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Evidence based studies on the results of group therapy.

Autor/autores: José Guimón
Fecha Publicación: 21/12/2010
Área temática: .
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Los tratamientos grupales cognitivos-conductuales reducen la utilización de la hospitalización y favorecen la estabildad y la vida independinte en la comunidad de determinados pacientes esquizofrénicos seleccionados. Los tratamientos psicoeducativos, especialmente si incluyen a la familia, se han mostrado también eficaces. Los pacientes depresivos han sido tratados con éxito en grupos de orientación cognitiva, interpersonal y psicodinámica. Los grupos en pacientes bipolares mejoran el cumplimiento y la evolución de estos pacientes. En el futuro es probable que se generalicen programas en hospitales de día para los trastornos de personalidad, con orientación mixta dinámica y cogntivo-comportamental. Los tratamientos grupales son útiles para pacientes con problemas de abuso de substancias, en especial cuando se realizan en programas de comunidad terapéutica.

Palabras clave: Basado en la evidencia; Terapia grupal.


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Vol. 2, núm. 3 - Agosto 2003

Revista Internacional On-line / An International On-line Journal

José Guimón

In this article the efficacy of different group approaches that have been proposed for the
management of psychiatric patients is reviewed.
There are few studies regarding group therapy with patients with anxiety disorders,but cognitivebehavioural techniques show positive results
Campaign to inform the public of the early signs of schizophrenia, aimed at increasing early
intervention and reduced the duration of untreated . Some integrated model of early treatment of
schizophrenia (primarily psychotherapeutic and dynamic-systemic approaches), working intensely
with families showed successful results.
The relatively few controlled trials of group psychotherapy in the rehabilitation of schizophrenic
patients present major methodological problems. The results seem to be better than those obtained
with individual psychotherapy. A dynamic understanding of the patient's psychopathology and
relationships with family and social networks could be very helpful. An reviewed of all relevant
randomised or quasi-randomised controlled trials on life skills programmes and consider that data
are sparse and that no clear effects were demonstrated. Psychoeducational techniques enhance
medication compliance including attitudes to treatment . Family therapy has been useful for treating
the patient in his own environment, and reducing relapse
Good results have been in outpatients suffering from major depression assigned to cognitivebehavioural and psychoeducational group therapy. Dynamic group therapy improved compliance
with medication in bipolar patients.
Groups are largely used throughout the world for patients who abuse substances, or in outpatient,
halfway programmes, or in hospitals for short or medium stays.
Significant, positive results have been found with Linehan's cognitive-behavioural groups approach in
borderline patients. Favourable results have been found with treatment based on group dynamic
psychotherapy in a day hospital.

Los tratamientos grupales cognitivos-conductuales reducen la utilización de la hospitalización y
favorecen la estabildad y la vida independinte en la comunidad de determinados pacientes
esquizofrénicos seleccionados. Los tratamientos psicoeducativos, especialmente si incluyen a la
familia, se han mostrado también eficaces.
Los pacientes depresivos han sido tratados con éxito en grupos de orientación cognitiva,
interpersonal y psicodinámica. Los grupos en pacientes bipolares mejoran el cumplimiento y la
evolución de estos pacientes.
En el futuro es probable que se generalicen programas en hospitales de día para los trastornos de
personalidad, con orientación mixta dinámica y cogntivo-comportamental.
Los tratamientos grupales son útiles para pacientes con problemas de abuso de substancias, en
especial cuando se realizan en programas de comunidad terapéutica.
Basado en la evidencia, terapia grupal
Evidence-based, group therapy

In this article we will first review the efficacy of different group approaches that have been proposed
for the management of psychiatric patients.

