RESUMEN

La formación tradicional para los terapeutas grupales se basaba en exponerles al trípode clásico de experiencioas de formación en toda psicoterapia : una experiencia personal en psicoterapia de grupo ; un programa de formación teórica y la supervisión.

En cuanto a la realización de una psicoterapia individual personal, recomendada por la mayoría de los programas, un cierto número de formadores de psicoterapia grupal -entre ellos los que tienen una orientación grupal analítica- consideran que una experiencia individual puede ser negativa puede ser negativa para la formación de un psicoterapeuta de grupo porque podría favorecer las resistencias. Adicionalmente se recomienda que los candidatos tengan una buena experiencia clínica antes de comenzar una formación en psicoterapia de grupo., parte de la formación.

Además de las supervisiones clásicas, en psicoterapia de grupo es útil la observación (mediante la participación en un grupo como observador-transcriptor, o el estudio de sesiones grabadas en vídeo). . La coterapia como medio de formación en psicoterapia de grup esta modalidad terapéutica posee un valor particular en la formación de los psicoterapeutas. A medida que se desarrolló en Europa la enseñanza del análisis grupal (Reik, 1993), los organismos de formación se dirigieron al Institute of Group Analysis de Londres para pedir conductores para esta experiencia. Como el conductor no podía, por supuesto, desplazarse cada semana, había que considerar otros formatos. Se hacía necesario efectuar cambios drásticos en las estructuras temporales del grupo: las sesiones semanales fueron sustituidas por sesiones en bloque, en general cuatro al día durante cuatro o cinco días, repetidas a intervalos de hasta seis meses. Después de más de veinte años de experiencia, la opinión compartida por los conductores de estos grupos, es que este formato es muy eficaz. Las observaciones de los analistas de grupo son similares. Los grupos en bloques presentan más cohesión, un proceso grupal más vivo y una capacidad mayor de los miembros del grupo de ponerse en contacto y de expresar emociones intensas. Además, se produce una transferencia más rápida (debido al "insular effect") y los conflictos pre-edípicos son reactivados más fácilmente.

La experiencia más sorprendente en este modelo es la facilidad con la cual los grandes intervalos han sido tolerados por los miembros del grupo. Esa facilidad parece deberse al hecho de que los miembros del grupo eran personas en formación y no enfermos. La mayoría de los profesionales habían seguido ya algún tipo de terapia, habían sido previamente seleccionados y estaban altamente motivados. Algunos estaban simultáneamente en terapia individual y en la experiencia grupal durante el período en que duró ésta.

Un gran número de experiencias en bloques han sido realizadas en el Institute of Group Analysis de Londres y diversos cursos de entrenamiento en bloques se organizaron en Europa con su colaboración. Surgieron fuertes discusiones en el Institute of Group Analysis, que empujaron a Malcom Pines a dar el título "to block or not to block, that is the question" a una conferencia que dio en Wetzinkon (Pines, 1976).

Este tipo de formato engendra cierta estimulación psíquica y una mayor idealización del conductor. También se ha señalado que los cambios de roles, propios a estas experiencias, facilitan el "ego training in action", lo que a su vez favorece un efecto terapéutico más intenso. A la crítica hecha por ciertos autores de que este formato no asegura una contención suficiente, los autores favorables a las experiencias secuenciales contestan que cada grupo en un seminario secuencial es contenido en un bloque y el bloque en un curso; que las instituciones que organizan los programas tienen una larga historia y que las fronteras están representadas por los organizadores, lo que facilita una identificación simbólica. En efecto, al margen del valor simbólico de la institución, el hecho es que en este típo de experiencia los conductores del grupo por lo general han trabajado juntos durante mucho tiempo, lo que genera una sensación de apoyo y de seguridad que permiten una regresión temporal. Por otra parte se subraya que la duración de las experiencias no es tan corta ya que se produce un fenómeno de perlaboración (Kaës).

Se han subrayado con todo ciertos peligros potenciales para el enfermo en el formato en bloque. En efecto, la regla de abstinencia no puede ser cumplida; puede haber incidentes de fronteras; la regresión es discutible y la transferencia negativa resulta difícil de expresar con motivo de la ausencia prolongada del analista que hay que conservar indemne. Se han propuesto ciertas precauciones para evitar estos peligros: ver a los nuevos miembros anteriormente durante algunas semanas; facilitar el desarrollo de un concepto de "grupo como una totalidad" y proponer, en ciertos casos, una terapia individual o grupal simultánea.

