Short-term group psychotherapy

In units for short-term hospitalisation, where the goal is to improve communication, patients who have kept their verbal ability and who are neither too regressive nor too agitated are integrated into a small group that meets five times a week, for one hour. This is called a 'verbal' session, and the leaders are very active. Certain leaders, in accordance with Yalom's (Yalom, 1983) precepts, put 'game' or 'go-around' techniques into play. Others (such as those in Bilbao), even if initially implementing this type of approach, have evolved towards more open meetings, by instigating conversations whose focus tends toward the usual, recurring themes in these groups (circumstances that resulted in destabilisation, problems caused by hospitalisation, the effects of medication, etc.).
The leader encourages patients to take advantage of these sessions to voice their preoccupations and vent their frustrations and complaints, constantly stimulating verbal communication. This type of intervention commonly suits the state and characteristics of the personality type that, most often, is dominant in this kind of patient: oral gratification (often devouring and destructive), hostility (either passively self-directed and/or destructive to others), having major deficits insofar as defence of the ego is concerned, as well as problems in adaptation, refusal and/or flight when faced with reality.
We give patients a psychopedagogical understanding of the meaning of symptoms and their relationship to situations in real life. One of the principal objectives is to render the patient sensitive to the possibility of change, whether hospitalisation is to be foreseen or ended following psychotherapeutic treatment.
In agreement with Yalom, we tried to conceive each session as an independent unit. Nevertheless, we arrived at the conclusion that this tendency towards discontinuity is a defence against the spontaneous appearance of relatively profound dynamic elements which, effectively, are continually in play from one session to the next. This obliges us to keep a certain analytical attitude whereas, conjointly, the appearance of a transference that cannot be handled must be avoided.

Short-term group work

In short-term hospitalisation units this type of group is organised; one that is informal in its atmosphere, intended to keep up psychomotor activities in patients, and promoting the possibilities of improving orientation and interaction with different members of the group. Patients suffering from severe mental disorganisation, incapable of maintaining a sufficient attention span, for which the 'verbal' groups described above are not suitable, take part five times a week, for one hour, in what Yalom termed a 'low group' and which we call a 'focus' or 'structuring' group. In this group are to be found patients who are not co-operative, hallucinating psychotics, patients suffering from delirium and in severe regressive states, or patients who, while not being psychotic, are too anxious or phobic to take part in groups at a higher level.
The session is organised, according to Yalom's method, into four stages: 1) orientation, lasting 2-5 minutes, during which the therapists introduce themselves, explain what the group is, its utility to patients, and so on; 2) a 5-10 minute warm-up, including several structured exercises, such as simple games and comments on participants (physical and mental states, feelings), in accordance with the group's situation in each session; 3) a 20-30 minute session of one or two structured activities, chosen in accordance with the group's daily needs, including sentences to complete, lists of values, and exercises intended to increase empathy; and 4) a review of the session with a quick conclusion covering the activities carried out.
We allow patients who take part in these groups to leave them when they wish, as the atmosphere of the session must be reassuring and show empathy for the patient. The therapist must focus his or her activities on helping patients, and help them to identify their problems, promoting relationships among them, and decreasing levels of anxiety, centring all the activity on the 'here and now'.
Patients who take part in this group sometimes perceive negatively the differences between it and the 'verbal' group. In our unit, we prefer to introduce patients into the different groups, not based on any diagnostic criterion, but with regard to their ability to communicate at the moment of their arrival. This explains the existence of heterogeneous groups at diagnosis level, but relatively homogenous ones insofar as the possibility of establishing relationships with others is concerned. Obviously, as we have already said, interventions do not address unconscious conflicts, but problems in daily life.

Medication information group

There are three major factors that influence negative attitudes towards psychotropics, especially neuroleptics: the cognitive element, the affective element, and the behavioural element. It is obvious that public awareness campaigns on the indications of these products, and the precautions to take against possible drug interaction and side effects, could help decrease bias, which is especially important for persons coming from more modest cultural and educational backgrounds. However we are more pessimistic regarding the possibility of influencing the other aspects, based on affective elements, which are often unconscious and very difficult to change. It is useful, in this context, to recall that a campaign aimed at the general public in an American city, waged through various media, failed after several months to improve the population's attitudes in any appreciable manner. Rather, it wound up annoying the very people it was meant to influence. Attempts at modifying attitudes with regard to psychopharmacological substances require, in addition to public educational programmes, campaigns directed at specific target populations, for instance the physicians who prescribe these drugs and the patients who take them, and their families.
A programme intended to modify the negative attitudes of schizophrenic patients and their families towards medication has been ongoing since 1987 at the Bilbao City Hospital (Eguiluz et al., 1999). Patients took part in eight groups and families in two groups, lasting 90 minutes each. The first 45 minutes are given over to a theoretical explanation of schizophrenia as an illness, as well as information about neuroleptics and their collateral effects. The second part of the session is focused on an open discussion. Participating patients have shown better compliance and fewer hospitalisations than others who did not take part in this programme. These kinds of groups are also employed, with some modifications, in the management of chronic schizophrenic patients.