Hager et al (Hager et al., 2000) say that two types of evaluation can be distinguished: "comparative"
and "non-comparative" evaluation studies. A question concerning the non-comparative or "isolated"
efficacy studies of a therapy is that they cannot simultaneously serve to answer the question
concerning the relative efficacy of two or more therapies aiming at the same goals or objectives. The
22 studies which have already been used by Grawe et al. (1994) in their comparisons of behaviour
therapies and short-term psychodynamic therapies, are reanalyzed and the Heger contends that it is
not possible to draw conclusions about the comparative efficacy of behaviour therapies and shortterm psychodynamic therapies due to the fact that the studies have not consequently been planned
and executed as comparative evaluations. Only amelioration of the 22 studies can be regarded--with
certain restrictions--as comparative outcome studies with respect to amelioration of certain
symptoms. A further analysis of these studies shows that there is no evidence of a "highly
superiority of behaviour therapies over short-term psychodynamic therapies.
There are few studies regarding group therpy with patients with anxiety disorders. Lubin (Lubin et
al., 1998) study the role of group therapy in treatment of posttraumatic stress
disorder (PTSD). They examine the effectiveness of a 16-week trauma-focused, cognitive-behavioral
group therapy, named Interactive Psychoeducational Group Therapy, in reducing primary symptoms
of PTSD in five groups (N=29) of multiply traumatized women diagnosed with chronic PTSD. At
termination, subjects showed significant reductions in all three clusters of PTSD symptoms (i.e.,
reexperiencing, avoidance, and hyperarousal) and in depressive symptoms; they showed nearsignificant reductions in general psychiatric and dissociative symptoms, at termination. The use of
structured, cognitive-behavioral elements within the group format may allow for more targeted
treatment of core symptoms of the disorder.
Another sutdy by van Dam-Baggen (van Dam-Baggen et al., 2000) discuss whether group social
skills training (SST) or cognitive-behavioral group therapy (CBT) works best to treat social anxiety in
psychiatric patients. It was shown that both SST and CBT were effective in reducing social and
general anxiety, decreasing the severity of psychopathology and increasing social skills and selfcontrol. Keeping in mind that this was a quasiexperimental study, the authors concluded that in a
clinical setting, group SST may be the best way to treat psychiatric patients with GSP
On the other hand, the use of online support groups is increasing around the world. .Finfgeld
(Finfgeld, 2000) underline the advantages and disadvantages these groups made of individuals
seeking assistance with problems such as depression, suicidal tendencies, substance abuse,
cancer,and eating disorders. Seminal findings suggest that these groups offer some over their
traditional face-to-face counterparts; however, they have also been identified many disadvantages
Groups are utlized with people of all ages but there are few contriolled studies on their results.
Asarnow et al (Asarnow et al., 2001) review the literature on psychosocial interventions for
depression in youth .
Wood et al.(Wood et al., 2001) compare group therapy with routine care in adolescents who had
deliberately harmed themselves. Adolescents who had group therapy wereless likely to be
"repeaters" at the end of the study, were less likely to use routine care, had better school
attendance, and had a lower rate of behavioral disorder than adolescents given routine care alone.
The interventions did not differ, however, in their effects on depression or global outcome.
Brent (Brent et al., 1998) assess the predictors of treatment outcome across treatments, as well as
those associated with differential treatment response of adolescent outpatients assigned to one of
three manual-based, brief (12 to 16 sessions) psychosocial treatments: cognitive-behavioral therapy
(CBT), systemic-behavioral family therapy, or nondirective supportive therapy. Predictors of poor
outcome may give clues as to how to boost treatment response. Subjects who come to treatment for
clinical trials via advertisement (versus clinical referral) may show more favorable treatment
responses. CBT is likely to be a robust intervention even in more complex and difficult-to-treat
Prevention and early intervention
As I reviewed in the previous issue of this Journal,Group techniques aimed at lessening negative
attitudes towards psychopharmacological medication and those that aim to reduce 'expressed
emotion' within the family can lower relapses.
Only in recent years has there been interest in early intervention, and a more optimistic attitude,
encouraged by the Scandinavian countries and by the International Society for the Psychological
Treatment of the Schizophrenias and other Psychoses (ISPS) (Klosterkotter et al., 2001;McGorry,
2001;G. E. Hogarty et al., 1997; Birchwood et al., 2001)
Scott and Dixon (Scott et al., 1995), in a review of the literature on the clinical outcomes obtained
by support and dynamic psychotherapy (both group and individual) and psychosocial skills training,
found that the reality-oriented approaches seem better than insight-oriented dynamic
psychotherapy.Among the most important factors aggravating social ineptitude, the role played by
hospitalisation has been widely discussed (Guimon, 1982; Guimón et al., 1982;Brouwn et al., 1958;

