1.4."Personal"therapy.

The so-called "Personal therapy" (Hogarty et al., 1997) and "Cognitive enhancement therapy" (CET) (Thornicroft , 2001) are long-term interventions for individuals with schizophrenia designed to increase the accurate appraisal of emotional states through psycho-education and behavior therapy techniques. It seems that personal therapy improves social adjustment but can increase the rate of psychotic relapse for some patients living independently of their families.

1.5.Family therapy

Family therapy has been useful for treating the patient in his own environment, and reducing relapse. The techniques are not based so much on the systemic model (which assumes that alterations in family communication can produce schizophrenia) as on psycho-educational techniques (explaining symptoms and therapeutic options to the family). They are based on the finding that the patient's presence produces alterations within the family, especially in those families, which tend to adopt excessively emotional attitudes ('high emotional expression') (Guimon & Cuperman, 1982). These psychosocial family interventions tend to improve the alliance with relatives reducing the adverse expressions of anger and guilt by the family, encouraging the relatives to appropriate limits (Thornicroft (2001).

Family interventions (Dixon, Adams, & Lucksted, 2000) seem to be of help in keeping patients in the community. A Cochrane collaboration systematic review has concluded that families receiving this intervention can expect less-frequent relapse and admission in their relatives with schizophrenia, without any additional burden of care. Multiple family models seem to be more effective than interventions for single families (McFarlane, 2000) in terms of reduced relapse rates and offering an expanded social network. Dixon (Dixon et al., 2000) in a review contend that the data supporting the efficacy of family psychoeducation remain compelling.

However, Pharoah et al (Pharoah, Mari, & Streiner, 2002), in a Cochrane review, evaluate the randomised or quasi-randomised studies and finds that family intervention may decrease hospitalisation and encourage compliance with medication but does not obviously effect the tendency of individuals/families to drop out of care. It may improve general social impairment and the levels of expressed emotion within the family. Professionals "cannot be confident of the effects of family intervention from the findings of this review".

On the other hand, there is a poor availability of these treatments in ordinary clinical settings (Penn, Kommana, Mansfield, & Link, 1999) and a substantial proportion of relatives refuse to attend a group and need sessions in the home (Leff, 2000).

2. USES AND ABUSES OF GROUP AND MILLIEU PSYCHOTHERAPY

2.1.Group psychotherapy

Even now, in certain developed countries (Sultenfuss & Geczy, 1996), schizophrenics who remain in long-stay units at psychiatric hospitals receive only pharmacological treatment.
Group psychotherapy, above all when the therapist actively tries to develop the social abilities and strategies for coping with stress, has been supposed to be useful, especially once florid symptoms are under control. The results seem to be better than those obtained with individual psychotherapy individual, which can be explained by the fact that the group offers socialisation experiences, behavioural models, and a more shared transference which is less dependent on the therapist (Guimón & Totorika, 1983). However, the treatment of chronic schizophrenics using analytical group psychotherapy has often been an exasperating, fruitless experience (Frankel, 1993), creating a strong emotional responses in the leaders which also reinforces a spiral of repeated failures.

Overall, the relatively few controlled trials of group psychotherapy present major methodological problems which limit their generalisability. Scott and Dixon (Scott & Dixon, 1995), in a review of the literature on the clinical outcomes obtained by support and dynamic psychotherapy (both group and individual) and psychosocial skills training, found that the reality-oriented approaches seem better than insight-oriented dynamic psychotherapy.
The so called Integrated Psychological Therapy (IPT),is a group-therapy modality intended to reestablish basic neurocognitive functions (Spaulding, Reed, Sullivan, Richardson, & Weiler, 1999) that showed incrementally greater gains compared with controls on the primary outcome measure, the Assessment of Interpersonal Problem-Solving Skills, after a six month intensive trial.

2.2. Milieu therapy

2.2.1.Therapeutic Communities

The use of principles from the so-called milieu therapy, based on the experiences of therapeutic communities organised into inpatient units, day hospitals, halfway houses and sheltered workshops, have improved the clinical prognosis and socio-occupational adaptation of chronic schizophrenics.
The best early study are that of Rapoport (Rapaport, 1974) on the Henderson Hospital followed by that of Whiteley (Whiteley et al., 1987) in the same place and that of The Association of Therapeutic Communities Research Group studied. More recently, other studies have been made at the UK . The methodologies used to carry out this studieas are: descriptive or evaluative, ideographic or nomothetic, sociological vs. psychological, or a combination of the above.
A controlled experimental study at Kingswood House concluded that it was almost impossible to link effect to cause when talking about multidimensional treatments such as those which are offered in a therapeutic community. An alternative method to experimental design is represented by the " cross-institutional design " which can be completed by several quantitative methods. An example of this methodology is that proposed by Moos for whom the " ward atmosphere scale " has been utilized in therapeutic communities (Moos, 1987, 1997) (Guimón, 2001) evaluates the social and physical atmospheres of units of treatment.
Several studies, of variable methodological quality, saw a favorable result with this type of approach in psychotic patients. Thus, De Hert et al. ((De Hert, Thys, Vercruyssen, & Peuskens, 1996) who followed up 120 young, chronic patients who took part in the rehabilitation program at the Night Hospital in Brussels, showed that most of them maintained the level of adaptation obtained and continued to live in the community, engaged in useful pursuits. Dauwalder and Ciompi (Dauwalder & Ciompi, 1995) proved the efficacy in the long term of a community-based program for chronic mental patients which resulted in a great number of them having jobs and independent lives even if most patients still needed professional help. On their side, Jin and Li (1994) observed that the number of suicides decreased and that the active participation increased at Yanbian Community Psychiatric Hospital, after its transformation from a residential facility for chronic psychiatric patients into a therapeutic community. Coombe (Coombe, 1996), in an account of principles and treatment practices given to the therapeutic community at the Cassel Hospital in London, underlined the ability of the therapeutic network to render possible, successfully, the treatment of families and individuals suffering from serious disorders.

