underway. There is no other standardized rating scale concerning the Greek population for this field of interest.

In addition, the experimental group had seven dropouts, four of whom had relapsed conditions when they abandoned the group. Of these four, one underwent forced hospitalization 2 months later. These patients have not been included in the final results. Other studies have presented higher percentages of dropouts (Montag et al., 2014).

Long-term studies will be necessary to examine several important issues raised by this research. First, it is important to explore whether benefits are sustained and generalized of having attended group psychotherapy. Second, replication is needed to examine whether greater improvement of psychotic patients’ clinical appearance is associated with improvement of psychopathological features in their drawings.

Finally, it will be important to explore which therapeutic factors (e.g., stronger group alliance at the midpoint of treatment, cohesiveness, and development of socializing techniques) further promote treatment outcomes in psychotic patients who participate in therapeutic groups (Johnson, Penn, Bauer, Meyer, & Evans, 2008), and which diagnostic categories of patients who are in group psychotherapy benefit the most (Leurent et al., 2014). That is, studies are needed to explore the benefits of group psychotherapy according to special needs of patients with clinical subtypes of psychosis (with more or less severe negative symptoms, with or without comorbidity, those who did and did not express a preference for group therapy), so as to identify the type of group psychotherapy that is most suited and effective for these patients.

Conclusion

Many aspects of the use of psychodynamically oriented group psychotherapy for psychotic patients are understudied. This controlled pilot study explored one aspect particularly understudied: exploring and evaluating psychopathological elements and color in the drawings of psychotic patients and how these are modified through the psychotherapeutic process. Creating a scale for the evaluation of pathological elements of drawing and color in the drawings of psychotic patients can be an especially helpful tool in the hands of art therapists working with psychotic patients. This approach can encourage and guide group analytic practitioners and art therapists who deal with psychotic individuals.

Footnotes

Appendix

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Irini Segredou is a group analyst and consultant psychiatrist at Attica Psychiatric Hospital, Athens, Greece. She holds full membership of the Group Analytic Society International, a doctorate in group psychotherapy concerning psychotic patients, and an MSc in social psychiatry. Her research focuses on group therapy, art therapy, psychosis, and addictions.

Christos Christodoulou is associate professor in psychiatry, University of Athens Medical School, Greece. He is the head of the Consultation-Liaison Unit in the Attikon University General Hospital, Athens, Greece. His research focuses on liaison psychiatry, suicidality, and clinical psychopharmacology.

Maria Samakouri is associate professor in psychiatry, Head of the Department of Psychiatry, School of Medicine, Democritus University of Thrace in the University General Hospital of Alexandroupolis, Evros, Greece. Her main area of clinical and research interest is social and community psychiatry.

Olga Antoniadou gained her medical degree from Athens Kapodistriako University and specialized in psychiatry in Athens, Greece. She trained for 2 years with the British Psychodrama Association, and had full Group Analysis training in Athens. She works in the private sector.

Evangelos Poulis, psychotherapist/psychologist, has obtained his BA in counseling psychology, and is currently working at the Alcohol Dependency Unit of Attica, Psychiatric Hospital, Athens, Greece, with patients and their relatives as a group and individual therapist.

Kyriaki Therapou obtained her BA in psychology and is currently working as a psychotherapist/psychologist specialized in systemic/family therapy at the Alcohol Dependency Unit of Attica Psychiatric Hospital, Athens, Greece, chairing sessions with alcoholic patients and their relatives.

Miltos Livaditis is emeritus professor in social psychiatry, Democritus University of Thrace, Greece. His primary interest is in philosophy of mind.

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