Multifamily groups

Experiences in extended groups (more than 40 members and sometimes up to several hundred members) are not easy to manage (Roberts, 1995), but can constitute a strong incentive for personal and social change. The extended group, as described and implemented by Kreeger (1975), De Mare (1992) or Ayerra (1997), provides what initially would seem to be a disagreeable experience, allowing participants to experiment with 'psychotic' symptoms, primal defence mechanisms, and insight into the political process (Roberts, 1995) through which a veritable microcosm of life outside the family circle can be created. For more than 20 years, we have included groups of this type in our seminars on block group training, and Ayerra periodically organises, with the OMIE Foundation, specific seminars on extended groups, which are remarkably useful for those working with schizophrenics to have a first-hand experience of 'psychotic' feelings.
The objective of these groups is to provide support to families, by offering a 'disagreement' and a differentiated interpretation of the phenomena experienced in the family circle. They began as 'psychopedagogical groups' and were transformed little by little into groups that are 'evolving through open discussion'. The multifamily group tries to overcome resistance arising not only from the patient, but from the families themselves, who can find common ground with other families going through the same difficulties and identify with their ongoing struggle.
In the experiences of Garcia Badaracco and Ayerra, families take part with patients and professionals in groups made up of 30 to 35 people. The sessions last 90 minutes, and are held on a weekly basis. The therapeutic attitude is based on the idea of a 'disagreement' which explains the presence of several members of the team who sit at strategic locations, next to those patients or their families who are undergoing the most delicate situations. In the same way, as usual, patients choose to sit in 'protected' locations, according to their state, very often next to the group's therapists. In this group, hallucinations arising from the subconscious or from transference are not interpreted although, in contrast, anxieties, subconscious desires and defence mechanisms are mentioned. Behaviours and interpersonal relationships are analysed in an attempt to highlight the positive aspects, the affective compulsions, and deep-seated needs which are often hidden beneath each conflict. It is a question of helping patients to find the path that lies between the rational and the irrational and to go beyond it, to the emotional stage. Confronted with the most primal anxieties, the response takes the form of a more intensive investment and greater self-control. Prolonged silence is counter-productive. One characteristic of the therapeutic team of the group is the spontaneity of its intervention, its renunciation of omnipotence and absolute knowledge by preferring to appear simply as fellow beings, furnishing daily examples intended to promote trust. The members of the group become co-therapists, treating aspects that they have slowly succeeded in resolving. The presence of families who have had positive experiences of this process is invaluable: they can guide others, giving them hope.
The multifamily group is also useful when important decisions must be made (hospitalisation, a possibly ill-considered and premature choice to leave the hospital too early, changes in therapeutic projects), and to help to prevent legal difficulties. Little by little, the group becomes more homogeneous, and we progressively leave behind the dissociated pedagogical group (families/patients, the sick and the healthy, people who are knowledgeable and those who are uninformed). We start to recognise that the same problems can be encountered for children and for families. In couples, conflictual situations start to appear. With the understanding that all the members are in the same predicament, have similar experiences, and that no one can manage to save themselves without help, acceptance crystallises around the fact that this principle also applies to institutions and to society.
Garcia Badaracco developed these groups to act as an exceptionally useful instrument in treating patients with schizophrenia and other serious illnesses within the context of their 'multifamily, psychoanalytical therapeutic community'. He also, additionally, records on videotape multiple therapy sessions of this type, which have a great value not only for teaching but also for research.

