The treatment of psychoses, particularly of schizophrenics, occupies a special place within the evolution of psychiatry and psychotherapy. Group therapy has come to play an important role in the treatment of psychotic disorder and it is a part of hospitalized patients’ therapeutic experiences. The goals of each group vary but they all have common purpose to increase patients’ awareness of themselves through interaction with other group members who provide feedback about their behavior, to provide patients with improved interpersonal social skills and decrease isolation. The purpose of this article was to provide a brief description of the implementation process of inpatients group therapy on the psychotic patients. Inpatients group therapy is effective when applied and considered as a part of a well organized and complete therapy aggregation, made up of: a) medical surveillance, (b) family information, therapy and sensitization, (c) self- supportive psychotherapy and (d) psychosocial restoration. Group Therapy should not be seen as a panacea, but as a therapy process whose role- instructing and supporting- are of high therapeutic importance not only for the patient, but for his close family environment as well.
inpatients group therapy, psychotic patients, psychosocial interventions, group therapist
The recent changes in Psychiatry, mostly after 1970, have made clear the attempt to drive the care of psychiatric patients from longitudinal treatments and institutionalism in psychiatric hospitals to short-term treatments in psychiatric departments of general hospitals, as well as out hospital settings .
The revolutionary changes in psychopharmacology, the abandonment of old therapeutic methods and the adoption of novel ones, and finally the participation of a mental health team have given drive to the creation of new treatment methods. Among them group therapy can be included, having though been submitted to necessary changes comparatively to the traditional one .
Group therapy is that type of psychotherapy, in which carefully selected patients are being placed in a group lead by an instructed psychotherapist, in order to stimulate the patients to help each other and cause changes to their personality and behavior .
The majority of psychiatric departments employs group therapy as a complement to their general therapeutic approach and has developed some type of groups, such as: interaction groups, music therapy groups, social capabilities group, analysis group, relaxation group, gardening group, art-therapy group, medicine-instruction group .
In the United States of America the group therapy is used in more of the half psychiatric departments of general hospitals. Is should be noted that in American society there is a misuse of group therapy, with people forming groups on any subject, including healthy people .
Group therapy is an important part of hospitalized patients’ therapeutic experiences. Groups may be organized in many ways in a ward. The goals of each group vary, but they all have common purpose to increase patients’ awareness of themselves through interaction with other group members who provide feedback about their behavior, to provide patients with improved interpersonal social skills and decrease isolation .
The group’s size in this type varies from 5 to 12 members, while the best is 6-8 people. Group sessions vary from once to twice a week, with duration of 60-90 minutes Groups may be open or closed. In closed group, the goal should be made explicit in the first session. In open groups, the goals should be reviewed at the beginning of a new persons’ first session. Patients are selected after proper history taking and detailed mental status examination .
Another important aspect is selection of topics for discussion. The topic selected for discussion should be congruent with the goal. Ideally, a patient begins a session by introducing an appropriate topic, all members relate that issue to their own situation and then start sharing coping strategies .
The therapeutic principles developed in the group therapy, traditional and inpatients Group Therapy are:
1. The reality orientation. Through their contact with others patients may improve their reality perceptive conception.
2. Transference. This may be varied concerning the different members of the team and the therapist or even collective as far as the group is concerned.
3. Identification. Other people’s behavior mimesis, in the frame of the group, in pretty helpful in finding new, healthier and more correct conducts.
4. Universality. Patients feel that they are not the only ones living with a problem and that many other people may be suffering as they do.
5. Group pressure. It helps constructively in the change of the group members’ inadaptable conduct.
6. Coherence. The members feel acceptable to each other, useful for the team, in which they work collectively to achieve common goals and aims.
7. Interpersonal cunning. It aims at the modification of the interpersonal conduct.
8. Interpretations. They may be given by the therapist, or even better by the group members.
9. Emotional relaxation and catharsis. They make up an important experience for the patients, who learn how to express their feelings in a manner which is not painful for them .
