Group programs for hospitalized depressive patients

In a study we have conducted for the past 6 years at the University Hospital of Geneva, a 10-bed unit for patients suffering from resistant or recurrent depression had registered an average length of hospitalisation of 28.78 days, with a median of 15 days(Guimón, 1998; J Guimón, 2001). The patients' average age was 44, and 42 was the median.Care of patients was articulated in individual and group moments, with each staff category taking part in both. Most of these patients had been hospitalised more than once before, so it is important that their pharmacological treatment be well evaluated. In this context, crisis intervention had to be associated with a more in-depth assessment of the incidence of depression on cognitive and relational skills.
At the arrival of each patient, a brochure was distributed stipulating ward rules. The programme of the group included a daily 15-minute staff meeting for all personnel, except for weekends. A social skills group, led by a nurse and a psychologist, meets during two hours per week, and a verbal group, led by two physicians, during one hour per week. The medication group, led by a resident and two nurses, met once a week for 30 minutes. A family group, led by a physician, with the participation of each professional category, met monthly during an hour and 30 minutes. Three recreational-occupational groups, led by occupational therapists and nurses, also meet for several hours a week.(J. Guimón, 2001b) .The results of this programme were highly satisfactory and they have been reported elsewhere (J. Guimón, 2001a)(Guimón, 2001, 2002).

PATIENTS WITH SUBSTANCE ABUSE DISORDERS

Outpatient groups

Groups are largely used throughout the world for patients who abuse substances, or in outpatient, halfway programmes, or in hospitals for short or medium stays.
Fisher (Fisher Sr. et al., 1996) studied two models of group therapy for patients presenting a double diagnosis of substance abuse and personality disorder. This semi-experimental study was led in a facility treating substance abuse, both on a outpatient and hospital basis. They developed three groups in each context: two groups were formed for the integral treatment of patients with a double diagnosis (substance abuse and personality disorder) and the third was used as a control group, with standard treatment.
One of the experimental groups was developed in accordance with the "illness-and-cure" approach. Its objective was the acceptance of substance abuse as a chronic illness, progressive and possibly fatal. In a similar fashion, although mental illness (personality disorder, for example) is not necessarily fatal, its evolution is typically considered to be chronic and progressive. This approach is based on the assumption that patients have an underlying biological vulnerability, characterised by a loss of control over substance abuse and mental disorders. After the start of treatment, the number of patients per group was set at 7 or 8 members. The groups were led in co-therapy by a principal investigator and another clinician. The immediate objectives in the illness-and-cure treatment model include the development of an identity as an 'alcoholic' or an 'addict', recognition of a loss of control over substance abuse and the effects of personality disorder, acceptance of abstinence as a treatment objective, and participation in group self-help activities such as Alcoholics Anonymous. They also developed a second experimental group in each location, with a cognitive-behavioral approach, which they compared with the other described above.

Therapeutic communities

There are, in addition, long-stay programmes which are more or less structured, sufficiently specific for substance abuse patients, offering an approach that ranges from very firm restriction on freedom to a progressive autonomy leading to total freedom acquired over successive steps during periods ranging from a few months to several years. Some of these programmes are carried out in centres that are directed in accordance with therapeutic community principles. Such programmes are often sidelined from global psychiatric care.