Otras opiniones desfavorables subrayan dificultades tales como la tendencia excesiva a la idealización y a la dependencia, favorecida en ese contexto, Con el fin de establecer un "milieu terapéutico" con orientación de "comunidad terapéutica", en las unidades de cuidados en las que hemos trabajado (Bilbao, Barcelona y Ginebra), desarrollamos durante los últimos veinticinco años un programa en "bloques" para la enseñanza interdisciplinar (psiquiatras, enfermeros y psicosociales). Nuestra objetivo era ofrecer una experiencia de participación personal no sólo a un grupo, sino también a una "comunidad didáctica" que permita vivir ciertas experiencias propias a las comunidades terapéuticas. Los cursos se desarrollan a lo largo de uno, dos o tres años mediante seminarios.

En el plano clínico y en el plano personal, el paralelismo entre el medio didáctico creado entre los estudiantes que han seguido el curso y el "medio terapéutico" que se desarrolla en las unidades de hospitalización breve gestionadas como lo hemos descrito anteriormente, es indudable. Esta similitud podría, en parte, provenir del hecho de que el personal terapéutico y didáctico formaba parte del mismo equipo en las dos experiencias: además, se desarrollaron de manera síncrónica.

SUMMARY

This article reviews the methods used for the training of group therapists during the last decades.In all group psychotherapy training centres the candidate is expected to undertake a a personal group experience, and in some centres a training in individual psychotherapy is required. Observation and co therapy are considered to be one of the most effective methods for teaching group psychotherapy and it features in most programmes . Another essential training activity consists in psychotherapy group supervision that can be done individually or as a group.

The author finally describes his experience with a "block" program for the training in group therapy developed in Bilbao, Barcelona and Geneva during the last 25 years.

PALABRAS CLAVE

Terapia grupal, instituciones de salud mental

KEY WORDS

Group Therapy, mental Health institutions

The obvious risks of psychotherapy being used by individuals with little preparation, points to the need for a certain number of minimal theoretical and practical imperatives in the training of future therapists. The range and quantity of techniques proposed in recent years complicates the task of working out a training syllabus to cover all of these. Regardless of the approach, however, most group processes present the same features. A psychoanalytical orientation is not an absolute requirement for techniques like behavioural group psychotherapy or group centred psychotherapy, based on the work of Rogers (Rogers, 1970), for example. Nevertheless, we do think that even for therapists with such orientations, analytically oriented programmes are the most valid to acquire basic training.

PERSONAL QUALITIES AND THEORETICAL PREPARATION REQUIRED OF THE PSYCHOTHERAPIST

Professional qualifications

Our view is that only candidates who are members of the traditional professions in the field of mental health should be admitted for training i.e. psychiatrists, psychologists, social workers and psychiatric nurses. We consider it ill-advised and even dangerous to train people in psychotherapy who have no previous systematic training in the field of mental health.

Personal qualities of a group therapist

M. Grotjahn (Grotjahn, 1971) had listed some of the qualities required of a professional wishing to work with groups: spontaneity, which over time one learns to use as a technical means ; self confidence and confidence in others ; the ability to act, sometimes allowing one's inner self to appear ; the fortress of the ego, capable nonetheless of changing roles depending on the patients, a sense of humour, to avoid infantilising the group unnecessarily, and allowing patients to see the therapist as a real person as opposed to the idealised transferential image of the " omnipotent father " ; the ability to use counter-transfer appropriately, sometimes allowing oneself to react spontaneously to its effect ; the ability to accept one's technical mistakes ; the ability to act not only as an interpreter but also as an observer and participant in psychotherapy.

As will be seen later, the future group psychotherapist needs to have personal experience of group psychotherapy, as this enables him/her to understand certain aspects of his/her personality exempt from conflict (activity-passivity, masculinity-femininity, enthusiasm-restraint, masochism-sadism, tolerance-intolerance, patience-impatience, etc.) which may not appear in individual analysis. These characteristics may be of no importance in individual analysis, but in group work, they may prove to be crucial. The supervising psychotherapist whose group contains a future group psychotherapist may try to help him/her modify his/her attitudes or in some cases, advise against continuing training.