Seva Diaz, 1979).
Gabbard (Gabbard, 1990) proposes some general guidelines for analytic psychotherapy with
schizophrenia: the main goal should be to establish a relationship; flexibility is necessary regarding
therapeutic approach and content; an optimal distance between the therapist and the patient should
be established; the therapist must create a setting (holding) that serves as a 'container'; he should
set himself up as an 'auxiliary ego', showing himself to be open, respectful, and candid; and he
should postpone making any kind of interpretation until a good relationship has been established.
However, Malmberg et al (Malmberg et al., 2002), reviewing the effects of individual psychodynamic
psychotherapy for people with schizophrenia conclude that, although the psychodynamic approach
may be more acceptable to people than a more cognitive reality-adaptive therapy, current data do
not support the use of psychodynamic psychotherapy techniques for hospitalised people with
Group psychotherapy, above all when the therapist actively tries to develop the social abilities and
strategies for coping with stress, has been supposed to be useful, especially once florid symptoms
are under control. The results seem to be better than those obtained with individual psychotherapy
individual, which can be explained by the fact that the group offers socialisation experiences,
behavioural models, and a more shared transference which is less dependent on the therapist
(Guimon et al., 1983; Guimón et al., 1983; Frankel, 1993)
Durint the last decade, thanks to better knowledge of deficit symptoms, it has been observed that
even simple learning activities are often difficult, due to certain patients' cognitive deficits.
Therefore, it has been decided to improve this deficit with cognitive rehabilitation modules. Thus
Hans Brenner (Brenner et al., 2000) and other authors have developed an integrated psychological
therapy (IPT) addressing deficits in the residential, vocational, and recreational domains of
community functioning and they propose that is more effective than other psychosocial treatments,
such as supportive group therapy and pure behavioural methods. However, Suslow et al (Suslow et
al., 2001) reviewing the literature on training on attentional functioning contend that there is
inconclusive evidence that attention training is effective in schizophrenia. The so called Integrated
Psychological Therapy (IPT),is a group-therapy modality intended to reestablish basic neurocognitive
functions (Spaulding et al., 1999) that showed incrementally greater gains compared with controls
on the primary outcome measure, the Assessment of Interpersonal Problem-Solving Skills, after a
six month intensive trial .However, in two Cochrane reviews, (Nicol et al., 2002;Cormac et al., 2002)
consider that data are sparse and that no clear effects were demonstrated.A modification of CBT
"Assertive Community Treatment (ACT)"has been shown in a Cochrane review (Marshall et al., 2002)
to facilitate that patients remain in contact with service
Psycoeducational techniques enhance medication compliance including attitudes to treatment,
substance misuse and insight (G. Thornicroft et al., 2001;menson et al., 2001; Henderson et al.,
2002; Pekkala et al., 2002)
Family therapy has been useful for treating the patient in his own environment, and reducing relapse
(G Thornicroft et al., 2001;Dixon et al., 2000;McFarlane, 2000;Pharoah et al., 2002;Penn et al.,
1999;Leff, 2000).
Combined therapies
Combining psychotherapy and pharmacotherapy sometimes (but not always) results in better
results, and clinical guidelines have been proposed for its correct indications (Segal et al., 2001). In
a major clinical trial, 1356 patients with depressive symptoms were enrolled in a randomised
controlled trial for depression (Unutzer et al., 2001). Clinics were randomised to usual care or to one
of two different quality improvement programmes that involved training local experts, who worked
with patients' regular primary care providers (physicians and nurse practitioners) to improve care for
depression through patient education assessment, and referral to study-trained psychotherapists.
The quality improvement programmes substantially increased the success rates of antidepressant
treatment. 16 sessions of Psychodynamic Supportive Psychotherapy in addition to pharmacotherapy
produced a significant reduction in personality pathology (mostly in cluster C psychopathology) in
depressive patients (Kool et al., 2003).
Several studies (Gitlin, 2001; Miklowitz et al., 2000; Miklowitz et al., 2003; Rothbaum et al., 2000)
have reviewed the efficacy of in individual and group (Colom et al., 2003) psycho-education ,
individual cognitive-behavioural therapy (Lam et al., 2003), marital and family interventions, and
individual interpersonal therapy in treatment-resistant bipolar disorder. Family-focused psychoeducational treatment appears to be the most efficacious adjunct to pharmacotherapy for bipolar
disorder (Miklowitz et al., 2003).
There is little evidence of the efficacy of suicide-prevention activities, although some general
measures (public awareness, optimising primary care, restricting the presentation of suicides in the
mass media, and restricting the access to means for suicide) may help (Althaus et al., 2001).
Brief group treatments in depressive patients
In a controlled clinical trial, Piper et al. (Piper et al., 1994; Piper et al., 1996) studied the capacity of
seven characteristics of patients to predict their success in an intensive psychodynamic group

