Vol. 2, núm. 3 - Agosto 2003
Revista Internacional On-line / An International On-line Journal
TRAINING TO BE A GROUP THERAPIST
José Guimón
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
PSYCHOTHERAPIST
AND
THEORETICAL
PREPARATION
REQUIRED
OF
THE
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 ".
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 intervision 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.
Supervision of the therapeutic team
Systems of psychiatric care which are managed with a " community " orientation tend to provide
patients with a series of " corrective emotional experiences ". The therapeutic team conceived as the
patient's " alter familia " is considered to be the main therapeutic agent of change. Thus the basic
therapeutic element lies in healthy communication between the various members of the team,
shared by patients through a suitable group programme. But in the course of treatment for patients
who are seriously ill, psychotic transfer, through a game of projective identification and projective "
counter-identification ", creates counter transfer in therapists, giving rise to multiple projections
which may result in the group feeling divided(Guimon, 1985) . Tension mounts within the teams,
members seek at all costs to maintain the impression of perfect harmony,the " ideal family ", while
maintaining an antiauthoritarian, egalitarian ideal by which the members of the team are all equal,
and refusing to recognise the obvious differences in professional training and personality. This leads
to what Sacks and Carpenter (Sacks et al., 1974) describe as a " pseudo-therapeutic community ".
As part of the indispensable process of community team consultation, these antitherapeutic attitudes
need to be changed to form " good enough teams "(Guimon, 1985) capable (like Winnicott's good
enough mother) of coping with the needs of patients and avoid burdening patients with the team's
own difficulties. Likewise other functions could be demanded from the " good enough team ":
teaching how to deal adequately with reality, care of the self and others etc., as well as setting up an
imaginary space or " illusion " (Winnicott, 1971) which in fact is the space for creativity and
psychoanalysis.
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ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
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