Theoretical training course

Candidates should undertake some courses of theoretical training, the syllabus comprising not only the actual techniques of group psychotherapy, but also the science of normal and pathological behaviour. The modalities of these theoretical courses vary according to the training centres. In some, they take the form of intensive courses before the group experience starts, while in others, lectures are spread out over the duration of training.

THE TRAINEE PSYCHOTHERAPIST'S PERSONAL EXPERIENCE

Individual psychotherapy training

Candidates must all have good clinical experience before starting training in group psychotherapy. Moreover it is indispensable for the candidate to have some degree of personal experience in individual psychotherapy. On the other hand, a number of group psychotherapy supervisors - particularly those with group analytical orientation - consider individual experience as potentially negative in training as a group psychotherapist, as it encourages resistance. Indeed, the same professionals had the most difficulty accepting the idea that the group has therapeutic potential which is beyond the scope of individual psychoanalysis. As most of these therapists had extensive experience in individual analysis, they tended to carry out individual psychotherapy within the group, neglecting to analyse certain idiosyncratic therapeutic processes. This phenomenon is well-known in psychotherapy. No therapist can work with too many different models and in any case, the fact of learning a technique which requires transforming the conceptual model demands a change of coordinates which is very difficult to achieve.

Whatever the case, even allowing for this relative deformation, in most group psychotherapy training centres the candidate is expected to undertake training in individual psychotherapy The AGPA requires those with university qualifications in medicine, psychology or social work to have at least two year's experience in their respective professions. Thus this organisation requires candidates to have completed a certain number of hours of supervised individual psychotherapy before starting the training course and a total of four hundred hours before finishing the course. Personal experience in individual psychotherapy is also strongly recommended, but the duration is not stipulated.

Group experience, part of group psychotherapy training

In 1960, according to a survey carried out in the USA, only certain psychotherapists considered the experience of a therapeutic group to be necessary ; ten years later, in a similar survey all the psychotherapists polled agreed with the conditions demanded by the AGPA, in considering it as entirely advantageous, and no one doubts its benefits today. Most authors see no difficulties raised by experiences of this kind, considering the group process as in no way precipitating or exacerbating the candidates' emotional problems. However, some authors have reported a number of risks in carrying out group psychotherapy with candidates who work together in everyday life, indicating the presence in some participants of anxiety, or defence against self-exposure, with a risk of " acting out " in relationships outside the group. Redlich and Astrachan (Redlich et al., 1969) draw attention to the appearance among some group members of " decompensation which is so great that their behaviour could be qualified as psychotic ".

Authors have suggested various ways of avoiding these difficulties. Thus for Bategay (Battegay, 1976), it is very important for candidates to have previously undergone individual psychotherapy. Several authors have stressed the need to differentiate between a treatment group and a supervision group, and suggest that arrangements be made so that the candidates experience the second type. Individual analysis is thought to be a more appropriately setting for candidate therapy. Whatever the case, various authors have shown that the group training experience clarifies areas such as relationships in the couple, the family, and in relation to authority, providing valuable experience of the group process. Even so, in addition to their intrinsic difficulties, groups of this sort can give rise to problems similar to those mentioned previously.

Experience in group psychotherapy observation

Group psychotherapy can be observed in various ways; either by participating in a group as observer-recorder, or by studying sessions recorded onto video. Observation, in its various modalities, is considered to be one of the most effective methods for teaching group psychotherapy and it features in most programmes . Some authors warn against the presence of observers for relatively short periods of time in group sessions, as this may disrupt their usual procedure. In their view this risk disappears if the presence of the observers or observer -recorders continues for a certain length of time. The variable introduced into a group by being observed through a mirror or by video recording is understandable. If this were merely used as a teaching experience, the ethical implications would need to be examined , considering the interferences which certainly occur in the therapeutic process. Nevertheless many authors stress the potential benefits of observation and the technical study of these recordings

Our own experience has been that given the relatively limited number of candidates in training, their participation even as observers within a group, has proved to be very useful.