The clinical setting of the inpatients groups shows some particularities and special interest as well. In the frame of a ward, the demands of the group therapy change and there are revolutionary changes in its application techniques too.
There are two main factors affecting this modification, and are related to needs of the psychotic patients:
• The nature and deduction of cognitive function,
• The insight of the numerous social stimulants received .
The various group therapy programs are designed and applied based on these factors. It is, thus, easy to comprehend that during the first phases of the disease (the incisive phase), some therapy models are not effective, and only the pharmaceutical treatment (P/T) is really crucial for the patient’s course. In the second phase, however, Group Therapy is able to provide corrective meddling to the cognitive and social performance lacks.
There are two patient categories which shape the G/T program:
a) Those who, after the first psychotic incidence and the proper pharmaceutical treatment, show low cognitive deduction and function satisfyingly to very well, not only socially but professionally as well, and
b) Those who recover with low rates and present heavier symptoms of residuality, and thus, strong social deduction caused by the person’s adaptability to the social practices before the initial stage of the disease [8,9].
The clinical setting of inpatients group therapy, as already mentioned, is different from the traditional Group Therapy and is recommended when it comes to the modification of the traditional Group Therapy techniques. More specifically, there is:
c) Non requisite patients’ mobilization (some of them take part involuntarily and have no faith in the Group Therapy usefulness).
d) Presence of continuous patient rotation (the residence in the group is brief- up to 3 weeks).
e) Non completion of a group therapy frame (low number of sessions during the patient’s treatment).
f) Lack of homogeneity of the psychopathological cases.
g) The patient lives intense and insuperable to him problems during his treatment and focuses on the help he is going to receive in order to untie them effectively.
h) The group therapy in the department is not an autonomous and selection therapy, but makes up a part of a therapeutic whole.
i) In Group Therapy, the staff takes part in it periodically, as a therapist. Consequently, there is neither the possibility nor enough time for the same therapist to prepare the patient for his participation in each session and always figure out the group’s makeup.
j) The coherence makeup in these groups is often.
k) Finally, the interpersonal approach of the patient’s conduct is not requisite, because of the time limits .
The group formation can be done in two ways:
1. The level approach, where patients are placed according to the function level:
• High: (sick, non disorganized with good social and cognitive function) with sessions up to 75 minutes, which stimulate the group’s stability without conflicts and eruptive situations, viewing on orientating and defining the patient’s problems which will establish his/her post-hospital remedy.
• Low: (sick regressed and disorganized) with sessions up to 45 minutes, which are mainly supportive and enhancing the construction of the patient’s orientation.
The advantage of this system is the maintenance of a proper and balanced for the needs of the participants’ level, so as to achieve the level group goals. However, in them, patients are clearly distinct in categories of functional and non functional, which may cause tenseness.
2. The team approach, in which all the newcomers in the clinic are introduced in 2-3 groups periodically and in sessions of 45-60 minutes for certain time periods. These groups do not have homogeneity and may accept patients of all levels and diagnosis, being although under the same stressful events .
The role of the group therapist is mainly attributed to mental health nurses and less often to psychiatrists and psychologists, as well as other therapists such as social workers and work-therapists. Because of the short duration of the inpatients groups, the group therapist should have the following characteristics: he should be energetic, quick, effective, supportive, structured and pellucid .
The therapist’s aim is:
• The therapist should actively structure the discussion in a way that encourages the group members to stay in a topic.
• When members interact spontaneously around an appropriate issue, the therapist should be quiet and allow the patients to feel a sense of mastery.
• Therapist should try to include all members in the group discussion by asking each one to express their views and feelings. Therapist should assist silent members to speak and should understand their reasons for silence.
• When there is conflict between members then therapist should not take sides rather encourage whole group to discuss issue in a way that leads them to understand why conflict has arisen.
• The therapist’s task is to help the group develop into a cohesive unit with an atmosphere conducive to the operation of curative factors and where confidentiality and non judgmental approach can be communicated to the group members [13,14].
