How to Keep `Psychosis’ Focus Groups Inclusive

I fervently believe that having survivor-led group therapy that redefines “psychosis” is missing in the system.

Over the last nine years, I’ve been leading what I call special message groups in multicultural settings. I have found that such groups can be run safely and have the power to transform lives. However, I do admit that when it comes to kicking people out of group to maintain group equilibrium and safety that I believe there are a few things to consider first.

Firstly, I believe that a group leader needs to be prepared for the fact that mad people show up in very different ways. Group facilitators need to be familiar with and recognize a wide variety of presentations or manifestations. Perhaps group members may feel like they are being mocked by others in the group via illusionary ideas of reference or even controlled by them. They may code up their language for protection. They may treat the facilitator as if the facilitator can hear the same voices they hear. They may not believe, in spite of stories shared, that the facilitator has experienced what they have.

I have prepared myself for these challenges by attempting to better define “psychosis.” I have reconstructed a definition that can sync up a wide variety of what have historically been defined as conditions. I believe if the leader is not prepared to accept all presentations, people will not feel safe talking about their experiences. Intolerance for people who show up in a different or what is perceived as a difficult manner can be extremely hurtful.

Secondly, I believe the facilitator can take measures to help train the group to be brave and tolerant of each other. I frame coming together with the specific purpose of sharing untold stories to be an oft neglected privilege that has unfortunately been denied because the “they” experts say it is not safe.

Spirit of Risk Taking

I am always willing to start out with my own story. I advocate for a spirit of risk taking by acknowledging that people in the group may be so used to dangerous or distressing experiences that guaranteeing safety would be a disservice. I also point out that despite what “they” say, this practice has been an effective movement in different countries and I’ve done it for a long time.

These kinds of comments are treating the “set of symptoms” as a neglected culture that is subjugated. In the earlier stages of group development, keeping the group focused on the things they have in common can help. Also, strongly supporting alienated individuals helps train the group to be more tolerant and can help avoid many problems that come up later in a group. It discourages them from expecting a trouble maker will be kicked out.

Thirdly, because there is a high degree of diversity in the mad community, I believe the facilitator needs to be extremely sensitive to all forms of culture, particularly pertaining to relevant issues of subjugation. Discerning the social factors that are affecting the person shows up in a difficult manner is key. Race, class, gender, sexual orientation, age, religion, education, legal justice history, substance abuse history, immigration, gang affiliation, disability, employment history are all social factors that can show up

It is wrong, I believe, to exclude someone because they are testing or trying to teach you about these kinds of issues. Some people may try to dominate the groups. A group facilitator needs to be prepared to accept, learn and support everyone. Again, a person who is not accepted on the basis of something that the facilitator is ignorant about or is not curious to explore, may do harm.

Fourthly, it may be necessary to meet with individuals outside of group to learn more about why they are hurting the group. If a group member is dominating to the point he or she is doing intentional harm, that individual may, in fact, be expressing a need to connect with you.

Perhaps, he is experiencing messages that are extremely misunderstood or there is a cultural issue with you that needs to be talked about.

But when the group is truly becoming unsafe for participants, which is rare, out-of-group meetings are necessary and the facilitator needs to work to better understand the problems that come up in group and clear up any cultural issues.

A meeting could involve two individuals. Making the time for this encounter outside the group is an important resource.

Behavior Contract

Finally, if taking the time for a meeting or two doesn’t improve the behavior, the leader can propose a specific behavior contract to protect the group. This approach is best utilized in real emergency circumstances and needs to be devoid of the leader’s cultural biases to the best of his/her ability. This approach is also something that requires the participant’s input so that the problem can be identified and an agreed upon solution can be proposed.

At the very least, the contract needs to be something the participant can buy into. When the participant takes the power to get involved, consequences can involve sitting some groups out or being referred to an individual therapist or perhaps a different group.

I’d suggest that if the participants take steps outside the group to improve themselves, the leader can be in communication with them, pining for their return.

It is true that many people who suffer from “psychosis” or message crisis also have complex histories, trauma and other co-morbid problems like substance abuse and nuero-diversity. I have seen these kinds of complex issues, that may challenge safety, get addressed within a group process as described, even by survivors who visit programs rather than work in them.

Tim Dreby, MFT is the award-winning author of, “Fighting for Freedom in America: Memoir of a `Schizophrenia’ and Mainstream Cultural Delusion.” He is currently working on a book that redefines “psychosis” across diagnostic categories and suggests solution strategies.

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