Inpatient and outpatient programming for mental health populations tends to include a variety of group interventions that target increasing knowledge about mental health problems, strengthening coping abilities, enhancing life skills, and addressing specific problems, such as substance abuse and trauma. However, despite the many protocols for group interventions, there is a lack of evidence regarding the appropriate timing of interventions to maximize effectiveness. Group assignment generally is by the nature of the individual’s problem (e.g., depression, posttraumatic stress disorder, borderline personality disorder) or by the type of intervention (e.g., emotion regulation, mindfulness skills), but often without adequate attention to the client’s cognitive and psychological readiness for the group. As a result, the wide range of functioning of clients within groups can interfere with effectiveness. The purpose of this article is to describe the application of a three-phase, conceptual model—the Surviving, Existing, or Living (SEL) model (Fuller, 2009)—for more closely matching the type and timing of group interventions to client status to improve treatment response.
Challenges to Effective Group Treatment
A frequent challenge to the efficacy of group treatment is that group members can vary significantly in functioning, even among those with the same diagnosis. For example, on an inpatient unit, an individual diagnosed with depression may be lying in bed nearly catatonic, actively suicidal with some reality impairment, or interacting with others and actively engaging in treatment. Individuals with severe psychosis, including those diagnosed with schizophrenia, can fluctuate in presentation in terms of reality testing, level of self and interpersonal awareness, cognitive ability, emotional awareness, and arousal level, even within a single treatment session or interaction. Such examples highlight the importance of a dimensional perspective on psychological problems that accounts for differences in severity. That is, mental health disorders (e.g., depression, anxiety, psychosis) are more accurately conceptualized along a continuum that considers the intensity and severity of interference in the person’s life than by oversimplified, categorical notions of “sick” or “well,” “depressed” or “not depressed,” or “psychotic” or “not psychotic.”
Differences within a diagnosis as well as differences between diagnoses can result in the level of functioning of members participating in any one group being too heterogeneous to be effective. Individuals who are reality-oriented and capable of abstract thinking and emotional processing may be placed in groups with members who are actively psychotic and have limited awareness of others. This is not only less effective but clinically contraindicated, as it can be distressing for group members when they are subjected to interventions beyond or beneath their current psychological capabilities. For example, some participants may progress by directly addressing emotionally laden topics, whereas other members may become overwhelmed and regress when affect is expressed. Differences in psychological status also make it more difficult for members to relate to and to trust one another. In summary, variability in psychological functioning within and between diagnoses can result in groups that are highly heterogeneous, which interferes with group cohesion and treatment response.
Even within a group more homogeneous in psychological functioning, issues remain regarding the appropriate timing of interventions. Clinical and empirical literature indicate that certain treatment interventions may be more effective at particular times, depending on the individual’s status. For example, research has indicated that many cognitive rehabilitation interventions may not only be ineffective when the client is severely inattentive (i.e., when acutely distressed), but may result in clinical deterioration (Silverstein, Menditto, & Stuve, 2001). Such data highlight the importance of waiting for a client to be sufficiently stable before introducing cognitive remediation interventions. As another example, individuals are more likely to be responsive to social skills training once they are less distressed and less self-focused, and therefore better able to notice and respond to others. Indeed, there is strong evidence that basic cognitive processing abilities are necessary for individuals diagnosed with schizophrenia to learn and respond to psychosocial interventions and to progress in social and vocational functioning (Brekke, Kay, Lee, & Green, 2005; Green, Kern, Braff, & Mintz, 2000). Cognitive-behavioral strategies for psychosis are more effective with those who have some awareness of their difficulties (Silverstein, Spaulding, & Menditto, 2006). For trauma treatment, it is important that the processing of traumatic experiences occurs once the person is able to regulate the emotions and related arousal that occurs with exposure to traumatic memories (Brewin, 2005; Briere & Scott, 2006). These examples support data indicating that the specific level of functioning may affect response to different psychosocial interventions (Patterson, 2008), and this conclusion has prompted the call for treatment to be flexibly determined by patient status rather than treatment method (Bachmann, Resch, & Mundt, 2003).