Mosher (Mosher & Feinsilver, 1971) compared the treatment program for young schizophrenic patients in the Soteria project with that of a small social environment, generally without neuroleptics. The atmospheres of treatment settings were evaluated using the Moos (Moos, 1997) COPES or WAS scales. The two systems managed to reduce, in a similar fashion, the serious psychotic symptomatology in six weeks, in general without anti-psychotic medication, as effectively as the normal hospital treatment, which included the routine utilization of neuroleptics. Shepherd (Shepherd & Murray, 2001) presented benefits and limitations of a new type of institutional solution - " the unit in a home " for patients suffering from severe disorders, who came forward in a health sector (Cambridge) in the United Kingdom. Another study (Nieminen, Isohanni, & Winblad, 1994) carried out in a therapeutic community unit for severely affected patients with an average hospital stay of 40 days, reported that the patients having obtained a better immediate result stayed 10 to 20 days longer in the hospital than did those who had an inferior result. A longer stay was associated with a younger age, a diagnosis of psychosis and the active and motivated participation in individual and milieu io.

Insofar as variables associated with therapeutic results (Guimón, 2001) were concerned, Holmqvist (Holmqvist et al., 1996) who carried out an analysis of the relationship between psychiatric diagnoses of patients, their self-image and the feelings of personnel towards patients in 17 treatment units for psychiatric patients presenting severe disorders, did not find important differences in any comparison. Werbart studied the exploratory factors and those of support in the milieu therapy oriented towards insight into three Swedish therapeutic communities with psychotic patients, by using the scales of the Community-Oriented Programs Environment Scales (COPES). The study showed that a beneficial psychotherapeutic environment needs organization and a setting, which corresponds to a well-defined treatment philosophy. The several structured studies that have been carried out showed that community meetings had the effect of reducing unfavorable ward incidents, in particular incidents with an aggressive character (Ng, 1992).
In regard to the value of specific techniques used in the programs, Winer and Klamen (Winer et al., 1997) presented a model of community relations for hospitalized patients which was led as a large-group interpretative psychotherapy centered on the examination of relationships between patients and personnel in the here-and-now. This model is useful even in short-term hospital units and with serious patients because it can provide a gauge of milieu, throwing light on undesirable conduct of both staff and patients, discovering anti-therapeutic attitudes in personnel, helping to improve compliance with treatment in patients and reducing the tension in the unit.

Several studies indicated the fundamental value of group therapy in these programs. Kahn et al. (Kahn et al., 1992), in a short-term hospital unit, made a comparison between the dynamics of groups which took place there and the atmosphere in the unit, finding very clear parallels between the process of group therapy and those of the ward. Isohanni et al (Isohanni et al., 1992) studied the degree of participation in group psychotherapies in a therapeutic community for severe patients and observed, for example, that the lack of participation (4% in all episodes) or the passiveness (14%) were associated with an inferior therapeutic result and depended principally on program characteristics (ward policy, short treatment times) and to diagnoses to personality disorder. The results suggested that the participation in the group, the therapeutic program, the patient's characteristics and the success of treatment are inter-related.

Concerning the efficacy of the different therapeutic mechanisms, (Holmqvist et al., 1994; Holmqvist et al., 1996) proposed a method to follow up the development of relations and to study those which are useful and useless, through a recapitulative list of words given to nurses, this list permits the measurement of the quantity of emotional arousal in a reliable manner. In another article, Holmqvist and Fogelstam (Holmqvist & Fogelstam, 1996) studied, in 21 small treatment houses, the feelings of countertransference of therapists in the milieu towards patients and their influence on the psychological climate in the unit .

2.2.2. Ward atmosphere in short stay units

In the short stay psychiatric units the patients have to deal with a high degree of stress, arising from short stays, acute symptomatology, auto and heteroaggression, rapid turnover of patients, limited space, etc.
During the last 25 years we have organised programs of milieu therapy in a certain number of short satay units through the organisation of a variety of groups of patients and staff (Guimón, Luna, Totorika, Diez, & Puertas, 1983). Group-analysis, with its particular emphasis on the "here and now" and on intermember cohesiveness, has shown itself to be, in the present study, a usefull stabilizing ("buffer") tool, through fostering involvement and support and allowing a controlled expression of anger and aggresiveness.
The patients-staff group is the key holding element of our group analytic program on account of its basic contribution in the creation of a "continent" for the anxieties arising in the ward. It is also of invaluable help because of the information it provides concerning each patient. The other groups also provide the patient with orientation and emotional support.
On the personnel side, tensions among the therapeutic team are reduced and incoming nursing personnel notice how their previous fears and appréhensions diminish.
On the whole, we had the impression that, despite a personnel shortage, a pleasant and supportive atmosphere was created in the wards. constitute a group-analytical network that makes for a more harmonious communication among the various units of the hospitasl. This systemic vision of the institution gives invaluable help in the understanding of the organizational problems and internal struggles that can soon be detected. This provides the input for the "healthy anticipatory paranoia" needed (Kernberg, 1979) in the management of these organisations.