OUR OWN EXPERIENCE OF INTENSIVE GROUP WORK

Courses in the Basque country

In 1974 in Bilbao, with the help of several collaborators from the Department of Psychiatry at the University of the Basque Country, we set up training in group psychotherapy, oriented to analysing the individual within the group, and developed with the help of Dr. Ylla, who as part of the departmental team, travelled up to Bilbao from Madrid each week. He was later seconded for two years by Dr. Carlos Gonzalez from Madrid. Most of the psychiatrists who participated in this training experience had individual psychoanalytical training. Mandated to set up a plan to reorganise psychiatric care in the Basque country, the author set up a training programme to guarantee fuller impact on the Institutions. Our consultant, Dr. Campos from Barcelona, helped to establish contacts with Institute of Group Analysis in London, and 1982, the first " Introductory Course in Group Work " was organised. This experience became a great focus of interest and, aided by other consultants, notably Drs.Arroyabe and Malcolm Pines, the course has continued to run each year, either on a weekly basis or in the form of " block sessions ".

In (Guimón, 1986, 1989; Guimón et al., 1985) the aim of offering mental health professionals the opportunity of examining their interpersonal relationships, a general course devoted to Group Work was set up in 1982. Contacts had been established with the Institute of Group Analysis in London. The experience attracted great interest. Eighty Mental Health professionals currently practising in the Autonomous Basque Community participated in this first course. The course is run according to two modalities: either as an Introduction to Group Work, which is scheduled every Friday afternoon, as two one and a half hour sessions over 32 weeks, or else as a series of seminars in which each seminar offers an experience of 18 hours covering the last three days of the week, 4 to 8 times a year. The course has since been run every year on a weekly basis in Bilbao, followed by a full three year training course.

We then incorporated a number of techniques from non analytical theoretical models with direct supervision, as used by Pacho O'Donnel, (an Argentinean psychodramatist), Olga Silberstein (family therapist from the Ackerman Institute in New York) and Bob Liberman (creator of the social rehabilitation programme in Los Angeles). A Foundation (O.MIE) was then set up to oversee training, which now included a three year group psychotherapy course, leading to a postgraduate Master's degree from the University of Deusto. Training has since been extended to Barcelona and Geneva.

The course in Barcelona

Thanks to the impetus provided by Dr.Sunyer activities identical to those described above were set up in Barcelona. The course is run as a series of six intensive seminars for training as a " Specialist in group activities ", or eight intensive seminars over a period of two years leading to leading to a " Masters in analytical group psychotherapy ". The courses take place from Friday to Sunday. Over 1,000 professionals have participated in training in Spain.

The course in Geneva

In 1994, after meetings between with some Geneva group therapists we decided (Guimón, 1998) to set up an introductory course at the Department of Psychiatry at the University of Geneva during the academic year 94/95.Example 80 . To establish a " therapeutic setting " with a " therapeutic community " orientation, we developed a "block" programme for interdisciplinary training (psychiatrists, nurses et psychosocial workers) in the care units of our Department. Our aim was to offer experience of personal participation not only in a group but also within a " teaching community " allowing certain experiences related to therapeutic communities to be lived out. The training staff included all those cited above, three consultants from the OMIE Foundation and a number of other collaborators from the Department of Psychiatry. Their respective roles (group leader, observer, group work supervisor, reading group coordinator) were attributed after group meetings. Deusto University agreed to recognise the course. The course was run over 4 seminars each lasting 4 days, and each including small groups, large groups, a section on theory and participant group work supervision.

The experience has been renewed each year, under the coordination of A. Fredenrich and S. Tissot and with the supervision of J.M.Ayerra. Since it began 350health professionals ( psychiatrists, psychologists, nurses and members of other health professions) have participated in the Geneva experience. The psychiatrists who participate in training, work in the canton of Geneva for the most part whereas for the other health professionals a higher percentage come from other cantons. The psychiatrists work mainly in the intrahospital services, but also in ambulatory psychiatry in the public sector. A few come from private practice, geriatric psychiatry, mental development services and substance abuse units. As regards the duration of training, most participated for a year although some continued training for 2 or 3 years.

