Containing Psychotic Patients with Fragile Boundaries: A Single–Session Group Case Study

Introduction

This article describes one session of an out-patient therapy group for individuals with severe disturbances, many of whom have schizophrenia or schizoaffective illness. The group meets once weekly for 45 minutes after which the co-leaders discuss the process and content, and then tabulate codes for each patient and a theme for the meeting of the group as a whole. It is called the Thursday Group, and has served psychiatric patients referred from several out-patient clinics or the in-patient service of a general hospital since 1985. For further description of this group see Hassan, Cinq-Mars, and Sigman (2000).

The purpose of the present paper is to describe how the group provides a firm boundary, within which members can participate regardless of the fragility of their own Ego structures. The provision of a firm boundary is of particular importance to individuals who have a vulnerability to psychosis. Indeed, psychosis has been conceptualized as involving weak Ego boundaries (McWilliams, 2011), this includes, for example, fears of fragmentation and annihilation, a coexisting wish for and fears of symbiosis with people leading to paralyzing feelings of ambivalence, and an experience of fragmentation of the self. The individual retreats to an inner fantasy world because internal and external realities experienced are too traumatic. The firm boundaries provided by the group are believed to moderate psychotic angst because they serve as a well-delimited container.

The group currently has 10 members, three of whom have difficulty attending regularly and were absent at the meeting to be described. One regular attendee was also absent. The group is open-ended and not time limited. Members have been in the group for varying periods of time, for example, three weeks, seven months, and the others from 2 years to 22 years. More than seventy individuals have participated in the group since its inception, some for only one or two meetings and others for several years. The group was initially formed to serve simply as a container for the depression, psychosis, and anxiety of its members. All members are on a pharmacotherapy regimen. Each year since 1997, pre-doctoral psychology interns have trained as group therapists.

The group’s goal has been oriented to developing a sense of connectedness among the members, most of whom are fairly isolated outside of treatment. The main role for the leaders is to be there with the individuals each Thursday and to tolerate or to bear participants’ illnesses with them so that they do not feel as alone in life. Because of the group setting, participants do not have to endure too much closeness while making their experiences known. There is potential for each individual to determine the level of intimacy that he or she can comfortably tolerate. Group members then can continue their lives with the important knowledge that others know some of their experiences. Testimony to the importance of this concept has been given over the years by various members: “An ear to listen is better than a person telling you what to do,” and “It’s where you could always have support, where you can say what you like, what’s on your mind. And you can hear others help you with your thoughts and say maybe it’s really this way, or maybe you could do this or that about it to help you. It kind of holds you and accepts you. When you go outside it’s really cold and you could really be alone.”

In 1998 a coding system was applied to the sessions with no particular agenda attached to it. Therapists record whether members express psychotic, manic, or depressed thoughts and behaviours. Therapists take note of the emotions observed: joy, anger, anxiety, sadness, or guilt and if it has indeed been expressed by the participants. In terms of verbal content, we note expressions of loneliness, loss, dreams, discussion of current or past relationships, humour, illness, current activity in members’ lives, helplessness, hopefulness, hopelessness, sexual preoccupation, and if members made supportive or insightful comments, engaged or participated in the group.

Sessions have never been tape-recorded or video-taped. Immediately after each session, the group leaders recall and note these behaviours, expressions, or emotions by consensus. Over the years, leaders began to notice some individuals shifting remarkably in their capacity to engage in more emotionally meaningful interactions during the meetings and to develop insight, humour, and support. We tabulated the data over a seven-year period for each member. The results suggested that, given enough time and support and acceptance, each participant can increase his or her own level of maturation and functioning in a group setting (Sigman and Hassan, 2006).

The meeting described here illustrates a range of solidity of Ego boundaries in the various group members who are prone to psychotic expressions as part of their symptoms of schizophrenia and schizoaffective disorders. The findings made us consider how the group as a whole, meeting at the same time and place with the same leaders, provides a container which allows an opportunity for safeness where group members can rely on firm boundaries and experience safe thinking or feeling experiences. It also made us consider how the group represents an object that may gradually be introjected into the psychic apparatus of individuals with porous Ego boundaries so that they may gain a more solid sense of self. We conclude that the group serves as an important auxiliary Ego function that helps provide structure in addition to increasing the mature defenses (such as humour) of individuals with psychosis, helping them develop insight, and providing them with support.

