Group psychotherapy in an acute inpatient setting: techniques that nourish self-esteem

This article describes a conceptual model and reparative techniques used in group therapy in a 15-bed acute inpatient psychiatric unit located in a 340-bed metropolitan trauma center. The group meets daily for 1 hr. The population reflects patients suffering from chronic mental illness and polysubstance abuse and those adapting to such complex medical problems as AIDS, spinal cord injuries, burns, and so forth. Using Roy and Roberts's (1981) adaptive modes of self-concept and interdependency, I describe how narcissism, the psychic structure designed to protect, repair, and restore the wounded self-esteem (Stolorow & Lachman, 1980), sustains group adaptations at the pregroup level. Lonergon (1980) described the pregroup phase as "parallel talk." It is similar to "parallel play" and generally reflects the developmental arrest or adaptive regression of individual group members. At this stage, group membership consists of a collection of individuals who use each other as an audience to whom they can express their narcissistic needs. Often, repeated blows to the patient's self-esteem result in a pervasive sense of powerlessness and helplessness. Patients gradually lose touch with their "real self" and become increasingly dependent on external cues to determine their feelings and behavior. The adaptive narcissistic need to depend on other people to feel whole suggests that group therapy can be a powerful tool in treating patients who suffer profound wounds to the self-esteem, prevalent in the population described. The reparative techniques used by the group therapist to initiate group involvement require the ability to tolerate and value a continuous pregroup phase. The patient with narcissistic behavior both craves and undermines attempts at group involvement.(ABSTRACT TRUNCATED AT 250 WORDS)