The Surviving, Existing, or Living (SEL) Model
In an effort to better match treatment interventions to client status, the author developed a three-phase, conceptual model entitled the Surviving, Existing, or Living (SEL) model. The SEL model is a practice-based model originally configured from the clinical and empirical literature to guide the type and timing of treatment for individuals diagnosed with schizophrenia (Fuller, 2009). Three general phases (Surviving, Existing, and Living) of the model are subdivided along a continuum into different levels of severity. In brief, the Surviving Phase is characterized by severe impairment in reality testing, logical thinking, and judgment, with limited awareness of self or others. This is often the phase of those with acute or chronically acute psychosis. The Existing Phase is denoted by increasing reality orientation, awareness of self and others, but a tendency to restrict experiences (including emotionally, interpersonally, behaviorally) to avoid getting overwhelmed. The Living Phase is characterized by a greater stability in reality testing and self-view and a fuller experience interpersonally, emotionally, and functionally. The phases are differentiated by where the individual falls on a continuum of eight different factors: self-development, threat appraisal, awareness of others, extent of hallucinations or delusions, cognitive awareness, logical thinking, emotional awareness, and goal-directed behavior. Details regarding the characteristics of each phase and correlate interventions are elaborated elsewhere (Fuller, in press). The dimensional assessment of multiple, critical factors along a continuum increases precision in determining client status, which then can hone selection of appropriate interventions according to group capabilities and needs. As a result, a better fit can be achieved between interventions and client readiness to increase participation, retention, and treatment efficacy.
Application of the SEL Model within a Mental Health Facility
The SEL model was implemented into the outpatient psychosocial rehabilitation program at a state psychiatric hospital to further tailor interventions to client status, increase homogeneity in functioning within groups, and facilitate a common language and conceptualization among disciplines for describing client status. This particular model was adopted because it had been developed by the author while working within that treatment setting. In keeping with the program’s overarching philosophy of rehabilitation and recovery, the phases were renamed Rehab I for the Surviving Phase, Rehab II for the Existing Phase, and Recovery for the Living Phase.
All members of the multidisciplinary treatment team, composed of nurses, social workers, case managers, psychologists, psychiatrists, occupational therapists, and recreational therapists, participated in trainings in the characteristics of each of the phases to ensure consistency. Each individual client was discussed to reach consensus on the appropriate phase assignment. When a client displayed features of two phases, agreement was made about best fit, balancing efforts to attenuate the person’s strengths and “stretch” capabilities, but not place the client in situations he or she did not yet have the psychological resources to manage. Groups were then designed to target salient issues and capabilities of a particular phase, and clients were assigned only to groups designated for their particular phase. Each time slot of programming offered at least one group for the Surviving Phase (Rehab I) and one group for the Existing Phase (Rehab II). Some groups combined Existing/Living Phase (Rehab II/Recovery) members together, but Surviving (Rehab I) groups remained separate due to the greater fragility of individuals in that most acute phase. Groups remained the same for a rotation of approximately 10 weeks (a common length of group treatment protocols), at which time each client was reassessed to determine any needed changes in functioning and phase level.
Attendance for each group therapy was monitored through daily group attendance sheets and weekly reports that were provided by group facilitators. The percentage who attended each group was calculated as the number of individuals who actually attended a group divided by the number scheduled for that group. These data were analyzed by the Quality Management Coordinator. Following the first quarter of implementing the SEL model for group assignment in the outpatient program, overall attendance for groups increased by 16%. In addition, group facilitators reported greater homogeneity in group composition.
Because of the success of the model, the framework was adapted for use within the hospital-wide psychosocial day treatment program, which included inpatient individuals with a broad range of diagnoses. To facilitate appropriate phase assignment for individuals across diagnoses, a checklist of basic characteristics was developed by professionals from the hospital’s multidisciplinary teams, based on clinical experience and knowledge of the literature (Table 1). General criteria related to reality orientation and logical thinking, attention span, ability and motivation to engage in treatment, emotional expression, level of interpersonal relating, and ability to engage in self-reflection were used to determine group assignment. General types of interventions for each phase are found in Table 2.
Table 1: Group Assignment Checklist
Table 2: Phase-Specific Group Intervention Guidelines
In the hospital-wide program, individuals in the Rehab I groups primarily remained those who were acutely psychotic or displayed other significant cognitive impairment (e.g., dementia). The majority of individuals fell into the Rehab II group, with fewer in the Recovery group. For this reason, some groups were combined for Rehab II and Recovery, with a smaller number of process groups for those in the Recovery group. The remainder of this article provides descriptions of the types of group interventions conducted in each phase.
