SUMMARY

The day hospital and other halfway houses in which group psychotherapy is the basic therapeutic instrument, are indispensable structures for maintaining severe psychiatric patients in the community.
During the last 25 years, programmes of milieu therapy in a certain number of short-stay units have been organised and a pleasant and supportive atmosphere was created in the wards.
In traditional psychiatric hospitals a specific 'milieu' can be created thru group programs playing a therapeutic role for some particular patients.
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

RESUMEN

La práctica psiquiátrica clásica tiene poco valor para la Asistencia primaria. En cambio, el psicoanálisis puede ser de gran ayuda para formar a los médicos generales en técnicas psicoterapéuticas sencillas y sobre todo para favorecer la capacidad de contención de los médicos de cabecera y los pediatras. En Atención Primaria se pueden aplicar también nuevas estrategias asistenciales como psicoterapias breves y focales, entrevistas de contención, entrevistas de elaboración de duelos concretos, seguimientos psicológicos, los procesos de flash psicoterapéutico. Hay técnicas mixtas con referencia psicoanalítica utilizando elementos técnicos conductistas, cognitivos conductuales o psicodinámicos: protocolos para la enuresis funcional o para la autonomización progresiva o para las técnicas de relajación.

Las urgencias psiquiátricas deben estar incluidas en las urgencias de los hospitales generales y se ha demostrado que la existencia de camas de estancia muy breve para la observación y el tratamiento agudo (entre 24 y 72 horas) de parte de estos pacientes puede evitar numerosas hospitalizaciones psiquiátricas. En este sentido, en el futuro, aumentará el número de servicios de urgencias hospitalarias que funcionen como verdaderos "centros de crisis", con personal específico y bien formado.

La "intervención en los momentos de crisis" (crisis intervention) idealmente exige detectar precozmente a los sujetos susceptibles de descompensarse, para establecer a su alrededor una verdadera red humana que les ayude a superarla.

La Hospitalización psiquiátrica en el Hospital General ha contribuido a atenuar la estigmatización de los pacientes psiquiátricos y de los profesionales de la Salud mental y al desarrollo de la Psiquiatría biológica . Por otro lado, la entrada en un hospital general presenta también para el enfermo la ventaja de ser menos traumática que una hospitalización en un centro psiquiátrico monográfico. Además, las hospitalizaciones en un hospital general tienden a ser más cortas que las estancias en un hospital psiquiátrico tradicional, con independencia del tipo de paciente tratado, y se sabe que los pacientes hospitalizados por estancias breves presentan mejor evolución ulterior que aquellos que son hospitalizados por períodos largos.

En cambio, se ha subrayado que este marco terapéutico favorece en exceso el enfoque biologista en detrimento del modelo de intervención relacional. Además, los profesionales que trabajan en los hospitales generales tienden a desarrollar cierta actitud omnipotente, persuadidos de que un tratamiento biológico a corto plazo es extremadamente eficaz, cuando, en realidad, lo que ocurre es que, con demasiada frecuencia, no son testigos de la evolución crónica de estos pacientes en el exterior.

Aunque numerosos países, sobre todo occidentales, hayan realizado enormes esfuerzos tendientes a la desinstitucionalización de los enfermos y a su retorno a la comunidad, gran parte de las camas de los hospitales psiquiátricos en todo el mundo siguen estando ocupadas en permanencia por pacientes que presentan más bien discapacidades sociales que enfermedades psiquiátricas.

En el futuro, gran parte de estas personas deberían poder vivir en establecimientos financiados y dotados de manera conveniente por los organismos sociales más que por los organismos de salud. Pero, a pesar de esto, siempre habrá cierto número de pacientes, aquejados sobre todo de psicosis funcionales crónicas, de síndromes demenciales, etc., para quienes serán necesarias estancias prolongadas en hospitales psiquiátricos, que tendrán entonces que ser reajustados para poder ofrecer actividades terapéuticas eficaces. Si no, habrá que crear nuevas instituciones para responder a estas necesidades .

En cuanto a la hospitalización parcial permite un puente entre la comunidad y la hospitalización total. Sin embargo, el porcentaje de pacientes admitidos para hospitalización que podrían alternativamente ir a un hospital de día no es mayor del 30-40% por lo que son deseables unidades integradas que ofrezcan una u otra alternativas.
En el futuro se realizarán algunos programas como alternativa a la hospitalización en casos de descompensaciones agudas en forma de tratamientos de crisis de uno o dos meses.

En cualquier caso, la desinstitucionalización de los pacientes psiquiátricos sólo tiene éxito cuando existen los recursos comunitarios adecuados, puesto que, en caso contrario, puede ser contraproducente por provocar, a la larga, una resistencia en la población a la aceptación de estos enfermos en su seno.