therapy programme aimed at patients with affective and personality disorders. Among them, two
personality characteristics (psychological sophistication and the quality of object relations) were
shown to be the strongest success predictors. Recently, specific intensive groups have been aimed at
helping to elaborate mourning, obtaining good results.
McCallum et al. (McCallum et al., 1993) compared the results of two dynamically-oriented group
therapy programmes, one brief, the other of long duration. Both were aimed at outpatients who
presented difficulty in managing personal losses due to death or separation. The post-sessions
assessments of positive and negative affect were carried out by the patients themselves, their
therapists, and the other patients in their groups. The psychodynamic work was independently
assessed, using the content analysis system. Patients who had suffered a separation presented more
affective inhibition. Positive affect increased over time, and a direct relationship was found between
positive affect and favourable results.
In earlier work along the same lines, Lieberman et al. (Lieberman et al., 1972) created a brief group
format -- eight 80-minute sessions -- in which the therapists were particularly aware of the need to
discuss, with those undergoing mourning, certain issues, such as the meaning of life and loneliness.
Other authors have developed analytical group psychotherapy programmes for depressive patients
with or without personality disorders (Rosie et al., 1995). In any case, it is noteworthy that the
majority of papers reporting on the results of brief group psychotherapy programmes with
depressive patients highlight that the results are more favourable with cognitive techniques or
interpersonal therapy than with dynamically-oriented techniques. The interpersonal approach has
been used in groups aimed at patients who have had episodes of major depression or dysthimia, but
not in bipolar patients, those who suffered from a psychotic depression, or who were considered at
risk for suicide.
McKenzie (McKenzie, 1990) explored, in his groups, each patient's type of depression, interpersonal
relationships, and the disorder's impact on their lives. The psychotherapy was centred on current
and future problems, rather than on past experiences. The 16 sessions lasted 90 minutes each, and
no medication was used. No new patients were allowed to join the group after the third session. This
format was adapted from Klerman and Weissman (interpersonal therapy, (Klermann et al., 1984)
and has been shown to be as effective as cognitive-behavioural therapy, and with perhaps more
lasting effects. Interpersonal therapy has been shown to have effects similar to those of
antidepressant medication, even in severe cases with marked endogenous symptoms. Interpersonal
group therapy is useful for all patients, including those who present a double diagnosis (major
Interpersonal therapy strategies are halfway between psychodynamic therapies and cognitivebehavioural techniques, and focus on relationships and their alteration, using models similar to those
of cognitive-behavioural therapy. Different categories of life stress are discussed (loss, mourning,
interpersonal disputes, role transitions, loneliness and social isolation). The therapist works more
with support techniques than with interpretations, trying to reinforce patients' coping and resourcemobilisation strategies. This model can also be used in a wider range of patients, such as those
presenting simultaneously with anxiety disorders and depressive syndromes.
Regarding the cognitive-behavioural approach, Stravynski et al. (Stravynski et al., 1994) reported
good results in a study in which outpatients suffering from major depression were assigned to 15session programme of cognitive-behavioural group therapy.
Bright et al. (Bright et al., 1999) compared the relative efficacy of professional and paraprofessional
therapists in providing group cognitive-behavioural therapy and mutual support group therapy, and
found clinically significant improvement, although more patients in the professionally-led cognitivebehavioural therapy groups were classified as non-depressed than in the paraprofessionally-led
Groups with bipolar patients
Contrary to the former pessimistic reports in the literature, Graves (Graves, 1993) described a study
conducted with bipolar outpatients, showing that dynamic group therapy improved their compliance
with medication and lowered their denial mechanisms, facilitating a higher consciousness of internal
and external stress factors.
For this type of patients, simple cognitive or psycho-educational techniques have been found to be
very effective. Honig et al. (Honig et al., 1997) described a controlled study using a multifamily
psycho-educational intervention in bipolar disorder. The parents showed a significant change from a
high to a low level of expressed emotion, compared with a control group. In addition, the patients
who had parents with a low level of expressed emotion were hospitalised less frequently than those
who lived with parents having a high level of expressed emotion. The multifamily groups were well
received by the participants, and there were only a few dropouts.
Weiner (Weiner, 1992) showed the positive impact of group therapy on bipolar outpatients who
attended at least 12 sessions over the course of a year. Kanas (Kanas, 1993), in a review of the
literature, suggested that bipolar patients could be treated in homogenous group therapy
programmes, in conjunction with lithium treatment. Interpersonal and psychodynamic techniques
were used. The groups' objectives included educating the patients regarding the nature of their
illness, helping them to learn how to manage their symptoms, and encouraging them to discuss
important interpersonal and psychodynamic issues. To reach these objectives, therapists used
techniques that included education and support, facilitating group discussion.