General Group Interventions by Phase
Rehab I Group Interventions
Rehab I (Surviving) groups target increasing reality orientation, promoting a sense of safety and self-awareness, and enhancing basic awareness of thoughts and emotions. The focus primarily is on the present, and tasks are brief to fit the short attention span of members. Rehab I group participants, if they focus on someone outside of themselves, tend to anchor to the group leader, with limited interaction with other members. Members tend to complete group tasks independently or with group leader assistance, rather than interacting with one another. Groups are smaller, generally a maximum of eight members, and—due to limited attention spans—last for 30 minutes. This time restriction allows for an introduction and presentation of one specific topic or activity.
Activities in Rehab I groups primarily address the main issues of the acutely psychotic or chronically acutely psychotic individual, although those with dementia may also be included. Reassurance of safety is particularly important to emphasize within the group as well as outside of the group. Activities that promote basic self-awareness and reality orientation are important, including sensory integration activities (i.e., exercises that enhance the processing of sensory input from the body and the environment), physical exercise, and tasks that broaden self-descriptions. Fundamentals related to thought and emotion recognition are emphasized through discussion and activities.
Rehab II Group Interventions
Rehab II (Existing) groups continue to increase self-definition and encourage self-reflection, enhance awareness and interaction with others, and build stress tolerance. Group exercises, for example, can move from the primary focus of the Rehab I phase on self-definition and reality orientation to more skill building. Specifically, as the person stabilizes, psychoeducational groups in this phase continue the development of basic cognitive and emotional skills, as well as social, vocational, and life skills. As a bridge between the acute and recovery phases, there is a balance in the Rehab II group interventions between continuing to bolster the individual’s coping and self-structure, while also gradually expanding his or her interpersonal and emotional experience. Groups last approximately 45 to 50 minutes.
Cognitive rehabilitation exercises may be beneficial in the Rehab II phase, although developing interventions that result in generalization of what is learned remains a challenge. Cognitive tasks begin with simple task requirements to ensure success without mistakes and gradually and slowly progress in difficulty. Basic cognitive work also involves continuing to increase awareness of thoughts, such as by having members count their thoughts for a specified brief time. Once group members are able to “think about thinking”(i.e., display metacognition), other fundamental cognitive strategies and mindfulness skills can be taught. Basic social skills can occur, including rudimentary conversation and assertiveness skills. Emotion identification continues and is enhanced by greater emphasis on emotional experience (starting with the physical aspect) as well as adaptive emotional expression, such as fundamental anger and stress management skills. Introductory groups for special topics (i.e., substance abuse, trauma, psychosis, depression, anxiety, and other psychological disorders) provide psychoeducation, facilitate awareness and acknowledgement of the negative effect of such issues for a person, and enhance motivation for change.
Recovery Group Interventions
Recovery (Living) phase groups are for individuals who have a better defined sense of self, more empathy for others, greater reality-based adaptive coping, and a fuller experience affectively, interpersonally, and behaviorally. Individuals functioning well enough to be in the Recovery group, if in treatment, primarily will be in outpatient programs. Participants display greater ability to think about thinking (general metacognition), more interpersonal interactions, and greater stress tolerance. Groups, therefore, can be more process-oriented, focusing on occurrences within the group and on expressing and exploring emotions and affectively laden topics. However, particularly for those with severe psychosis such as schizophrenia, continued social deficits, mistrust, and vulnerability to emotional overwhelm necessitate careful titration of emotionally provoking topics in this group. Therefore, emotional exploration is counterbalanced by in vivo use of coping strategies and psychoeducation. Similarly, although more of the past may be explored, this is balanced with promoting awareness of and adaptive coping with the present and with developing realistic future goals. Advanced topics on self-esteem, interpersonal relationships, anger and stress management, adaptive skills, and social and vocational skills can be offered. Groups in the Recovery phase addressing special issues (e.g., substance abuse, trauma) can provide further education, exploration, and processing. Relapse prevention groups may target symptom and medication management.