Cotherapy as a means of training in group psychotherapy.

We are all familiar with the technical problems posed by the practice of cotherapy. As well as its universally recognised advantages , this therapeutic modality is of particular value in training therapists. Apprenticeship of this kind gives the best results when an experienced therapist acts as cotherapist to a novice therapist, enabling the latter to gain personal experience without an intermediary and to have his/her task supervised directly. Another modality [6] is used by certain authors, whereby cotherapy is carried out by two residents having undergone similar preparation. A more experienced therapist supervises the task, being present at the session, observing it on video or listening to an account of the session. Rosembaum calls attention to the possible dangers of cotherapy. As group psychotherapy becomes increasingly common in psychiatric assistance, he writes, so administrators are increasingly favourable to rapid group therapy training, and increasingly use cotherapy as the most effective method. In such cases, administrators must clearly define the roles of cotherapists, if they are to avoid "terrible problems of rivalry". Very often, according to Rosembaum, the most experienced therapist leads the group and the novice has to content him/herself with "sitting at the master's feet". Or else, he adds, what is even worse, after a certain time the student considers him/herself to be well-trained and begins to teach new therapists, with ever having had the opportunity of confronting a group alone. For Rosembaum, in the case of cotherapy, both therapists need to have similar clinical experience ; in this way the therapists work with one another, rather than one for the other. If this is not the case, he says, the quality of treatment diminishes, and thus from the patient standpoint, this particular type of technique should be avoided. Other authors ask themselves the same ethical questions.

Supervising psychotherapy groups

Group supervision

Another essential training activity consists in psychotherapy group supervision. This can be done individually or as a group; the person supervising receiving the information concerning the session either verbally through the therapist's report, by observation through a mirror, or by watching a session recorded onto video. Foulkes used this modality extensively with excellent results, and many consider it to be one of the most successful forms of apprenticeship(Foulkes, 1954)

In the Department of Psychiatry of Geneva University (Guimón, 2001), to improve their performance in conducting groups which meet weekly or once a fortnight for an hour and a half, we introduced a innovative seminar in which those conducting the groups could undergo supervision of their work, in groups bellow.

Team supervision ("The process group ").

A process group is generally held to be a training group for students or a group experience aimed at improving staff relationships. Process groups are also formed to teach group dynamics and concepts such as norms, roles and authority. But when such groups are introduced into institutions, their main aim is usually to modify the way the staff operates. Authors who write about process groups support the use of traditional group theory such as psychoanalytical theory or Bion's theory in understanding group dynamics (Alonso et al., 1993). Many of these authors however, advise changing leadership techniques in order to harmonise aspects of the process group, which differ from those of a psychotherapy group.

Cohn (Cohn, 1994a) describes his experience in leading a training group of mental health workers who would go on to lead groups of chronic patients. The elements to focus on using object relationship methodology, include the effects of projective identification on different continent environments. Understanding and using the counter-transfer responses of the course leader helps to reveal the unconscious objectives of chronic patients in perpetuating their internal and interpersonal lives through their effect on the group leaders working with them and on each of them. This insight can produce interventions which may lead to a more constructive outcome.

In any case it is true that in the institutional context, the process group designed for staff and trainees has become increasingly unpopular as a resource , while the need for such groups has increased. Cohn (Cohn, 1994b) believes that the reason why process groups are not used more often is a combination of a failure to understand the nature of these groups, and the inability to distinguish between process groups and traditional psychotherapy groups. The author defines the process group in the institutional setting as " a group which is set up to use its own process in the aim of studying and developing a person in his professional role within the institutional or clinical setting ". According to this definition the person and the professional role are understood as somewhat different, but as experiences and aspects of identity which are equally authentic. This idea stands in opposition to the more traditional point of view whereby " the real person " keeps his truest thoughts and feelings separate from his professional self (preferably at home).

In place of this, we recognise that, although the aspects of personal and professional identity are somewhat different, each person's professional role is an authentic part of his identity which needs to be taken into consideration at work. Moreover the above definition of a process group focuses on the use the individual makes of the group process for improving the way he/she operates professionally, rather than on the collective group process being the focal point of interest.