Group programs for hospitalized depressive patients
In a study we have conducted for the past 6 years at the University Hospital of Geneva, a 10-bed
unit for patients suffering from resistant or recurrent depression had registered an average length of
hospitalisation of 28.78 days, with a median of 15 days(Guimón, 1998; J Guimón, 2001). The
patients' average age was 44, and 42 was the median.Care of patients was articulated in individual
and group moments, with each staff category taking part in both. Most of these patients had been
hospitalised more than once before, so it is important that their pharmacological treatment be well
evaluated. In this context, crisis intervention had to be associated with a more in-depth assessment
of the incidence of depression on cognitive and relational skills.
At the arrival of each patient, a brochure was distributed stipulating ward rules. The programme of
the group included a daily 15-minute staff meeting for all personnel, except for weekends. A social
skills group, led by a nurse and a psychologist, meets during two hours per week, and a verbal
group, led by two physicians, during one hour per week. The medication group, led by a resident and
two nurses, met once a week for 30 minutes. A family group, led by a physician, with the
participation of each professional category, met monthly during an hour and 30 minutes. Three
recreational-occupational groups, led by occupational therapists and nurses, also meet for several
hours a week.(J. Guimón, 2001b) .The results of this programme were highly satisfactory and they
have been reported elsewhere (J. Guimón, 2001a)(Guimón, 2001, 2002).
Outpatient groups
Groups are largely used throughout the world for patients who abuse substances, or in outpatient,
halfway programmes, or in hospitals for short or medium stays.
Fisher (Fisher Sr. et al., 1996) studied two models of group therapy for patients presenting a double
diagnosis of substance abuse and personality disorder. This semi-experimental study was led in a
facility treating substance abuse, both on a outpatient and hospital basis. They developed three
groups in each context: two groups were formed for the integral treatment of patients with a double
diagnosis (substance abuse and personality disorder) and the third was used as a control group, with
standard treatment.
One of the experimental groups was developed in accordance with the "illness-and-cure" approach.
Its objective was the acceptance of substance abuse as a chronic illness, progressive and possibly
fatal. In a similar fashion, although mental illness (personality disorder, for example) is not
necessarily fatal, its evolution is typically considered to be chronic and progressive. This approach is
based on the assumption that patients have an underlying biological vulnerability, characterised by a
loss of control over substance abuse and mental disorders. After the start of treatment, the number
of patients per group was set at 7 or 8 members. The groups were led in co-therapy by a principal
investigator and another clinician. The immediate objectives in the illness-and-cure treatment model
include the development of an identity as an 'alcoholic' or an 'addict', recognition of a loss of control
over substance abuse and the effects of personality disorder, acceptance of abstinence as a
treatment objective, and participation in group self-help activities such as Alcoholics Anonymous.
They also developed a second experimental group in each location, with a cognitive-behavioral
approach, which they compared with the other described above.
Therapeutic communities
There are, in addition, long-stay programmes which are more or less structured, sufficiently specific
for substance abuse patients, offering an approach that ranges from very firm restriction on freedom
to a progressive autonomy leading to total freedom acquired over successive steps during periods
ranging from a few months to several years. Some of these programmes are carried out in centres
that are directed in accordance with therapeutic community principles. Such programmes are often
sidelined from global psychiatric care.
The "concept-based" model
Psychotherapeutic approaches to treating drug addiction have, above all, followed the therapeutic
communities concept, which began in the United States in the 1950s with the Synanon programme,
followed by others along the same lines, such as Daytop. These were programmes led, in an
authoritarian manner, by former addicts, with little participation from physicians or professionals in
general. In Europe, this format integrated professionals trained in community management, who
were required to have certain abilities such as flexibility and emotional distance. Interesting
programmes came out of these efforts, such as the Proyecto Hombre in Spain, and in some countries
they were supported by the government or the Roman Catholic Church.
The majority of these demanded a total abstinence from drugs, and rejected the use of medication.
However, as drug abuse rose in 1980s, many communities became oriented towards accepting
patients in treatment with methadone or psychotropics, featuring a more intensive role for
professionals, and a shorter stay for the patients.
Technically, these programmes revolved around the idea of the 'encounter', which was proposed by