The clinical instructions refer to the patient’s preparation, the group formation, the group’s structure, the training and supervision of the special techniques application:1. Patients’ Preparation
The therapist initially focuses on the indispensability of the G/T and its aims. The therapist mainly notes:
2. It helps to the change of conduct, the comprehension of the disease and its prognosis, the possibility of mutual opinion exchange, as well as to active mutual aid.
3. The training and comprehension of the simplicity that characterizes the rules of the team.
4. The compliance with the team’s rules (working hours observance, stopover to the sessions, acceptance and respect of the other people of the team .5. Formation
The group’s coherence and identity are being insured. The group is made up of people with similar psychopathology diagnosis, introduced according to their functionality and balance concerning social, cultural, ethnical and racial origin, the gender and age .6. Structure
More specifically, there are inpatients groups, where the patients succession is continuous (new patients after the incisive phase enter these groups, while others leave it). The groups consist of 6-8 members who meet in one or more sessions of 60-90 minutes’ duration .7. Leader-Therapist
Usually, two therapists participate, namely the leader and the co-therapist- assistant. The presence of the assistant aims at helping the therapist in chief to maintain the reality inspection, to conform patients having swelter and eruptive tendencies, and generally to ensure the congruous function of the team, restoring the balance in it. What is more, he takes part in the model-roles, settlements and exercises instruction .8. Clinical education and Supervision
It is requisite that exist: a) the coexistence of a therapy “couple”, consisted of a beginner and an experienced therapist, (b) the group’s supervision by a person specialized in psychotic patients so as to intervene if there is no improvement in the team, if the therapist- chief is let down by the interventions result as well a if there are conflicts and confrontations between the therapy couple, (c) the use of several supervision means, such as video camera, mirror etc .9. Special techniques’ application in Group Therapy
- Prevent the patients from being exposed to many stimuli: as already mentioned, a patient in the first and incisive phases of the disease, as well as disorganized patients of low functionality are not allowed to participate in interaction groups. The methods employed evoke to the patient aggravation condition and total isolation. The gradual adaptation, where the patient gains more resistance to anxiety is a correct and suggested technique.
- Education and Reality inspection: the member’s instruction lies upon the general information about their sickness, its prognosis, the reason which lead to the aggravation of their condition, the ways of avoiding reversion, the identification of positive symptoms and the need to comply with the P/T. In groups, thanks to interaction, the members communicate their experiences on how they live with the problem, how they come over their psychotic condition elements, the encouragement and the course of their disease.
- Maintain the discussion on recent and timely issues of living: the patients discuss over subjects which are directly related to everyday life. They refer to problems that engross them, such as family, work, their relation with their co-patients and how they get on with each other.
- Focus on the positive side of the themes discussed: the discussion is rolling on the positive points of the narrations so that the goals of the team be more feasible and in the realms of reality. These goals are mutual support, encouragement and mutual aid through consultation.
- Focus on the group’s orientation: a) towards interaction and (b) towards social education depending on the patient’s functionality. In interaction groups, patients are encouraged to express their emotions and problems, and they are rewarded for this. Within the groups, they recognize their problems, find solutions and answers through their in between relationship, while they receive consultation and moral solidarity and support by the other members. The patients live confidence and are not obliged to refer to very personal issues. They learn to manipulate anxiety through the team, and therefore the social and professional relationships. Everything happens within the therapy environment is employed as an example by the therapist, who asks and seeks after the members’ annotation and opinion over these themes.
In the second groups of social education through roles and models function, which the therapist himself represents, the patients are asked to improve their sociality and abilities. They are taught the indispensability of communicating with people, of perceiving their false thoughts and social conducts, the reasons that lead to these conducts, one’s actions consequences, and through the team they seek for alternative solutions so that the dysfunctional conducts can be altered. The group therapy context ensures the protection and safety of its members, gives the impression of family and home atmosphere and encourages the members to stay in touch independently of the sessions [17,18].