Clinical Implications and Conclusion
This article described the application of the SEL model in mental health settings for enhancing specificity of group therapy interventions. Although originally designed for conceptualizing the phases of schizophrenia, the SEL model has been expanded for assessing and understanding functioning of individuals with a range of psychological problems in both inpatient and out-patient settings. Use of the framework facilitates a common language and understanding to tailor the interventions of different disciplines based on the current level of functioning of the individual. This article advocated for phase-specific interventions based on client characteristics to guide and facilitate the type and timing of treatment strategies. Although research is needed to determine the benefits of this specific model for enhancing treatment efficacy, it is hoped that the emphasis on tailoring interventions based on client status and integrating diverse theoretical approaches continues to be a central focus of future clinical endeavors for group treatment.
- Bachmann, S., Resch, F. & Mundt, C. (2003). Psychological treatments for psychosis: History and overview. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31, 155–176 doi:10.1521/jaap.18.104.22.16830 [CrossRef] .
- Brekke, J., Kay, D.D., Lee, K.S. & Green, M.F. (2005). Biosocial pathways to functional outcome in schizophrenia. Schizophrenia Research, 15, 213–225 doi:10.1016/j.schres.2005.07.008 [CrossRef] .
- Brewin, C.R. (2005). Implications for psychological intervention. In Vasterling, J.J. & Brewin, C.R. (Eds.), Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives (pp. 271–291). New York: Guilford Press.
- Briere, J. & Scott, C.S. (2006). Principles of trauma treatment: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage.
- Fuller, P.R. (2009). Surviving, existing, and living: Phase-specific psychotherapy for schizophrenia. Abstracts of the 16th ISPS International Congress, June 16–19, 2009, Copenhagen, Denmark. Psychosis: Psychological, Social, and Integrative Approaches, 1(Suppl. 1), S25.
- Fuller, P.R. (in press). Surviving, existing, or living: Phase-specific therapy for severe psychosis. London: Routledge.
- Green, M.F., Kern, R.S., Braff, D.L. & Mintz, J. (2000). Neurocognitive deficits and functional outcome in schizophrenia: Are we measuring the “right stuff”?Schizophrenia Bulletin, 26, 119–136 doi:10.1093/oxfordjournals.schbul.a033430 [CrossRef] .
- Patterson, T.L. (2008). Adjunctive psychosocial therapies for the treatment of schizophrenia. Schizophrenia Research, 100, 108–119. doi:10.1016/j.schres.2007.12.468 [CrossRef]
- Silverstein, S.M., Menditto, A. & Stuve, P. (2001). Shaping attention span: An operant condition procedure for improving neurocognitive functioning in schizophrenia. Schizophrenia Bulletin, 27, 247–257 doi:10.1093/oxfordjournals.schbul.a006871 [CrossRef] .
- Silverstein, S.M., Spaulding, W.D. & Menditto, A.A. (2006). Schizophrenia. Cambridge, MA: Hogrefe & Huber.
Group Assignment Checklist
|Check all criteria that apply. All criteria met in the lowest category (starting with Surviving) designates category assignment.
|Rehab I (Surviving)
||Rehab II (Existing)
|Severe impairment in reality testing, logical thinking, and judgment
||Mild to moderate impairment in reality testing, logical thinking, and judgment
||Minimal to no impairment in reality testing, logical thinking, and judgment
|Poor attention span (averages 5 to 10 minutes per task)
||Can attend for at least 20 to 30 minutes
||Can attend for up to 50 minutes
|Limited ability to engage in treatment
||Low to moderate motivation to address and change problems that led to hospitalization
||Moderate to high motivation to address and change problems that led to hospitalization
|Limited awareness or appropriate expression of emotions
||Emerging awareness of emotions
||Increased awareness and appropriate expression of emotions
|Limited awareness of others
||Awareness of others/some interactions with peers
||Increased interaction with others
||Can engage in self-reflection
Phase-Specific Group Intervention Guidelines
|Rehab I (Surviving)
||Rehab II (Existing)
||Present and future focus
||Past, present, and future focus
||Psychoeducational/skill building (basic)
||Psychoeducation/skill building (advanced)
||Didactic/process groups/relapse prevention
|Label and contain emotions
||Increase awareness and management of emotions
||Encourage more emotional expression
|Activities of daily living
||Basic life skills
||Advanced life skills
|Basic self-awareness work
||Basic social skills
||Advanced social skills
|Label and normalize thoughts
||Basic cognitive skills
||Advanced cognitive skills