behaviourists as an alternative to the psychoanalytically oriented groups used in therapeutic
communities for mental patients, since they believed that, in the case of addicts, insight might
constitute an excuse for not changing. In Synanon, the encounter group was called 'the game' or
'reality-attack therapy', and included direct confrontation (sometimes exaggerated) without fear of
retaliation. In recent years, these groups have become less intensive and more sensitive, evolving
towards a form of intense dialogue, in which 'confronting is as important as being confronted'. With
all of this, it is more difficult to direct these activities without specific training, although the former
addicts resent this, since they feel they have lost power and influence. On the other hand, more
scientific concepts have been introduced gradually, with psychiatric diagnosis and assessment.
Broekaert (Broekaert, 2001) pointed out that a drug-free therapeutic community defines itself
according to various parameters: it should try to become integrated into the community at large,
offer a sufficiently lengthy stay, both the patients and personnel should be open to questioning, and
former addicts should have a high profile as role models. As to the clients, they should be called
'residents' (as opposed to 'patients', who need treatment to which they submit passively), and it
should be accepted that they are immature, innate manipulators, who suffer from fears and
anxieties, and that they use violence to hide their weaknesses; above all, there must be a prevailing
belief that they can be educated through a therapeutic programme.
In sum, this therapeutic philosophy springs from a number of different sources (Christian doctrine,
Alcoholics Anonymous, Synanon, the humanist theories of Maslow and Rogers), all based on the
possibility of personal growth and change.
The treatment phases include: crisis intervention (for detoxification in a few days); out-patient
(living outside several times a week); reception (admission in a non-demanding regime), in order to
prepare for the community during a few weeks; induction, during which motivation is tested;
hospitalisation, in which the community is used as treatment during one year in a hierarchically
structured environment; phase of acceptance and security, learning to express emotions and modify
behaviour in encounter groups and other therapeutic contexts; and social reintegration, through a
halfway house or return to the client's own home.
Recent modifications have included the development of more complex networks involving more
flexible programmes and customised treatment, e.g., for those with a dual diagnosis, or for chronic
patients who need medication. Among the new therapeutic communities, noteworthy are those
specialised in other groups, such as the children of addicts, homeless persons, patients suffering
from post-traumatic stress disorder, prisoners, immigrants, prostitutes, and AIDS patients.
The "democratic" model
When we discuss democratic therapeutic communities, we are generally referring to a model
developed by psychiatrists with a participatory focus, although they have never been truly
democratic: the roles were allotted, and a patient could be cured, but not form part of the staff; they
never aimed for equity in the parcelling out of power or responsibility. In any cases, these
programmes allow all of their members to have a very high level of participation in decision making,
with a high degree of information sharing, and a great deal of emphasis on listening to others.
The differences between these two models today
Over the years, different countries have adopted these two community therapy models, tailoring
them to their needs and cultural particularities. For example, in Italy the democratic community
therapy model is particularly prevalent in the treatment of mental illness, whereas in England it is
mainly used in treating personality disorders. It seems that in Italy, there is more open
communication and overlapping between democratic therapeutic communities and concept-based
ones, particularly at the management level, with their directors and staff psychiatrists taking part in
the same congresses and belonging to the same professional organisations.
However, two important differences can be observed. First, is the fact that the concept-based
community is nearly always aimed at those whose primary problem is drug addiction, independent of
their 'secondary' problems or incidents that may arise over the course of treatment. On the other
hand, democratic therapeutic communities are nearly always aimed at those diagnosed with
personality disorders or who are mentally ill. These persons may also be addicted to drugs, but not
necessarily. The second major difference is that the staff of democratic therapeutic communities
comprises professionals only, whereas that of a concept community may include former residents.
Although outside of Europe, the majority of therapeutic communities for drug addicts are highly
structured with a strict staff hierarchy, many European therapeutic communities use a more
egalitarian model. These are more similar to therapeutic communities in the psychiatric field using a
democratic structure (Jones, 1952). However, therapeutic communities with more than 25 residents
have usually adopted the hierarchic structure of American programmes. European therapeutic
communities are now, in turn, also influencing their American counterparts - for example, their
emphasis on introducing creative activities into programming. In addition, they have shown that the
residents can learn new skills, such as gardening, agriculture, and printing, during their stay in the
programme. In Europe, as in the United States, detoxification centres have been created that are
linked to certain therapeutic communities, and in some cases, day centres and evening programmes
have been developed based on the drug-free therapeutic community concept.
Therapeutic communities in Europe have also begun to expand their range of patients to selfdestructive behaviours other than drug addiction. Moreover, the concept of hierarchic therapeutic