The "concept-based" model

Psychotherapeutic approaches to treating drug addiction have, above all, followed the therapeutic communities concept, which began in the United States in the 1950s with the Synanon programme, followed by others along the same lines, such as Daytop. These were programmes led, in an authoritarian manner, by former addicts, with little participation from physicians or professionals in general. In Europe, this format integrated professionals trained in community management, who were required to have certain abilities such as flexibility and emotional distance. Interesting programmes came out of these efforts, such as the Proyecto Hombre in Spain, and in some countries they were supported by the government or the Roman Catholic Church.
The majority of these demanded a total abstinence from drugs, and rejected the use of medication. However, as drug abuse rose in 1980s, many communities became oriented towards accepting patients in treatment with methadone or psychotropics, featuring a more intensive role for professionals, and a shorter stay for the patients.
Technically, these programmes revolved around the idea of the 'encounter', which was proposed by behaviourists as an alternative to the psychoanalytically oriented groups used in therapeutic communities for mental patients, since they believed that, in the case of addicts, insight might constitute an excuse for not changing. In Synanon, the encounter group was called 'the game' or 'reality-attack therapy', and included direct confrontation (sometimes exaggerated) without fear of retaliation. In recent years, these groups have become less intensive and more sensitive, evolving towards a form of intense dialogue, in which 'confronting is as important as being confronted'. With all of this, it is more difficult to direct these activities without specific training, although the former addicts resent this, since they feel they have lost power and influence. On the other hand, more scientific concepts have been introduced gradually, with psychiatric diagnosis and assessment.
Broekaert (Broekaert, 2001) pointed out that a drug-free therapeutic community defines itself according to various parameters: it should try to become integrated into the community at large, offer a sufficiently lengthy stay, both the patients and personnel should be open to questioning, and former addicts should have a high profile as role models. As to the clients, they should be called 'residents' (as opposed to 'patients', who need treatment to which they submit passively), and it should be accepted that they are immature, innate manipulators, who suffer from fears and anxieties, and that they use violence to hide their weaknesses; above all, there must be a prevailing belief that they can be educated through a therapeutic programme.
In sum, this therapeutic philosophy springs from a number of different sources (Christian doctrine, Alcoholics Anonymous, Synanon, the humanist theories of Maslow and Rogers), all based on the possibility of personal growth and change.
The treatment phases include: crisis intervention (for detoxification in a few days); out-patient (living outside several times a week); reception (admission in a non-demanding regime), in order to prepare for the community during a few weeks; induction, during which motivation is tested; hospitalisation, in which the community is used as treatment during one year in a hierarchically structured environment; phase of acceptance and security, learning to express emotions and modify behaviour in encounter groups and other therapeutic contexts; and social reintegration, through a halfway house or return to the client's own home.
Recent modifications have included the development of more complex networks involving more flexible programmes and customised treatment, e.g., for those with a dual diagnosis, or for chronic patients who need medication. Among the new therapeutic communities, noteworthy are those specialised in other groups, such as the children of addicts, homeless persons, patients suffering from post-traumatic stress disorder, prisoners, immigrants, prostitutes, and AIDS patients.

The "democratic" model

When we discuss democratic therapeutic communities, we are generally referring to a model developed by psychiatrists with a participatory focus, although they have never been truly democratic: the roles were allotted, and a patient could be cured, but not form part of the staff; they never aimed for equity in the parcelling out of power or responsibility. In any cases, these programmes allow all of their members to have a very high level of participation in decision making, with a high degree of information sharing, and a great deal of emphasis on listening to others.

The differences between these two models today

Over the years, different countries have adopted these two community therapy models, tailoring them to their needs and cultural particularities. For example, in Italy the democratic community therapy model is particularly prevalent in the treatment of mental illness, whereas in England it is mainly used in treating personality disorders. It seems that in Italy, there is more open communication and overlapping between democratic therapeutic communities and concept-based ones, particularly at the management level, with their directors and staff psychiatrists taking part in the same congresses and belonging to the same professional organisations.
However, two important differences can be observed. First, is the fact that the concept-based community is nearly always aimed at those whose primary problem is drug addiction, independent of their 'secondary' problems or incidents that may arise over the course of treatment. On the other hand, democratic therapeutic communities are nearly always aimed at those diagnosed with personality disorders or who are mentally ill. These persons may also be addicted to drugs, but not necessarily. The second major difference is that the staff of democratic therapeutic communities comprises professionals only, whereas that of a concept community may include former residents.
Although outside of Europe, the majority of therapeutic communities for drug addicts are highly structured with a strict staff hierarchy, many European therapeutic communities use a more egalitarian model. These are more similar to therapeutic communities in the psychiatric field using a democratic structure (Jones, 1952). However, therapeutic communities with more than 25 residents have usually adopted the hierarchic structure of American programmes. European therapeutic communities are now, in turn, also influencing their American counterparts - for example, their emphasis on introducing creative activities into programming. In addition, they have shown that the residents can learn new skills, such as gardening, agriculture, and printing, during their stay in the programme. In Europe, as in the United States, detoxification centres have been created that are linked to certain therapeutic communities, and in some cases, day centres and evening programmes have been developed based on the drug-free therapeutic community concept.
Therapeutic communities in Europe have also begun to expand their range of patients to self-destructive behaviours other than drug addiction. Moreover, the concept of hierarchic therapeutic communities has been successfully used in treating alcoholics.

The future of therapeutic communities with addict patients

Although research has shown that the time spent in a programme is the main predictor of success, these programmes have recently tended to become shorter, a trend seen in many countries during the 1990s. Relatively inexpensive psychosocial self-help programmes are being transformed into short-stay programmes following a medical model. Indeed, methadone maintenance programmes are being considered in various countries, by politicians and by doctors (aided and abetted by the pharmaceutical industry) as the solution to the problem of heroin addiction. Due to all of these and other factors, the future of the traditional therapeutic communities is in doubt.
In any case, drop out is a frequent problem in these programmes and, for example, Keen et al. (Keen et al., 2001) found low levels of completion and high levels of unplanned departure in a residential rehabilitation centre in a 1-year programme for chronic heroin users
Good results have been reported in a special programme created for the integrated treatment of a dual diagnosis involving schizophrenia and substance abuse (Hellerstein et al., 2001), 2001). However, Ley (Ley et al., 2002), evaluating the effectiveness of six relevant studies, concluded that there is no clear evidence supporting an advantage of special programmes for people with problems of both substance misuse and serious mental illness, and ends saying that 'implementation of new specialist substance misuse services for those with serious mental illnesses should be within the context of simple, well designed controlled clinical trials'.