Ward atmosphere in these units

In short-stay psychiatric units, the patients have to deal with a high degree of stress, arising from short stays, acute symptomatology, auto- and hetero-aggression, rapid turnover of patients, and limited space. Group analysis, with its particular emphasis on the 'here and now' and on inter-member cohesiveness, has shown itself to be, in our experience, a useful stabilising ('buffer') tool, through fostering involvement and support and allowing a controlled expression of anger and aggressiveness.
The patient-staff group is the key holding element of our group analytic programme, due to its basic contribution to creating a 'container' 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 staff side, tensions among the therapeutic team are reduced and incoming nursing personnel notice how their previous fears and apprehensions diminish.
Overall, we had the impression that, despite a personnel shortage, a pleasant and supportive atmosphere was created in the wards, constituting a group-analytical network that makes for more harmonious communications among the various units of the hospital. This systemic vision of the institution provides invaluable help in understanding its organisational problems and internal struggles, which can soon be detected, providing the input for the 'healthy anticipatory paranoia' needed (Kernberg, 1979) in the management of these organisations.

THE ROLE OF THE TRADITIONAL PSYCHIATRIC HOSPITAL

The transformation of the dominant role traditionally played by the psychiatric hospital is one of the fundamental features of new trends in psychiatric care in Western countries. A large number of beds in psychiatric hospitals throughout the world remains permanently occupied by patients with social handicaps rather than psychiatric illnesses. The majority should in the future be able to live in establishments that are state funded and suitably equipped, rather than in health care organisations.
Nevertheless, there will always be a number of patients who, for the most part, suffer from chronic functional psychoses and dementia syndromes, for whom long-stay will continue to be necessary. It will be difficult to modify psychiatric hospitals due to the particularities inherent to their organisation, and we have come to question the justification for maintaining them. However, some kind of psychiatric hospitalisation will continue to be necessary, to fulfil certain functions. The first of these is the role of protecting the patients themselves (asylum), in a case where their survival mechanisms prove insufficient in an increasingly conflict-ridden world. Then there is a therapeutic role for particular patients whose condition demands a series of treatment in a specific 'milieu', which can only be found in certain specialised psychiatric centres, difficult to create in a general hospital.
A rehabilitation unit for 12 psychotic patients has been set up in the psychiatric hospital of Belle-Idée, which depends of the University of Geneva's Department of Psychiatry (J. Guimón, 2001). The average stay is 51. 61 days; the mean is 20 days; the average patient age is 38, and the median, 35. The care programme for patients includes individual and group activities, each professional category taking part in both aspects of treatment. The multidisciplinary team includes psychiatrists, psychologists, nurses, social workers and psychomotor therapists. The patients generally have a low functioning level, resulting in social and family problems, and difficulties and resistance to a care programme in an outpatient setting. For younger patients and those with a more recent onset of illness, the work is centred on integration and acceptance of the illness itself, on the meaning that the illness may have for each patient, and on maintenance and the possibility of improvement of skills.
The individual care programme is characterised by discussions with doctors and nurses, occupational and psychomotor therapy sessions, and social service interventions. At the arrival of each patient, he or she receives a 'welcoming' brochure, which provides the ward rules, the schedule, and a list of activities and medical nurses' names. A complete group programme has been developed over the last few years. The group made up of patients and staff (known as the ward group) meets daily, except for weekends, during 30 minutes. A group for the rehabilitation of cognitive deficits (in accordance with Brenner's methodology) is led by an occupational therapist and a nurse, four days a week, for 20 minutes. A psycho-educational group for medication is conducted by a resident and two nurses for 30 minutes per week. Two nurses lead a group on social skills (using Liberman's model) for 45 minutes, once a week. A family group, under the direction of a physician with the participation of a representative from each professional category, meets once a month for 90 minutes. Three recreational/occupational groups (storytelling, sports and creativity) are conducted by nurses for one hour each week.

THERAPEUTIC COMMUNITIES

As we reviewed in the previous issue of this Journal 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 (Rapaport, 1974;Whiteley, 1980; Whiteley et al., 1987) .
New methodologies have proposed by Moos for whom the " ward atmosphere scale " has been utilized in therapeutic communities (J Guimón, 2001; Moos, 1987; Moos, 1997) 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 (De Hert et al., 1996; Dauwalder et al., 1995 ;Coombe, 1996)
Mosher (Mosher et al., 1971; Mosher, 1971) compared the treatment program for young schizophrenic patients in the Soteria project with that of a small social environment, generally without neuroleptics. Other authors (Shepherd et al., 2001; Nieminen et al., 1994) present the benefits of new type of institutional solutions
Insofar as variables associated with therapeutic results were concerned several authors (Holmqvist & Armelius, 1996; Holmqvist & Fogelstam, 1996; Winer et al., 1997) show the diminution of unfavorable ward incidents, in particular incidents with an aggressive character.
Several studies indicated the fundamental value of group therapy in these programs. (Kahn et al., 1992; Isohanni et al., 1992)