communities has been successfully used in treating alcoholics.
The future of therapeutic communities with addict patients
Although research has shown that the time spent in a programme is the main predictor of success,
these programmes have recently tended to become shorter, a trend seen in many countries during
the 1990s. Relatively inexpensive psychosocial self-help programmes are being transformed into
short-stay programmes following a medical model. Indeed, methadone maintenance programmes
are being considered in various countries, by politicians and by doctors (aided and abetted by the
pharmaceutical industry) as the solution to the problem of heroin addiction. Due to all of these and
other factors, the future of the traditional therapeutic communities is in doubt.
In any case, drop out is a frequent problem in these programmes and, for example, Keen et al.
(Keen et al., 2001) found low levels of completion and high levels of unplanned departure in a
residential rehabilitation centre in a 1-year programme for chronic heroin users
Good results have been reported in a special programme created for the integrated treatment of a
dual diagnosis involving schizophrenia and substance abuse (Hellerstein et al., 2001), 2001).
However, Ley (Ley et al., 2002), evaluating the effectiveness of six relevant studies, concluded that
there is no clear evidence supporting an advantage of special programmes for people with problems
of both substance misuse and serious mental illness, and ends saying that 'implementation of new
specialist substance misuse services for those with serious mental illnesses should be within the
context of simple, well designed controlled clinical trials'.
Overall tendencies
These patients are difficult to manage in individual analytical psychotherapy, due to their instability,
which is frequently related to a loss of self-esteem and identity confusion. The course of therapy
tends to be disturbed by intense transferences and various acts, such as suicide attempts, attacks of
rage, and self-mutilation caused by suicidal thoughts. Kernberg (1968) recommended confronting
these patients and interpreting their negative transference early on, whereas other authors (Buie et
al., 1982) advise therapists to limit themselves to acting as a holding environment for the patient
and avoid interpretations. There is a high percentage of drop-out in these patients. Group therapy,
traditionally used in these patients when they are hospitalised, is currently considered of particular
interest for outpatients. Springer and Silk (Springer et al., 1996) designed an efficient, short
programme, and discussed, particularly, the advantages and disadvantages of Linehan's dialectical
behaviour therapy (Lineham, 1987; Lineham, 1993). Indeed, group therapy offers the advantages of
being less expensive, making transference easier to manage, and producing an improvement in ego
functioning (Kretsch et al., 1987) and interpersonal functioning (Schreter, 1970, 1978), a drop in the
patient's regressive tendencies (Horwitz, 1980, 1987). Moreover, these patients are more likely to
take advice or engage in confrontations with other patients than with the therapist, and they have
the possibility to relate with them on an equal level.
Group therapy should be part of a multidimensional programme, and the group should, in principle,
be heterogeneous. The orientation of groups tends to be eclectic, and although open psychodynamic
groups are the most frequent, others (Klein, 1993) focus on such aspects as acting out, splitting,
countertransference and eroticisation of relationships.
Group therapy was found to be as efficient as individual therapy in a program of 'managing
emotions' (Dawson, 1988; Dawson et al., 1993) and patients who participated in groups showed
better treatment compliance. In these programs therapists show themselves as permissive even if
they forbid acting out. Regular attendance at meetings was not obligatory, which meant that only
30% of regular participants, forming the nucleus of patients, was more or less constant, while there
was also a much larger subset of patients who showed up from time to time at the group meetings,
searching for occasional help. A controlled study comparing individual and group psychotherapy
(Clarkin et al., 1991) showed better results with this approach.
Significant, positive results have been found with Linehan's cognitive-behavioural approach. This
method was first proposed for young women who were parasuicidal, and was then extended to
persons with behavioural problems to resolve 'dialectic' failures. Indeed, from a theoretical point of
view, Linehan made reference to this dialectic reasoning, which brings into opposition poles such as
active passiveness versus competency, demonstrative crises versus emotional inhibition, and so on.
These programmes combine individual and group approaches in problem-solving and in skills
training. In the psycho-educational groups, patients are taught a certain number of skills in
regulating emotion, interpersonal functioning, and stress tolerance. Patients take part in these
groups during at least one year, and then participate in help groups, or groups to reinforce skills
application. In individual and concomitant therapy, which lasts at least one year, we teach patients
to integrate these skills into daily life. Rules to generalise apprenticeship in the outside world (even
using the telephone) are proposed. The group is closed or, at the maximum, slowly opened.
The psychoanalytical approaches are especially based on the theory of object relations. Most of the
approaches have been developed in hospital environments or in halfway centres, based principally
on the work of Kernberg, who used the psychoanalytical model of object relations. The accent is
placed on increasing the fortress of the ego and improving the experience of realities, with an