PALABRAS CLAVE

Terapia grupal, instituciones de salud mental

KEY WORDS

Group Therapy, mental Health institutions

The remedicalisation of the psychiatric profession has provided new specialists with solid training in neurobiology, and given them access to the new substances developed. While this biological approach has led to considerable advances in psychiatry over the last 20 years, it has also substantially weakened the relational approaches, particularly the psychoanalytical.

With the changes that have taken place in psychiatric practice in terms of cost containment ( managed care) primary mental health services, emergency psychiatry, crisis intervention and consultation-liaison psychiatry take on added importance. Alternatives to psychiatric institutionalisation such as short stay units in general hospitals, day centres and residential units are developed. Different types of group interventions play a primordial role in the therapeutic armamentarium of these programs .

PRIMARY CARE, EMERGENCIES AND CRISES

It is common knowledge that most people presenting mild or moderate psychiatric disorders are seen by general practitioners who, while they fulfil a fundamental role, often fail to recognise these problems. ome emergency services are on the increase in big cities, and have already proved to be successful. Crisis centers as alternatives to hospitalisation have been successfully developed in some countries (Alanen et al., 2000) and a Cochrane Review on the effect of these interventions for people with severe mental illnesses (Joy et al., 2002) concludes that home care crisis treatment, coupled with an ongoing home care package, 'is a viable and acceptable way of treating people with serious mental illnesses'. In all these activities group therapy plays an important role thru the provision of an adequate containment.

Containment ((Bion, 1959; Winnicott, 1971) is defined as the ability to be faced with anxiety, to comprehend it and project it in a fashion to rob it of its negative power. There is internal containment (dealing with one's own object representations), microsocial containment (the mother, the original family unit, the analyst) and external containment (social networks). The formal systems (health care workers, family doctors ) and several informal groups ( social networks, sporting clubs, the clergy) can serve as containers until they are overcome by pathology or by social discord arising from the disorder and mental h health professionals are called upon to act. Some group activities (Balint's groups, "process" groups, etc.) can, in any case, favor the containment element provided by family doctors, pediatricians, APS nurses, mental health teams and non-professional centers in the population.

OUTPATIENT CARE AND HALF WAY FACILITIES

Treatment of severe psychiatric patients in community-oriented settings has been the most important contemporary development in mental health planning. Sectorisation, which emerged from the French post-war 'sectorisation' policy and American psychiatry in the 1960s, has rendered a valuable service to psychiatric care by allowing the deinstitutionalisation of many psychiatric patients, and by avoiding hospitalisation for many new cases. Sectorisation has made possible the continuity of care between the hospital and non-hospital services, particularly in catchment areas of under 200,000 inhabitants, where there are smaller-sized teams and more fluid communication.

Now that the optimism born 30 years ago from the efficacy of medication has diminished, much of the general public considers the deinstitutionalisation of severe mental patients as a threat to the security and the well-being of the population, and this increases opposition to their departure from hospitals even further. The day hospital and other halfway houses are thus indispensable structures for maintaining these patients in the community. In a day hospital, group psychotherapy is the basic therapeutic instrument. Some day centres treat patients from the very first manifestations of their disorder through to complete remission, whereas others focus on rehabilitation of patients following treatment in hospital.

In a day hospital we have created in Geneva (J Guimón, 2001) both types of patients are accepted, in different but complementary programmes. The first therapeutic function of this day hospital is to offer the patient a setting, which allows him or her to shore up internal checks and balances, and to receive psychiatric attention. A second function is to furnish emotional support, so that the patient's self-esteem is reinforced. The group dynamic seeks to create an atmosphere in which 'pathogens and pathogenic ties' can surface, and then be addressed and modified.

In a day hospital we have created in Geneva (J Guimón, 2001) both types of patients are accepted, in different but complementary programmes. The first therapeutic function of this day hospital is to offer the patient a setting, which allows him or her to shore up internal checks and balances, and to receive psychiatric attention. A second function is to furnish emotional support, so that the patient's self-esteem is reinforced. The group dynamic seeks to create an atmosphere in which 'pathogens and pathogenic ties' can surface, and then be addressed and modified.

The programme includes the prescription and control of medication, the organisation of psychotherapeutic activities based on the comprehension of the dynamic factors that intervened in triggering the illness, and the techniques which aim to combat the symptoms characteristic of schizophrenic deterioration: difficulties of an intellectual type, apathy and libidinal objectal withdrawal, isolation in the patient's introverted world. The days begin with a coffee break and include lunch and three small groups a day, which comprise verbal psychotherapy (dynamic and cognitive) twice a week as well as group activities in the form of discussion (free, on medication, on social information, on daily life) and various activities (artistic expression, theatre and video, body movement, cooking, games). In addition, there are two median groups: general assembly (which unites all caregivers and patients once a week) and the multifamily group (which unites all patients, their families and caregivers) once a month.