The group process is an important vehicle for discussing inner experience, resulting both from contact with the patient and the impact of the system of treatment identified for an individual , and the way in which leadership techniques and the task following on from the group's focus of interest, can provide a more effective group experience.

Leaders of training programmes for psychiatry and psychology students report that they are less inclined to develop process groups due of the lack of qualified leaders and disquiet about violating ethics such as double relationships (personal communications).

Many authors would say that the main aims of process groups and psychotherapy groups differ in the sense that the basic objective of a process group is educational, while the basic objective of a therapy group lies in personal change and growth. However, while this distinction is useful, the author's experience is that the individual always joins a process groups in the expectation, hope and fear of being personally influenced by being part of a group. Even in contexts like A.G.P.A. workshops, with clearly stipulated educational objectives, the leaders constantly have to translate an intense personal experience into conceptual learning. /apprenticeship.

Supervision of didactic experiences (intervision and the frontiersman)

It follows naturally that intervision between the various trainers involved in the teaching programme is essential for the programme to function well. The activity is systematically included in our syllabuses, as a blocked unit and in the integrated seminars on clinical group supervision. But another form of experience supervision has proved to be particularly useful in our training programmes.

This involves introducing different qualified observers for each seminar, who are successively introduced into the different activities of each unit and participate later in intervision meetings. The frontiersman, as this type of participant is referred to in London, is a " senior " person, outside the training team, who at the end of a block of training draws up a report describing how he/she saw the experience.

TRAINING COURSES IN GROUP PSYCHOTHERAPY

The partial aspects reviewed in the preceding paragraphs were taken into account when designing the training syllabuses in the various centres. Courses vary in the range of subjects offered. They also vary in terms of the importance placed on participating in a psychotherapy group, the point at which the candidate is allowed to begin group psychotherapy and the way the task is supervised.. Candidates are not always expected to have completed a full course of study in individual psychotherapy.. The Institute of Group Analysis in London has set up a two year training course, following an introductory course. Candidates are not required to have undergone individual psychoanalysis. Some Associations have laid down their requirements for group psychotherapy certification. It would seem to be quite reasonable to suggest that a future psychiatrist has experience in the area of awareness groups or training groups, to observe groups, participate in certain activities as cotherapist, to have had responsibility at some stage of leading a psychotherapy group under the control of a supervisor and to have a certain theoretical grounding all of which authorises residents at the end of their third year to set up a number of groups: inpatient groups, post cure groups, support groups, family groups etc. As we have already said, we are not in favour of extending psychotherapy to professionals who do not work in the field of mental health. It is clear that some people have particular personal qualities in the area of communication; despite this, we think that it is only possible to begin training in psychotherapy after having undergone this preparation. But this in no way prevents us from proposing awareness programmes open to participants from awareness groups, members of the community who are particularly involved with a population exposed to mental illness: teachers, members of the clergy, etc.

On the other hand far more demanding programmes exist for the training of group psychotherapists with full psychoanalytical orientation. (the Postgraduate Center in New York). In this case, the experience of analytical group psychotherapy comes after individual psychoanalysis, thus avoiding the simultaneity of the two techniques which, for many authors and as reflected by our own experience, gives rise to difficulties of transfer, unless both treatments are undertaken with the same therapist. In his last years, Foulkes (Foulkes, 1975) was said to consider it unnecessary for the future analytical group therapist to undertake individual psychoanalysis and suggested that, on the contrary, the first stage of all individual psychoanalysis should begin as a group. Juan Campos (Campos, 1998) shares this view ; he believes that individual analysis should only be advised if, after analytical group psychotherapy, the candidate still has serious personal problems to resolve. Our view is that group psychotherapy proves more useful to a candidate after individual psychoanalysis.

As described earlier, training in the form of " block sessions " has become widely developed in Europe over recent years, through the GAS and EGATIN, as well as in response to the participation of analysts from the London group in the training courses in other European countries. The views published on this subject converge in accepting that experimental groups set up in the form of " block sessions " are specifically therapeutic experiences. It has been theorized that they demand the resistance of the ego and the " capacity to be alone " in the here and now, in the absence of the " mother-group ", a " potential space" which persists between one session and the next and which is one of the acceptances taken up by the Foulkian concept of " matrix ".