attempt at internal reconstitution. From a technical point of view, the splitting mechanism is
reinforced rather than fought, and they propose open exteriorising of aggression and the realisation
of group interpretation based on the 'here and now', which favours cohesion.
Certain authors, in comparing these two approaches, have pointed out that in both of them, the
therapist is strongly committed, even if the attitude of Kernberg is neutral and that of Linehan is
active, with attitudes of reinforcement. However, the expression of aggressiveness is encouraged by
Kernberg, whereas Linehan does not encourage it, and Linehan is not interested in the here-and-now
of the group, nor in group phenomena.
Wood et al. (Wood et al., 2001) compared group therapy with routine care in adolescents (most of
them borderline) who had deliberately harmed themselves, and found that those who had undergone
group therapy were less likely to be 'repeaters', although their global outcome did not differ. Hawton
et al. (Hawton et al., 2002) evaluated all randomised controlled trials regarding the effectiveness of
treatments of patients who have deliberately self-harmed, and found reduced rates of further selfharm for depot flupenthixol versus placebo, and for dialectical behaviour therapy versus standard
Groups in residential settings
Because of the risks of acting out, the therapist must be able to count on a support system offering
more holding for these kinds of patients, i.e., a hospital unit (which should be avoided as much as
possible in order to not embark on a prolonged and counterproductive relationship with the
institution) or a day hospital.
Using a dynamic perspective, recent work by Bateman and Fonagy (Bateman et al., 1999), 1999)
has shown favourable results with treatment based on dynamic psychotherapy in a day hospital.
These authors compared the evolution of 19 patients, whose treatment in hospital was partially
oriented from a psychoanalytical point of view, with the same number of patients who had received
general psychiatric treatment. Self-mutilating behaviour and suicide attempts decreased during the
18-month programme. Moreover, the average hospital stay was shorter than for those who followed
specific treatment.
In the hospital environment (and also in halfway institutions), the treatment is carried out in settings
where several caregivers interact. Adshead (Adshead, 1998), in light of attachment theory, reported
that the hospital environment provides security only if caregivers are capable of tolerating both the
external demands of the system and the internal demands of patients. He pointed out that
therapeutic relationships between staff and patients are only repetitions and recreations of internal
object relations, and that responses from the team to splitting and to projective identification can
sometimes be negative. He further indicated that a certain number of negative reactions can be
detected through the patronising and contemptuous way that caregivers may sometimes express
themselves to the patient; moreover, that certain excessive reinforcements of the regulation of
services, for example the inappropriate use of restriction on movement, may result from this attitude
on the part of staff. Adshead also remarked that the conflict between therapist and patient may be
exacerbated by the new organisation of cost containment, particularly in a managed-care system,
e.g., by the interference of insurance companies. Finally, he pointed out that problems in the unit's
structural organisation, such as inadequate accounting practices, lack of leadership, difficulties in
communication and violation of boundaries, can seriously aggravate the condition of patients.
The programme developed at the Francis Dixon Lodge is an example of these issues. The patients
are generally hospitalised because of their destructive manner of expressing their mental pain. After
three weeks of hospitalisation, staff embark on a psychodynamic programme, which includes
predictions regarding transferential reactions that they can expect, and which try to cover the selfaggressive behaviour (feelings of abandonment, trigger situations, and so on). Personnel try to forge
a therapeutic relationship in which the patient feels sufficiently reassured to explore avenues of new
relationships, while allowing him or her access to the horrors of the past, which may carry so much
negative emotion that they could even endanger the relationship. In addition, they consider acting
out to be an expressive and defensive function and that even more self-destructive behaviour can be
an attempt to avoid another catastrophe (psychosis, hetero-aggression, etc.), which can be
experienced as more destructive to their own integrity.
These patients, because of their poor self-esteem, do not know how to ask for help in an appropriate
manner, and do so by provoking crises, which causes the therapeutic team to counter-react. Staff
explains to patients that they must learn to talk about their suicidal feelings or their ideas about selfmutilation, explaining that they try to be tolerant, but that we also expect them to modify their
behaviour. They try to avoid patients' feeling of omnipotence when they trigger self-aggressive
activities, and pay special attention to phenomena of hostile and envious dependency, by trying to
avoid or to manage negative therapeutic reactions.
Springer (Springer et al., 1996), based on the existing literature, proposed a framework in which an
effective, short-term group treatment can be organised, particularly emphasising the advantages
and disadvantages of the adaptation of Linehan's dialectical behaviour therapy by using it in a shortterm programme for hospitalised patients. For their part, Dolan et al. (Dolan et al., 1997) evaluated
the impact of psychotherapeutic treatment on the principal symptoms of 137 hospitalised patients
with personality disorder. They noted a significantly greater improvement in those treated than in
the 'non-admitted' group, as well as a significant, positive correlation with length of treatment.
Similarly, Hafner and Holme(Hafner et al., 1996) conducted a prospective study on 48 residents of a

therapeutic community, 34 of whom presented borderline personality disorders in order to determine
which elements of the programme were most useful. A reduction in significant symptoms on the
Brief Symptoms Inventory took place at discharge after an average stay of 64 days, and the rates of
admission to hospital fell significantly during the year after discharge. Patients rated group therapy
as the most useful element of the programme. A five-year follow-up study by Sabo et al. (Sabo et
al., 1995) on 37 hospitalised patients presenting borderline personality disorder evaluated the
changes in two forms of self-destructiveness. They noted that suicidal conduct diminished
significantly, but that self-aggressive conduct, although it presented a certain downward trend, did
not drop significantly, nor did aggressive ideation (both suicidal and self-destructive).
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patients suffering from borderline personality disorder, concluding that it was necessary to carry out
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