Vol. 2, núm. 3 - Agosto 2003
Revista Internacional On-line / An International On-line Journal
THE ROLE OF GROUPS IN A CHANGING MENTAL HEALTH SCENARIO
José Guimón
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.
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 intermember 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 BelleIdée, 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 sociooccupational 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)
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ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
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