Several studies [19,20,21,22] have been made on the effectiveness of Group Therapy for patients with schizophrenia. During these studies, the therapeutic bid of G/T was evaluated, through the application of several methods on different patient groups. So, there are studies on either internal or external patients, who are either in the incisive or the remission phase of psychotic elements, and who are subsumed in groups with specific focus and orientation, such as social education, supportive, and empathy.
Their results are written down as following:
• The Group Therapy which is empathy orientated does not always lead to positive results for patients in incisive occurrence of schizophrenia, while it is thought as useless and inefficient for institutionalized patients .
• The Group Therapy which is interaction orientated, when made through a long period of time (up to 60-80 sessions), may help supportively the mobilization of the hospitalized patients concerning their social and interpersonal conduct .
• The Group Therapy aiming at teaching social abilities and problem settlement is reasonably efficacious for lasting internal patients and for day hospital patients, thanks to the development of cognitive functions and conductive practices .
• The Group Therapy aiming at interaction mainly helps the lasting external patients (particularly the institutionalized ones) improve their social conducts and communication, and thus, deduct their social isolation. Moreover, for inpatients with high functional level and mild psychotic symptoms, the G/T application is a convenient therapy approach being much more effective if continued and after the hospital remedy. In contrast, for lasting external patients, its application does not give encouraging results of efficacy [20,22].
• When Group Therapy is orientated to interaction through social education, it may turn out to be effective for lasting external patients. The results reach their peak for these patients either with “homework entrusting”, or with education on problematic situations, similar to those patients might affront in their everyday life .
Based on the findings of studies, and taking into account the appearance of cognitive functions in schizophrenia, it is safe enough to gather the following:
• Group Therapy in the incisive phase of the disease causes an aggravation of the patients’ clinical and psychotic condition, because of the warped perceptive functions, and should therefore be excluded. Their introduction in groups evokes anxiety and confusion to them, as they are not able to respond satisfyingly to social situations.
Thus, Group Therapy can play an important role only when it comes to patients whose psychotic elements are in remission, and always under the sleepless eye of the leader- therapist of the team, so that a reappearance of some positive element is conceived betimes. With this method, the patient is orientated to a more supportive and focused on the problem Group Therapy [23,24].
• The less psychotic patients and those who are of high functionality respond better to the Group Therapy, and mostly to the interaction caused by the group. This happens thanks to their good pre-morbid situation, to the quick improvement of their psychotic condition, to the moderate up to good maintenance of the cognitive functions, and these patients’ ability to satisfyingly manipulate their social and professional relations’ anxiety. In Group Therapy conditions, which represent a miniature of the society, this member is able to comprehend other people as well as himself, through the development of relations within the team and can more easily adapt and incorporate in his previous life (social- professional).
Therefore, patients of high functional level, who nevertheless have fears, insecurities and are not permissive of the numerous stimuli from interaction, are introduced in groups with more leading and constructed techniques of Group Therapy, so that their social reintegration is achieved through the stimuli deduction [25,26,27].
Inpatients group therapy is effective when applied and considered as a part of a well organized and complete therapy aggregation, made up of: a) medical surveillance, (b) family information, therapy and sensitization, (c) self- supportive psychotherapy and (d) psychosocial restoration.
The excellent knowledge of the group techniques, the correct evaluation of the patient (of his cognitive- conductive function ), the study of the research attempts are all basic circumstances for the application and success of the group therapy. What is more, each patient’s needs should always be taken into account, at the phase of his clinical condition each time, and particularly his anxiety and his cognitive level at the present appearance of the disease.
Group Therapy should not be seen as a panacea, but as a therapy process whose role- instructing and supporting- are of high therapeutic importance not only for the patient, but for his close family environment as well. It should not be forgotten that Group Therapy’s goal is the patient’s social incorporation and the regain and maintenance of his sociality, the healthy expression of his emotions and his return to reality.