Elio Frattaroli, M.D., describes introspection as "to look inward or rather to feel inward...then put into words what you perceive or feel." Jay Early, Ph. D., reviews the value of introspection in therapeutic change, "making the unconscious conscious," and seeing "awareness as curative in itself."

Introspection alone has its place. Less censorship and more honesty occurs in diaries and journals, knowing they're "for my eyes only." Writing letters expressing anger, grief, gratitude, love and other emotions, to the living or dead, to be saved or discarded, opens the floodgates of feelings. "Goodbye" letters to drugs, alcohol, self-mutilation, and other harmful behaviors elicit self-awareness that fosters change. Artistic expression in poetry, drawing, collages, working with clay, composing music and lyrics, including rap songs, requires time, space, and a quiet environment respecting each participant's privacy.

Lynn Bunnell, M.S. Ed., CTRS, CADC, incorporates introspection and interaction in Strategies Using Art For Self-Reflection, using art and reflection questions to "help people look at themselves in greater depth and then apply what they find to the to the here and now. As they reflect on their drawings, participants create their own meaning and significance, leading to deepened self-awareness." She then suggests participants share drawings and answers to reflection questions.

Sandra Negley, MTRS, CTRS, in Crossing The Bridge – A Journey In Self-Esteem, Relationships, And Life Balance addresses "self-esteem development, childhood messages, inner talk, feelings and beliefs...in order to make personal life changes and participate in self-discovery work, core beliefs must be identified." This is facilitated as participants read thought-provoking prose and "journalize." Sharing their work is optional and to be done with caution in small groups with trusted peers.

Jay Early, Ph. D., author of Healing Responses and Therapeutic Change and Interactive Group Therapy, contends, "While awareness is important and healing can emerge entirely as an internal process, healing responses from others provide a form of corrective emotional experience that is crucial to therapeutic change." He identifies the following seven types of healing responses occurring in groups:

• Caring
• Disconfirming
• Meeting needs
• Protection
• Reinforcement
• Reparation
• Healing relationship

Psychoeducational groups incorporate introspective and interactive principles to promote healthy thoughts and behaviors. The most common example involves worksheets.

• Interactive: leader presents the topic and elicits discussion or brainstorming
• Introspective: independent worksheet completion
• Interactive: sharing of responses

Other methods could include:

Poetry

• Interactive: distribute a poem to be read a poem in unison
• Introspective: people write answers to thought-provoking questions independently
• Interactive: share responses

Role Plays

• Interactive: members re-enact a parable, verbally or via pantomime, with a narrator
• Introspective: people answer related worksheet questions
• Interactive: narrator asks people to share their responses

You can also use interactive activities that require introspection. Here are some ideas:

• Distribute worksheets, have people ask a partner the questions, record responses, then "present" the partner to the group.
• Cut up worksheet into individual questions, place in envelope or bowl, have each ask a question of the person next to him/her.
• Have people anonymously write their most pressing problems on slips of paper, toss them in a bowl, then have them randomly pick problems and brainstorm solutions.
• Place inspirational verses, poems, booklets, and quotes, etc., in bowls and have each select a message, read aloud and share its personal relevance.
• Photocopy workbook questions on five or six different topics, and have five or six volunteer "questioners" each select a page. List categories on board. Other members take turns selecting a topic and answering the questions asked by the person holding the relevant page. The "questioners" also select and answer on any topic but their own.
• Answer questions aloud from BINGO cards or in quiz show formats.
• Have teams develop questions for the opposing team to answer.
• Conduct role-plays where the audience coaches the actors in conflict resolution or assertive communication or other skills.
• Pantomime where people read facial expressions and body language, define an emotion, and share times they felt that way and how to cope.
• Act out a talk show, run a panel discussion and use a debate format requiring formulating ideas and opinions then substantiating them or changing one's view based on differing views.
• Allow people to select card questions relevant to their particular needs, have them answer orally, and offer feedback. Stacks of cards on Self-Esteem, Reflection, Recovery and other commercially produced products available through Wellness Reproductions and Publishing are fantastic for this purpose.

Special Tips for Severely Impaired Patients

Remember the old saying quoted by Dr. Frattaroli, "Nothing human is foreign to me." He refers to "a core set of human emotional experiences that any of us, regardless of chemical imbalances or genetic states, have access to." He encourages us to talk to the "core healthy self." Otherwise you see only the symptoms and never meet the person. The leader sets the stage and exemplifies appealing to the healthy core of each member. The sickest among them will usually rise to the occasion.