PATIENTS WITH BORDERLINE DISORDERS

Overall tendencies

These patients are difficult to manage in individual analytical psychotherapy, due to their instability, which is frequently related to a loss of self-esteem and identity confusion. The course of therapy tends to be disturbed by intense transferences and various acts, such as suicide attempts, attacks of rage, and self-mutilation caused by suicidal thoughts. Kernberg (1968) recommended confronting these patients and interpreting their negative transference early on, whereas other authors (Buie et al., 1982) advise therapists to limit themselves to acting as a holding environment for the patient and avoid interpretations. There is a high percentage of drop-out in these patients. Group therapy, traditionally used in these patients when they are hospitalised, is currently considered of particular interest for outpatients. Springer and Silk (Springer et al., 1996) designed an efficient, short programme, and discussed, particularly, the advantages and disadvantages of Linehan's dialectical behaviour therapy (Lineham, 1987; Lineham, 1993). Indeed, group therapy offers the advantages of being less expensive, making transference easier to manage, and producing an improvement in ego functioning (Kretsch et al., 1987) and interpersonal functioning (Schreter, 1970, 1978), a drop in the patient's regressive tendencies (Horwitz, 1980, 1987). Moreover, these patients are more likely to take advice or engage in confrontations with other patients than with the therapist, and they have the possibility to relate with them on an equal level.
Group therapy should be part of a multidimensional programme, and the group should, in principle, be heterogeneous. The orientation of groups tends to be eclectic, and although open psychodynamic groups are the most frequent, others (Klein, 1993) focus on such aspects as acting out, splitting, countertransference and eroticisation of relationships.
Group therapy was found to be as efficient as individual therapy in a program of 'managing emotions' (Dawson, 1988; Dawson et al., 1993) and patients who participated in groups showed better treatment compliance. In these programs therapists show themselves as permissive even if they forbid acting out. Regular attendance at meetings was not obligatory, which meant that only 30% of regular participants, forming the nucleus of patients, was more or less constant, while there was also a much larger subset of patients who showed up from time to time at the group meetings, searching for occasional help. A controlled study comparing individual and group psychotherapy (Clarkin et al., 1991) showed better results with this approach.
Significant, positive results have been found with Linehan's cognitive-behavioural approach. This method was first proposed for young women who were parasuicidal, and was then extended to persons with behavioural problems to resolve 'dialectic' failures. Indeed, from a theoretical point of view, Linehan made reference to this dialectic reasoning, which brings into opposition poles such as active passiveness versus competency, demonstrative crises versus emotional inhibition, and so on.
These programmes combine individual and group approaches in problem-solving and in skills training. In the psycho-educational groups, patients are taught a certain number of skills in regulating emotion, interpersonal functioning, and stress tolerance. Patients take part in these groups during at least one year, and then participate in help groups, or groups to reinforce skills application. In individual and concomitant therapy, which lasts at least one year, we teach patients to integrate these skills into daily life. Rules to generalise apprenticeship in the outside world (even using the telephone) are proposed. The group is closed or, at the maximum, slowly opened.
The psychoanalytical approaches are especially based on the theory of object relations. Most of the approaches have been developed in hospital environments or in halfway centres, based principally on the work of Kernberg, who used the psychoanalytical model of object relations. The accent is placed on increasing the fortress of the ego and improving the experience of realities, with an attempt at internal reconstitution. From a technical point of view, the splitting mechanism is reinforced rather than fought, and they propose open exteriorising of aggression and the realisation of group interpretation based on the 'here and now', which favours cohesion.
Certain authors, in comparing these two approaches, have pointed out that in both of them, the therapist is strongly committed, even if the attitude of Kernberg is neutral and that of Linehan is active, with attitudes of reinforcement. However, the expression of aggressiveness is encouraged by Kernberg, whereas Linehan does not encourage it, and Linehan is not interested in the here-and-now of the group, nor in group phenomena.

Wood et al. (Wood et al., 2001) compared group therapy with routine care in adolescents (most of them borderline) who had deliberately harmed themselves, and found that those who had undergone group therapy were less likely to be 'repeaters', although their global outcome did not differ. Hawton et al. (Hawton et al., 2002) evaluated all randomised controlled trials regarding the effectiveness of treatments of patients who have deliberately self-harmed, and found reduced rates of further self-harm for depot flupenthixol versus placebo, and for dialectical behaviour therapy versus standard aftercare.