Results

Two evaluation studies

The results of these experiences were evaluated by two coordinated studies in Bilbao by A. Gonzalez Pinto and in Geneva by V. Vucetic. In the course of the first study, the evolution of certain symptomalogical variables was studied in relation to SCL-90, social adjustment, SAS, attitudes to mental health on the Cohen and Struening scales etc. before and after the group training blocks, continuously or looking at both modalities simultaneously. The differences were marginal and rarely significant, which may be explained by the low level of sensitivity of these instruments in a population of people " with no psychiatric pathology ". During the 1999 Geneva training course, participants were presented with a battery of self evaluation questionnaires, designed to evaluate certain aspects of the group process and the changes perceived in both professional and personal terms. The evaluation was carried out in such a way that the anonymity of each participant was respected. As the results are still being analysed, we can only present the preliminary results, based on evaluations made at the beginning and end of the course, as regards the satisfactoriness of the perceived effects.

This course was conducted as four seminars (block sessions) from March to December 1999. It was organised and structured in the manner described above. There were 68 participants divided into 6 small groups of 11 to 12. The level of non-response to questionnaires varied from 7.4% to 14.7% at the beginning and end of the course, respectively. Practically all the participants at the start of the course expressed a certain level of expectation in relation to the dual aspect of training, at both professional and personal levels. A high degree of satisfaction was expressed in relation to the last seminar as a whole. Only two participants declared a certain degree of dissatisfaction. The level of satisfaction is particularly high in the case of the small experiential groups. Participants placed less value on the teaching modules (supervision and theory groups). The satisfaction expressed during the first seminar can virtually be superimposed. At the end of the course we asked participants to assess the effects they perceived at the outcome of training as a whole. Practically all those who replied recognised having derived certain benefits both in professional and personal terms(Guimón et al., 1988). Insight into group dynamics and self awareness are the most common elements listed as having improved to a considerable extent. Changes were perceived more in terms of understanding than in improving therapeutic practice. A comparison between the doctors' group and that composed of other participants revealed no significant differences in terms of the aspects previously described, apart from age (the doctors being younger). These results led to the conclusion that this training was a positive subjective experience for almost all participants. The emotional impact of group cohesion, common for this kind of intensive seminar, is likely to exert an influence on the degree of satisfaction and the evaluation of effects which prove to be very high. Participants confirm the subjective importance of apprenticeship through experience, placing particularly high value on the experiential modules (small groups) as compared with the pure teaching modules (Guimón et al., 2000). The fact that virtually all the participants had derived personal benefits, even if most of them (71.4%) had previously undergone individual therapy, suggests that the group experience in terms of developing emotional insight (" therapeutic ", " self awareness ") is both different and complementary to the experience of individual therapy. Training of this kind involves the interlinking of personal and professional aspects, as was evident both in the expectations and in the perceived effects expressed by the participants. Our impression is that the experiences in Bilbao, as in Barcelona and Geneva have brought about greater integration among health professionals in the various teams, by providing them with a meeting place and a common theoretical frame of reference, which is highly useful to all.

Differences were observed between the weekly courses and the intensive seminars. A number of questions and fears attended the launching of block sessions, but the experience gained over the years has shown that, despite certain disadvantages with this training modality, there are some extremely encouraging advantages.

Theoretical course

The theoretical course is at a clear disadvantage in the intensive seminars held at the end of the week, for several reasons: there are far fewer lectures and seminars; in an experience of this kind which demands different forms of energy, intellectual receptivity is distinctly lower in terms of attention, memory, capacity to associate etc.; reading is not as effective if it is tackled in discontinuous phases, with long intervening gaps, and by skimming the texts, as when time is set aside regularly.

Small group experiences

In regard to the awareness experiences, it is true that the university is not the most conducive setting in which to offer professionals experiences involving the personal processes which lead to the emotional insight so essential to our clinical activities. But as time passed we were surprised to discover a veritable process (including emotional development) taking place among the students in Barcelona who participated in the block sessions. There are several possible explanations for this phenomenon: the experience is far more intense, defences are highly activated and exposed to ruptures; these cannot be restructured from one group to the next because of the proximity in time and allow personality problems to come to the fore which, in an experience carried out over a week, may pass by unnoticed; the process of repetition in starting and finishing, the end of each week, provides familiarity with this type of problematic inherent to any process of change; whereas in the experience based on work throughout the week, after having approached the initial difficulties at the outset, several months go by before envisaging the end, thus allowing the group to slow down the process and to easily develop the fantasy of a long duration; there is no need for haste in developing the process, there are very long silences and a more marked tendency to function in a defensive and rationalising manner; in the intensive experience, there is no time to get bored, it takes less time to warm up and immobility is impossible as, before it can set in, the end is already in view, like a micro-existence with all its components. As a result, the group is in a permanent state of conflict, further exacerbated by the effects of tiredness resulting from the experience itself or adjacent effects: travelling, staying in a foreign city etc. Logically, this permanent conflict is what essentially enables understanding, finding solutions and changing; the participants in the intensive experience are more aware of the emotional and economic investment; it is important to take into account that besides the admission fees there are costs for travel, accommodation; they also have to give up Saturdays and Sundays etc. In fact, our opinion has changed over time and we no longer feel that the experiences of the intensive type are so inferior to those carried out weekly. Indeed my own experience leads me to think that they are not just on a par, but can even be more useful as corrective experiences for professionals in the field of Mental Health, who all possess extraordinarily strong defence systems which could lead to the failure of longer analysis.

