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Presentation – Research and clinical application of group therapy within mental health services

Since its creation in the forties, group psychotherapy has undergone various changes. Compared to its initial approach in fact, a variety of adaptations inspired by theoretical models and interventions have been implemented. Thus, we agree with Yalom (2005) who prefers to speak of group therapy sub-divided in various  settings: by illness (such as psychosis, eating disorders) to self help groups; from those conducted in prison to those conducted in a prestigious private setting; Cognitive-behavioral, psychoanalytic, psychodrama group therapy.
In this monograph for the Funzione Gamma journal edition, we discuss how the Mental Health Service in Italy and its counterparts abroad utilizes the different group interventions and models inspired by them. The collected papers not only offer the reader the evidence that public services meet the statutory mandate of care but that they also combine the valuable attributes of learning, of shared thought, experimentation and research. We must also add that “far from being just a setting, the institution enters into the life of the group and marks out its characteristics, potential and specific limits” (Patalano, 2014, p. 33).

On this premise, we have identified four different subject matters in the following articles inspired by the characteristics described above regarding groups conducted within the public health sector.

The first subject matter regards new forms of learning

In Tarallinis’ paper describing her experience as a trainee psychologist we have an example of how and what can be learned in healthcare if one shows curiosity and respect. Through an exchange with the professionals and patients and her careful observation in fact, she was able to improve both her knowledge and her reasoning.

De Sanctis explains how supervision in a psychiatric ward can be an opportunity to confront, compare and analyze a patient’s deepest dynamics and how these can subsequently trigger the dynamics of the operators. The author poses some critical questions regarding the use of psychotropic drugs and the possibility of renewing the doctor-patient relationship with a greater use of theoretical intervention models. For this purpose, he briefly introduces us to some very interesting not-medical models: Multi-family Psychoanalysis Group, Recovery and Open Dialogue.

Finally, Hinshelwood in his description of the complex relationship between psychoanalysis and psychiatry, even though he talks about past experiences, maintains still current notions in his critical thinking. Notions which help us understand what more psychoanalysis can do within institutions besides the mere care of the patient. The examples he recounts concern the pioneering yet effective intervention of “institutional and organizational training” aimed at young trainee psychiatrists in a large English psychiatric hospital. The author’s intention is to avoid that the trainees assume a predominantly “medical and pharmacological” approach but rather that they maintain a certain curiosity and attention for the intra-psychic, group, inter-group and institutional dynamics.

The second subject matter concerns research paths and the possibility to experience professional growth

The two contributions of Bello & Baroni deal with the issues of qualitative research and action research. The authors re-read and analyzed the transcriptions of various audio recordings from two different group psychological settings in a Therapeutic Community: a Multi-family Psychoanalysis Group and a rehabilitation Group. Both action research and the methodology used (Grounded Theory) were able to restore clinicians and participants to the role of protagonists of this experience in mutual respect of their roles (Bertini, 2012).
The results of the study in the first article allowed the authors to critically revise their interventions as conductors of a Multi-family Psychoanalysis Group and highlight the rich and complex content that emerges in this kind of group setting.

In the second article, Bello & Baroni, using the  same investigative tool, follow the start up and the evolution of a rehabilitation Group with persons suffering from severe psychiatric disabilities. The article allows us to observe how the initial group setting proposed by the operators, is slowly metabolized by the patients and how it expresses the creative identity of the therapeutic centre. Patients gradually “customize” the group and decide how to use it and where to go with it.

The contribution of Bernabei et al. illustrates a CBT-oriented treatment group specifically structured for acute psychiatric inpatients and used the Emotional Schema Therapy (EST) model as illustrated by Leahy (2009). The authors  explain the results of a research design involving a large sample of inpatients, which  confirm the importance of using the group tool with people with serious psychiatric disorders and provide interesting elements of reflection on the effectiveness of the therapeutic treatment carried out.

The third subject matter relates to the sharing of thought

The article by Perini proposes a reflection on the role of psychoanalysis, in this case seen as a clinical approach to organizations, and whether it can contribute to empowering individuals, working groups and the institution itself. According to the author, a methodological reorganization of psychoanalysis should be attempted  (discarding the usual settings, overcoming mistrust for interdisciplinary dialogue) in order to deal with the reality of organizational elements.

The article by Musillo et al. explores a sensitive matter such as the relationship between a Therapeutic container (a Community) and a very run down social context (neighborhood). It explains how the authors strived to bring the Therapeutic Community into its surroundings in order to overcome the obstacles, fears and stigma related to mental suffering. Thus, the centre becomes a resource for the community of the particular neighborhood in question and a more livable and friendly place for patients. This mutual exchange also ensures that the operator can no longer hide behind his role but becomes a sort of social mediator between the inside and the outside.