Groups in residential settings

Because of the risks of acting out, the therapist must be able to count on a support system offering more holding for these kinds of patients, i.e., a hospital unit (which should be avoided as much as possible in order to not embark on a prolonged and counterproductive relationship with the institution) or a day hospital.
Using a dynamic perspective, recent work by Bateman and Fonagy (Bateman et al., 1999), 1999) has shown favourable results with treatment based on dynamic psychotherapy in a day hospital. These authors compared the evolution of 19 patients, whose treatment in hospital was partially oriented from a psychoanalytical point of view, with the same number of patients who had received general psychiatric treatment. Self-mutilating behaviour and suicide attempts decreased during the 18-month programme. Moreover, the average hospital stay was shorter than for those who followed specific treatment.
In the hospital environment (and also in halfway institutions), the treatment is carried out in settings where several caregivers interact. Adshead (Adshead, 1998), in light of attachment theory, reported that the hospital environment provides security only if caregivers are capable of tolerating both the external demands of the system and the internal demands of patients. He pointed out that therapeutic relationships between staff and patients are only repetitions and recreations of internal object relations, and that responses from the team to splitting and to projective identification can sometimes be negative. He further indicated that a certain number of negative reactions can be detected through the patronising and contemptuous way that caregivers may sometimes express themselves to the patient; moreover, that certain excessive reinforcements of the regulation of services, for example the inappropriate use of restriction on movement, may result from this attitude on the part of staff. Adshead also remarked that the conflict between therapist and patient may be exacerbated by the new organisation of cost containment, particularly in a managed-care system, e.g., by the interference of insurance companies. Finally, he pointed out that problems in the unit's structural organisation, such as inadequate accounting practices, lack of leadership, difficulties in communication and violation of boundaries, can seriously aggravate the condition of patients.
The programme developed at the Francis Dixon Lodge is an example of these issues. The patients are generally hospitalised because of their destructive manner of expressing their mental pain. After three weeks of hospitalisation, staff embark on a psychodynamic programme, which includes predictions regarding transferential reactions that they can expect, and which try to cover the self-aggressive behaviour (feelings of abandonment, trigger situations, and so on). Personnel try to forge a therapeutic relationship in which the patient feels sufficiently reassured to explore avenues of new relationships, while allowing him or her access to the horrors of the past, which may carry so much negative emotion that they could even endanger the relationship. In addition, they consider acting out to be an expressive and defensive function and that even more self-destructive behaviour can be an attempt to avoid another catastrophe (psychosis, hetero-aggression, etc.), which can be experienced as more destructive to their own integrity.
These patients, because of their poor self-esteem, do not know how to ask for help in an appropriate manner, and do so by provoking crises, which causes the therapeutic team to counter-react. Staff explains to patients that they must learn to talk about their suicidal feelings or their ideas about self-mutilation, explaining that they try to be tolerant, but that we also expect them to modify their behaviour. They try to avoid patients' feeling of omnipotence when they trigger self-aggressive activities, and pay special attention to phenomena of hostile and envious dependency, by trying to avoid or to manage negative therapeutic reactions.
Springer (Springer et al., 1996), based on the existing literature, proposed a framework in which an effective, short-term group treatment can be organised, particularly emphasising the advantages and disadvantages of the adaptation of Linehan's dialectical behaviour therapy by using it in a short-term programme for hospitalised patients. For their part, Dolan et al. (Dolan et al., 1997) evaluated the impact of psychotherapeutic treatment on the principal symptoms of 137 hospitalised patients with personality disorder. They noted a significantly greater improvement in those treated than in the 'non-admitted' group, as well as a significant, positive correlation with length of treatment. Similarly, Hafner and Holme(Hafner et al., 1996) conducted a prospective study on 48 residents of a therapeutic community, 34 of whom presented borderline personality disorders in order to determine which elements of the programme were most useful. A reduction in significant symptoms on the Brief Symptoms Inventory took place at discharge after an average stay of 64 days, and the rates of admission to hospital fell significantly during the year after discharge. Patients rated group therapy as the most useful element of the programme. A five-year follow-up study by Sabo et al. (Sabo et al., 1995) on 37 hospitalised patients presenting borderline personality disorder evaluated the changes in two forms of self-destructiveness. They noted that suicidal conduct diminished significantly, but that self-aggressive conduct, although it presented a certain downward trend, did not drop significantly, nor did aggressive ideation (both suicidal and self-destructive).
Finally, Schimmel (Schimmel, 1999) stressed the efficacy of therapeutic community treatment for patients suffering from borderline personality disorder, concluding that it was necessary to carry out further research to evaluate its efficacy for other diagnostic groups because, in principle, this intensive treatment approach can be very appropriate for patients who are resistant to treatment by other means.