The solidity of one’s Ego boundaries has been referred to as emotional insulation (Ormont, 1994). If, for example, an individual has weak emotional insulation, he may go through life feeling acutely vulnerable and defend himself against this feeling (as we believe our newest member, Earl, did in the session we will describe). The theme of this particular group as a whole was felt to be the “fragile boundaries,” with which members of the group were struggling. This was expressed in many ways and at several levels by all six members in attendance. At the individual level, some group members experienced porous boundaries between fantasy and reality to various degrees.

At the group level, the boundary that the group provided normally was about to be removed, as this meeting was the last one before a Christmas break of one week. The break in the group meeting schedule may have accounted for the theme of fragile boundaries, as this momentary discontinuation altered one of the basic rules of the group, which is meeting every seven days.

The Session

Brett, a Caucasian male of Irish-Catholic descent, is diagnosed with chronic schizophrenia. He is currently the patient having participated in the group the longest. During the session he began his yearly ritual of distributing Christmas gifts—a calendar and card—to each group member. It is relevant to note that throughout the year Brett is soothed by giving gifts of music tapes to other group members on their birthdays. He enjoys when the group is linked together as each member passes the tapes around in a circle to each other. Given the impending separation during the upcoming Christmas break, his action may have been an effort to hold the group together. It is as though the sharing of the tapes physically connects the group members and reinforces the group boundary, a social process from which he may draw to help solidify his own Ego boundary.

The offering of gifts by Brett during the session triggered the first manifestation of the meeting’s theme of fragile boundaries. The group’s newest member (having joined the group two weeks earlier), Earl, an African American man with schizophrenia reacted strongly. When Brett handed him his gift and card, Earl was unable to accept the gift or even the card. When asked why he could not accept anything, he stated: “You sell yourself if you accept a gift.”

After declining the gift, Earl began to speak in a grandiose and delusional manner about a large-scale multinational engineering project he was working on with the Organization of Petroleum Exporting Countries (OPEC), making a pipeline connecting various countries. Earl named each country involved, one after another, taking the pieces and making them into a whole, as if he were sewing together pieces of fabric to make a quilt, or threading beads onto a string to make a necklace.

At this point Brett verbally surmised that Earl would not accept the gift because of skin colour restrictions. Brett explained to the group, in a kind of defensive protestation, that his social worker who is African American and originally from the Ivory Coast had accepted a gift. (Brett, perhaps as a way to give structure and boundaries to his fragmented inner world during psychotic decompensation, is very conscious of mankind being of different colours—and divides humanity into black, white and yellow. At his most psychotic moments he speaks of threes, though the significance of three in particular has never been clear.) At this meeting, however, Brett was rather well and very joyful to be giving gifts. He was also very confused at Earl’s refusal of the calendar. We tried to reassure Brett that this was not a rejection of him as a person, just of the gift that Earl was unable to accept.

Further illustrations of fragile boundaries kept appearing throughout the session. Another patient, Deena, went on to speak of her nightmares that she could recall. She said they had to do with her work and her studying (Deena’s first psychotic episode occurred while she was studying for a Master’s degree and recently, when she became stressed at her volunteer job, she experienced mini-psychotic episodes). She revealed to the group that when she spoke to her psychiatrist about the nightmares he suggested she be tested for sleep apnea. She went on to explain that she preferred to treat her sleep issues “in a psychological way,” by thinking “good thoughts” before bedtime. Again, focus blurred on the boundaries between fantasy and reality and between being awake and asleep.

At this meeting Deena was also experiencing the loss of another group member (Theo) who phoned her during the week, telling her that he would not return to the group as he did not feel it was helpful to him. Deena said: “Theo is my best friend,” and expressed her great sadness.

Dan picked up on Deena’s theme of nightmares and spoke of his frightening experience the previous evening. He said: “I had an out-of-body experience and was very scared that I would not be able to get my spirit back into my body.” He felt his boundary to be extremely fragile in that experience. Furthermore, Dan was trying to cope with his girlfriend’s wish to change the nature of their relationship, and he showed us burns on his arms he had gotten from being distracted while cooking. Dan’s girlfriend is his former fiancée of several years, and she currently was asking for the boundaries between them to be clearly defined. Dan had always struggled with closeness and distance with her, and he needed to be in charge of the “space” between them otherwise he became very angry.