Gold reflects on the destructiveness and creativity present in individuals, groups and in the institution and invites us to overcome a paranoid-schizoid position which leads us to believe that all bad things should be avoided and fought. The author refers  to a view of death instinct in its everyday and civilized manifestations, not as original sin, but as part of an inevitable biological and psychological evolutionary process. His invitation is therefore, to confront the aggression and destructiveness that patients frequently offload onto care givers and institutions and try to go beyond and let it wash over them.

Finally, the fourth subject matter focuses on the treatment of mental suffering

De Tomas’ contribution illustrates a peculiar outside the (institutional) walls clinical activity known as mountain therapy. Taking the treatment of psychiatric disorders away from the typical institutional context is a considerable challenge which places the patient and the operator in a joint position and forces them to confront  the difficulties of movement and physical and emotional proximity. Thanks to the active and encouraging presence of operators however, patients experience the outdoor world (which normally procures feelings of anguish and persecution) in a more relaxed manner and are able to tolerate if not overcome their feelings. This kind of context leaves operators in a more vulnerable position compared to the more classic setting, but can be a unique opportunity if they can overlook their own fears and proceed with acceptance and tolerance.

The paper by Bello et al. puts forth the perspective of a psychiatric ward where patients are often conducted against their own will either because they refuse treatment or because their suffering cannot be managed elsewhere. The authors explain the complex and vital institutional organization and show us how they organize and implement group therapy; namely, placing the patient at the center of their decisions and actions. Their group intervention aims to become a point of reference not only for patients but for all the staff present on the ward too.

The work by Sammartano and Di Leone allows us a direct glance into group psychotherapy for severe psychiatric out-patients. The authors focus their description on the processes of fixed-term group psychotherapy sessions and on the various organizational dynamics of a Mental Health Center. They analyze exactly what happens in the relationship between operators, during the submissions for group psychotherapy and in the various institutional steps. Finally, they  also take into consideration difficulties and resistances expressed by patients when asked to move from a reassuring and privileged one-to-one psychotherapy to group therapy.

The article written by Godfrey and Smith is somewhat along the same lines as they describe their work in a psychotherapy department provided by the British National Health Service (NHS). Bearing in mind Bions’ thought and the Tavistock Institute Group Relations approach, the authors examine how the many correlative services can be slotted together, acting like a jigsaw of provision, and consider their impact upon group psychotherapy. The description of a clinical case exhaustively exemplifies their logic.

From another theoretical point of view, the Lacanian one, Gale addresses his attention to the dynamics of group therapy in an English Therapeutic Community. Assuming that the mental structure is formed in the early years of life and that it cannot be changed and that symptoms represent the way certain people try to deal with their own lives, the Therapeutic Community provides people with psychotic disorders the possibility to reach a stabilization through the identification with a role in the Community itself (such as a cook for example). Operators, albeit maintaining an analytical position and avoiding a hierarchical role should try to accompany  and support patients through their suffering.

Hinshelwood and Mingarelli in their article, bring their attention to the adolescent world and to Therapeutic Communities for troubled teens. Adolescence, with its evolutionary transition characteristics and its rituals, usually represents a challenge for parents  and adults in general. Such a challenge can become disruptive when it is expressed through thoughts and behaviors that require therapeutic intervention. The authors help us to think about the risks of anti-therapeutic behaviors that a single or a group of educators in a Therapeutic Community can put in place.

Finally, we would like to add that this edition is the result of the creativity and initiative of  Stefania Marinelli. She entrusted it to us after meeting one of the curators during a lecture he conducted at her university course. We would like to give our most sincere thanks to her and to all our colleagues and friends who have made it possible.

References

Bertini, M. (2012). Psicologia della Salute. Milano: Raffaello Cortina Editore.

Fava, E., Masserini C., Efficacia delle psicoterapie nel servizio pubblico. Milano: Franco Angeli, 2002.

Patalano, R. Istituzioni e servizi. Un’introduzione storico-critica. In Neri, C., Patalano, R., Salemme P. (a cura di). Fare gruppo nelle istituzioni. Milano: Franco Angeli, 2014.

Yalom, I. D., Leszcz, M. The Theory and Practice of Group Psychotherapy (5th edition). New York: Basic Books, 2005.

                 Translated by Debra Mandatori

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