Yalom emphasizes support for any effort at participation: if they arrive late, compliment their coming, if they leave early, recognize how long they were able to stay, allow them to be silent, reinforce efforts to help peers even with inappropriate advice. He tells patients the goals are to learn to concentrate, listen, share, and deal with shyness. The suggested format includes orientation and preparation, warm-up exercises, structured exercises, and review of the session.

Warm-up may involve each member making an observation about another such as something the person on the right was seen doing earlier that day or say something briefly about a feeling experienced that day.

Yalom's structured exercises have major thrusts:

Self-Disclosure

He suggests giving each a sheet of paper with open-ended questions and a few minutes to answer (introspective). Themes such as anger, isolation, or others can be addressed. Then pair up people to exchange sheets and ask for clarification about partner's responses. The whole group then re-convenes and each shares the partner's work and tells anything new he/she learned about the person, (interactive). He notes that art can be similarly used for solo, dyad and whole group activities. Patients can use a worksheet or papers folded into 4 sections and draw a coat-of- arms: best accomplishment, nicest gift, important person, or keenest interest.

Empathy

Have each select a couple of magazine pictures he/she thinks the person on the right might like, then share reasons for the selections.

Here-and-Now Interaction

People may complete open-ended questions such as: "The person who knows me best in this group is ______________." "What I like most about this group is _____________________."

Didactic Discussions

Leader asks questions and group members share answers.

Personal Change

Sentence completion, solo, then in dyads, then with whole group sharing is suggested using open-ended questions such as: "Two things I want to change about myself are ___________________________." Peers provide feedback on ways to facilitate positive change.

Tension-Relieving Games

To be used judiciously to avoid conveying that staff members have given up on more intense therapeutic methods. One member may leave the room for a few minutes while another member changes his/her appearance in some way, such as takes off glasses, switches shoes with someone else, etc.

Review of the Session

People may share the most important concept learned, the tensest moment, who took risks, what new thing was learned about each member, etc.

All clients, regardless of functioning level, benefit from interaction. In the words of Ralph Waldo Emerson, "It is one of the most beautiful compensations in life that no man can sincerely try to help another without helping himself."

REFERENCES

Bunnell, L., Strategies Using Art for Self-Reflection. New York: Wellness Reproductions & Publishing, LLC, A Guidance Channel Company, 2004.

Dunn, J., The Psychodynamic Process: Putting the Psyche Back in Psychiatry: An Interview with Elio Frattaroli, MD. Psychology Online Journal and American Institute of Psychology and Health, 2002.

Early, J., Healing Responses and Therapeutic Change. http://www.earley.org. and Interactive Group Therapy, (press).

Negley, S., Crossing the Bridge, A Journey in Self-Esteem, Relationships and Life Balance. New York: Wellness Reproductions & Publishing, LLC, A Guidance Channel Company, 2000.

Yalom, I., Inpatient Group Psychotherapy, Chapter 6, The Lower-Level Psychotherapy Group: A Working Model. 1983.

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ABOUT CAROL BUTLER, MS, ED., RN, C

Carol is a Nurse Educator at San Bernardino County California's Arrowhead Regional Medical Center, Behavioral Health Department. She has a Master of Science in Education and School Counseling, a Certificate in Alcohol and Drug Studies, and is a Board Certified Psychiatric and Mental Health Registered Nurse. She is a member of the American Psychiatric Nurses Association and the Alliance for Psychosocial Nursing and is a certified instructor for Management of Assaultive Behavior.

She has worked in mental health for twenty-five years as an Adult Educator, Evaluator, Counselor and Job Placement Specialist in Vocational Rehabilitation, an Employee Assistance Counselor, and a Psychiatric/Mental Health Nurse.

100 INTERACTIVE ACTIVITIES for Mental Health Health and Substance Abuse Recovery was developed during her six years of psychoeducational group facilitation with children, adolescents and adults recovering from emotional problems and substance abuse. She has developed seminars on Professional Burnout Prevention, Handling Patients and Families in Crisis, and Dealing with Angry People, and provides monthly in-services on a variety of topics for mental health professionals.

Valuable free time is spent with husband, family, pets and books.

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