Brett then associated to Dan’s out-of-body experience by speaking of reincarnation and how this idea gives him comfort. He said: “We are only on Earth for a little while, but then can exist after death.” He then told us about what he had received from his sister for Christmas—a wrapped gift set of CDs. We asked Brett if he planned to listen to them, as he had a habit of collecting tapes and never opening them. He would bring his collection to the group in pristine wrapped condition and then pass them around the room in a kind of attempt to link the group wordlessly. He acknowledged he would not open the gift for a while but would keep it wrapped on the shelf to look at it. Was this a way of holding himself (represented by the CDs) together for a time over the holidays?

Dillon spoke up when Deena said she missed Theo, the former member. Dillon recalled the previous session in which Theo recounted how he was trying to cope with the extreme stress of an elderly ill family member moving into the small home he shared with his parents many months ago. Dillon said he could understand Theo’s feeling distressed about his physical space at home having been invaded by this elderly aunt. Dillon explained that he knew what it felt like to have too many people in the house. He said he would experience this when relatives would come to stay over Christmas. He said he needed time for himself. When asked how he planned to cope, Dillon said he would go out to shovel snow, take a walk, etc. Dillon’s good sense of how much closeness and distance he could tolerate demonstrated a good deal of insight into this part of his self this session. Although this limited tolerance to closeness indicated the presence of fragile boundaries, at this point Dillon’s boundaries were clearly stronger than Earl’s, who could not even tolerate accepting a calendar, as this would invade his porous boundary.

After mention of Theo by the other group members, Andy revealed she was very offended by references Theo had made in the previous session to “cucumbers entering body parts.” Andy is sexually repressed and felt intruded upon by his comment. Andy is a very competent mother of a daughter and helps several young relatives with homework each day after school. To keep herself together she swims rigorously each day and limits her food intake to just a little bit of pita bread and humus every day. She appears to deal with her own fragile boundaries through self-sacrificing and restrictive behaviours of many kinds.

After the Session

In discussion after the group session, much time was spent reviewing Earl’s reaction to Brett’s gift giving and the possible causes for it as the leaders were so affected by Earl’s response.

Given what appears to be Earl’s phenomenological experience of a fragmented self, in which his Ego is lacking proper boundaries with the outer world, this sentiment might reflect an underlying fear in Earl of being annihilated—an important subjective experience of individuals experiencing psychosis (Atwood, Orange, & Stolorow, 2002). The very idea of accepting a gift may have triggered fragmentation fears in Earl. It could be interpreted that Earl might experience gifts from the outside as further threats to his very precarious sense of a unified self.

One of the leaders (AL) suggested that the OPEC pipeline fantasy might serve the function of holding the fragmented pieces of Earl’s self together and, therefore, symbolizes a boundary between the inside and the outside (i.e. Earl’s self and the selves of others).

It is his mind’s continuous effort to keep united all the fragmented pieces of his self that translates into this conscious, yet psychotic, and overinvested pipeline fantasy. Indeed, it has become clearer during later sessions that this fantasy project is predominant in Earl’s inner world: It is all he can talk about, and his mind is constantly busy becoming structured by and through it. In this regard, it seems that for Earl, running the pipeline around the world and refusing Brett’s gift were aimed at the goal of self-containment.

Earl’s fragile Ego boundaries can also be tied to his precarious and porous sense of identity. It is doubtful that Earl had an engineering background and it is believed that his work history is a delusion, perhaps related to a wish to find his identity by merging it with that of his father, who Earl reported was an engineer and OPEC employee.

Earl’s fractured self was further exemplified by his belief in his ancestry. Earl was treated during a period of several months in a hospital affiliated with the Jewish faith and subsequently Earl identified himself as Jewish, specifically “a Falasha”—an Ethiopian Jew. In reality, Earl was born in Texas and had lived in Africa with his adoptive American parents before moving to Canada. Earl’s claim of having Falasha identity was interpreted as his having absorbed an identity during his treatment at a Jewish Hospital, which was in keeping with the notion of Earl having porous Ego boundaries.