Supervision

In our experience of training in block sessions, supervision spaces (" task reflection ") take place once during each of the four days of each seminar. To avoid this space being contaminated by the emotional atmosphere generated by the " experiential " groups, we tried to change the composition of the groups by introducing members from other groups. But this solution proved too complicated to organise and we decided to maintain the same composition for both types of group. To avoid the emotional contamination referred to, we advised supervisors to actively ask participants take turns presenting the real group experiences they had had or intended to organise in the near future. The aim of this being to avoid communication being reduced to the free floating type of discussion. Whether due to this recommendation or to the general atmosphere of an experience which encourages emotional content rather than risk or practices, we observed that supervision sessions tended to be poor, with somewhat conventional content and little commitment from participants.

From a theoretical atmosphere to a teaching atmosphere

From a clinical point of view and in terms of attitude, students who followed the general course in the form of blocked sessions evolved in a more positive manner than those who participated in sessions throughout the year, but this is due more to the high continent capacity of the " teaching setting " which developed during the intensive courses than to the high emotional content. There is an undoubted parallel with the " therapeutic setting " which develops in short confinement wards(Guimon et al., 1983; Guimon et al., 1992). Of course this similarity could partly stem from the fact that the therapeutic and teaching staff were part of the same team in both experiences; they were also run simultaneously. But one needs to look beyond superficial remarks; a deeper analysis might involve applying more or less objective scales for measuring atmospheres, such as those developed by Moos and adapted to Spain by Sunyer and Sanchez de Vega in 1988(Sunyer, 1990).

Integrated supervision seminars

While it is true, as we have already pointed out, that the supervision experience carried out in the context of training blocks has considerable limitations, in the context of institution supervision carried out at Belle-Idée in Geneva, the experience was completely different. A large number of groups are developing in the different units at Psychiatry Clinic I with different theoretical orientations, run by various mental health professionals. Since the beginning of 1998, supervision seminars have been organised for these group activities. the sessions start on Wednesday afternoon and develop in four parts. In the first part lasting one hour, the staff in charge of the different units meet with the clinic Director and the group activity coordinator (S. Ehrensperger) to discuss developments in the different activities. A typology was created to characterise the different groups. A description was made of the various group activities in line with this typology. An attempt is made to standardise and to some extent " manualise " the different activities so that they can be consistently developed over time, despite the changes in group leaders. New groups are then formed in response to need. A theoretical session takes place for 75 minutes, involving a revision of the reference literature on the various group models, followed by discussion of the pros and cons and their feasibility of use in our clinic.

Supervision of the groups conducted in the various units by different therapists or leaders is carried out in the form of a groups' group combining 5 to 8 group leaders under the coordination of a supervisor from outside the clinic and a co-supervisor. For an hour and a half, the different groups are described and discussed by members. This sometimes entails presenting a new group for each session in turn. Other leaders prefer to let the group function through more free-floating discussion around a particular line of thought.

At the end of the groups' group, the coordinators from each group meet for an hour in an inter-vision group where they discuss the contents of supervised groups, while respecting anonymity as far as possible.

Supervision of the teams had been suggested as a part of the supervision seminars but was not sufficiently subscribed to. We therefore chose to carry out supervision in the care setting, for the second year (1999), at the point when the various teams change shift i.e. at 2 pm, the supervisor moving from one unit to another.

The supervision seminars have provided an overview of both the institution and the therapeutic teams. Our experience closely follows that of Frankel [25] who set up a training group for mental health professionals who in turn conducted groups of patients. Basing his study on object-related theoretical concepts, he looked at the effects of projective identification on various "containing" environments. The fact of detecting the complicated game of mutual identification between the leader and the teaching group participants, improved understanding of the same phenomena within the care units.