On the therapeutic team, in varying percentages, can be found psychiatrists, psychologists, social workers, occupational therapists, and psychomotor therapists. Professionals have in general received training in individual and group psychoanalysis, and possess a certain amount of knowledge regarding family therapy and social networks. Communication between therapists is in the form of meetings of working groups.
This kind of program have been shown efficacious. A recent Cochrane Review (Marshall et al., 2002)(Marshall et al., 2002) compared day hospital versus outpatient care for severe psychiatric disorders, and found that there was evidence from one trial suggesting that day treatment programmes were superior to continuing outpatient care in terms of improving psychiatric symptoms. On the contrary, another Cochrane review (Catty et al., 2002) did not find any randomised trial evaluating the effects of non-medical day centre care for people with severe mental illness.

GROUPS IN THE PSYCHIATRIC UNITS OF THE GENERAL HOSPITAL

Over the past 30 years most Western countries have set up small, short-stay psychiatric hospital units within general hospitals. Admissions to general hospitals have contributed to reducing the stigmatisation of psychiatric patients and mental health professionals, and to the development of biological psychiatry.
On the other hand, it has been argued that this type of procedure weighs excessively in favour of the biological approach, to the detriment of the psychosocial model of intervention. Moreover, professionals who work in general hospitals tend to develop a certain all-powerful attitude, with the impression that short-term biological treatment is highly effective, whereas they lack any feedback on the chronic evolution of these patients outside hospital.
The trend towards shorter stays has encouraged the use of biological rather than psychodynamic treatments in these units. In order to minimise this bias, group-analytical programmes have been established at some short-stay units(Yalom, 1983). During the last 25 years, we have organised programmes of milieu therapy in a certain number of short-stay units. In one of our studies, the results of the programme organised at Bilbao University Hospital over the last 25 years were viewed as positive from a clinical standpoint (Guimón et al., 1983). We contend that these positive effects were the result of the atmosphere created in the wards through the organisation of a variety of groups, we now describe .

Staff group

This group meets for half an hour early in the morning, from Monday to Friday, with all available personnel attending. The goals are to gather and share information on the evolution of the patients and problems arising in the ward since the last meeting. Interpersonal problems among the members of the staff are also occasionally taken up. This makes for a better understanding of the ward atmosphere, and a more comprehensive approach to the patient. Interpersonal difficulties and interprofessional competitiveness are often dealt with under the guise of theoretical disagreement, and become manifest at times in the form of lateness, absence or rationalisations.

Staff-patients group

This group's meetings are held early in the morning during the week, for periods of 45 minutes. All patients are urged to attend, and do so unless exceptional circumstances intervene. The sessions are conducted by a skilled group analyst. Approximately 40 chairs are arranged in a circle with the conductor seated always in the same position. Most of the personnel attend, and usually sit close to the more disturbed patients. The goals of this 'quick medium-size open group' are to facilitate the integration of the incoming patients to this new environment, the discussion of the situation of the outgoing patients, and to encourage the patients' active involvement in their therapeutic plans. Although a psychoanalytic reading of the communication is, of course, undertaken later by the staff, the interventions are carried out in a psycho-educational vein.
The conductor actively encourages each patient to participate in an open discussion. Patients are asked to talk about the tensions and conflicts arising among themselves and with the staff. Attempts are also made to show them how these reactions are often distorted by the psychopathology itself. They are invited to talk about their general condition, contrasting their assertions with those of the other patients. They share objective and subjective feelings about their symptoms. The therapist in charge conducts the group bearing in mind some ubiquitous topics: reluctance to take medication, side effects, unawareness of the illness, fears of being discharged, and so on.
Suggestions, protests and the patient's initiatives are worked out through structuring the group by giving the members responsibilities. Thus, once a week, the meeting takes the form of an administrative session, in which a president and a secretary of the assembly is elected by the patients from among themselves, and in which a plan of activities (plays, mural work, etc.) is organised. All of this contributes to the development of the healthy and creative aspects of the patient that otherwise would go unnoticed.
With this group, we try to guide the patient all along from the abstract to the actual, from the delusional to the real. We foster communication and interpersonal relationships. We try to integrate patients into an atmosphere that provides information concerning the many aspects of their lives, family, and friends. The presence of staff members in these groups enables the patients to have a closer relationship with them. This dispels persecutory feelings and resolves conflict that would otherwise persist. This environment fosters the transparency and directness of both patients and the therapeutic team. Resistance arising in the patients, such as fears of criticising others or being punished, tends to disappear soon. Irregular attendance on the part of the doctors arises during certain periods, under the pretext of overwork, but in reality reflecting a devaluation of the group approach, which can spread to the test of the team. This generally depends on the attitude of the ward leader towards group or milieu therapy. On the other hand, excessive nursing staff rotation results in sporadic attendance and a lack of commitment to the group. This is often fomented by the institution itself, which is reluctant to have its auxiliary personnel involved in these kinds of 'specialised' activities.
These problems are best worked out through the participation of the staff in the postgroup meeting created for this purpose. This meeting is, besides, a valuable means of sharing information about the patients.