Update On Earl

Although Earl currently lives in a group home and attends morning activities at the hospital for about one hour daily, for several months after being discharged he chose to spend all of his free time in the dayroom of the hospital ward where he was previously an in-patient, even sitting in the same lounge chair. More recently he has changed chairs. Prior to his hospital admission, Earl was found living in a sub-basement cave-like apartment with no electricity, just candles. He had been eating the same two foods every day (tomato sauce and crackers) and was very psychotic. He remains psychotic but speaks now, and seems to enjoy coming to the hospital activities and to the group. In the present group session, reality, fantasy, memory, and identity of self and other are all strikingly porous for Earl and may be a reflection of his fragile Ego boundaries.

Conclusion

The present paper describes a group session with the theme of fragile boundaries, and considers the mechanism of the group that advances the psychological development of its members. Each of the members present in the session described works overtime to hold him- or herself together, and each struggles daily with the environmental, social, and biological correlates of schizophrenia. How poorly they tolerate proximity to people can also prove to be problematic, as related by Guntrip (1962):

Thus we can understand Earl’s constructed world of a multinational pipeline as a striving towards an inner life, while he is incapable of a true relational life with the other members at this point. We expect that over time he will be less afraid of relationships in the real world if he manages to remain in the group over a period of years. Furthermore, we expect that the group as a whole will become an important object for Earl, one that he may use to help support his striving toward a more stable and solid sense of self. It may be possible that the group exists as a similar object for all of its members.

Over time we have seen immense change in individuals’ capacity to withstand relationships in the group. We believe that the group supports the development of stronger Ego defenses for each member through object relations, which allows a relationship to form between a “self” and an “other” from which the self is experienced as sufficiently differentiated. When Dan first attended the group he was silent for six months, now he doesn’t stop talking. Dillon initially told us he suffered “social anxiety disorder,” although “paranoid preoccupations” might have described his experiences better. Recently, he revealed he used to take anxiolytic medication prior to each group meeting. In this meeting he was able to speak of his great empathy with Theo. Brett is in his element at Christmas and at group members’ birthdays, when he can feel the joy of giving but the rest of the year he appears to be extremely fragile.

An interesting aspect of the group dynamic is the parallel process that occurs between group members and group leaders. This particular session had a noticeable impact on the leaders, who felt excitement not only about the material that unfolded during the session, but also about the after discussion. The need to interpret the material afterwards, and then write about it, might have been the extended expression of our increased effort during the session to contain, structure, metabolize, and mentalize some of the material for patients, which was particularly raw and threatening. Leaders of the group, therefore, functioned not only as containers, but also as mentalizing agents for affects and thoughts that the patients could not yet hold and think about by themselves. Through their capacity for reverie, leaders of the group could tolerate the patients’ psychotic productions (i.e. delusional material) and create sense from what, at first, appeared to be only non-sense. Such a process facilitated the development of the patients’ own abilities to bear their feelings and to think (Bion, 1962). Therefore, leaders functioned as allies to these patients, who are hard at work holding themselves together.

It is our experience that for many patients threatening issues such as separation, isolation, and intimacy are associated with psychological crises that often result in subsequent breakdown and rehospitalisation. The group can serve as a buffer for some of these crises. When patients address their threatening issues within the group, they can use the leaders’ capacity for reverie to transform their otherwise raw affective experiences into metabolized ones, which are far less damaging. Through the group’s capacity for containment, they can better bear difficult emotional experiences. An earlier study (Sigman, 1996) demonstrated that 14 patients who had participated in the group for more than two years had decreased their hospitalisation days by more than 50%. The goal of the group, however, remains simply to be with the members as they speak of their struggles and joys, and to offer a sense of stability in terms of connectedness, support, tolerance, and non-judgment. In this spirit, the group is remarkably inviting to new group members whenever they join, and it is very welcoming to the new interns and summer Masters level practicum students that change over year after year. During the specific session that was reported on in the present paper, there was an impressive amount of tolerance, acceptance, and containment offered by the group to any given individual who was speaking. The point that we wish to underscore in this paper is that, in addition to providing opportunities to experience support and to practice tolerance and nonjudgement, the group may serve as an auxiliary Ego-structuring mechanism for its members, who wrestle with fragile Ego boundaries. It is in this respect that the group is an important stabilizing force for its members. By offering its members access to a containing entity and a thinking apparatus, the group contains, and it is hoped, transforms patients’ psychotic processes and fosters psychological growth.