formación del terapeuta grupal

7/25/2019 Formacin Del Terapeuta Grupal

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Vol. 2, nm. 3 - Agosto 2003

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

TRAINING TO BE A GROUP THERAPIST

os Guimn

RESUMEN

La formacin tradicional para los terapeutas grupales se basaba en exponerles al trpode clsico deexperiencioas de formacin en toda psicoterapia : una experiencia personal en psicoterapia degrupo ; un programa de formacin terica y la supervisin.

En cuanto a la realizacin de una psicoterapia individual personal, recomendada por la mayora delos programas, un cierto nmero de formadores de psicoterapia grupal -entre ellos los que tienenuna orientacin grupal analtica- consideran que una experiencia individual puede ser negativa puede

ser negativa para la formacin de un psicoterapeuta de grupo porque podra favorecer lasresistencias. Adicionalmente se recomienda que los candidatos tengan una buena experiencia clnicaantes de comenzar una formacin en psicoterapia de grupo., parte de la formacin.

Adems de las supervisiones clsicas, en psicoterapia de grupo es til la observacin (mediante laparticipacin en un grupo como observador-transcriptor, o el estudio de sesiones grabadas envdeo). . La coterapia como medio de formacin en psicoterapia de grup esta modalidad teraputicaposee un valor particular en la formacin de los psicoterapeutas. A medida que se desarroll enEuropa la enseanza del anlisis grupal (Reik, 1993), los organismos de formacin se dirigieron alInstitute of Group Analysis de Londres para pedir conductores para esta experiencia. Como elconductor no poda, por supuesto, desplazarse cada semana, haba que considerar otros formatos.Se haca necesario efectuar cambios drsticos en las estructuras temporales del grupo: las sesionessemanales fueron sustituidas por sesiones en bloque, en general cuatro al da durante cuatro o cincodas, repetidas a intervalos de hasta seis meses. Despus de ms de veinte aos de experiencia, laopinin compartida por los conductores de estos grupos, es que este formato es muy eficaz. Lasobservaciones de los analistas de grupo son similares. Los grupos en bloques presentan mscohesin, un proceso grupal ms vivo y una capacidad mayor de los miembros del grupo de ponerseen contacto y de expresar emociones intensas. Adems, se produce una transferencia ms rpida(debido al "insular effect") y los conflictos pre-edpicos son reactivados ms fcilmente.

La experiencia ms sorprendente en este modelo es la facilidad con la cual los grandes intervaloshan sido tolerados por los miembros del grupo. Esa facilidad parece deberse al hecho de que losmiembros del grupo eran personas en formacin y no enfermos. La mayora de los profesionaleshaban seguido ya algn tipo de terapia, haban sido previamente seleccionados y estaban altamentemotivados. Algunos estaban simultneamente en terapia individual y en la experiencia grupaldurante el perodo en que dur sta.

Un gran nmero de experiencias en bloques han sido realizadas en el Institute of Group Analysis deLondres y diversos cursos de entrenamiento en bloques se organizaron en Europa con su

colaboracin. Surgieron fuertes discusiones en el Institute of Group Analysis, que empujaron aMalcom Pines a dar el ttulo "to block or not to block, that is the question" a una conferencia que dioen Wetzinkon (Pines, 1976).

Este tipo de formato engendra cierta estimulacin psquica y una mayor idealizacin del conductor.Tambin se ha sealado que los cambios de roles, propios a estas experiencias, facilitan el "egotraining in action", lo que a su vez favorece un efecto teraputico ms intenso. A la crtica hecha porciertos autores de que este formato no asegura una contencin suficiente, los autores favorables alas experiencias secuenciales contestan que cada grupo en un seminario secuencial es contenido enun bloque y el bloque en un curso; que las instituciones que organizan los programas tienen unalarga historia y que las fronteras estn representadas por los organizadores, lo que facilita unaidentificacin simblica. En efecto, al margen del valor simblico de la institucin, el hecho es que eneste tpo de experiencia los conductores del grupo por lo general han trabajado juntos durantemucho tiempo, lo que genera una sensacin de apoyo y de seguridad que permiten una regresin

temporal. Por otra parte se subraya que la duracin de las experiencias no es tan corta ya que seproduce un fenmeno de perlaboracin (Kas).

Se han subrayado con todo ciertos peligros potenciales para el enfermo en el formato en bloque. Enefecto, la regla de abstinencia no puede ser cumplida; puede haber incidentes de fronteras; la


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regresin es discutible y la transferencia negativa resulta difcil de expresar con motivo de laausencia prolongada del analista que hay que conservar indemne. Se han propuesto ciertasprecauciones para evitar estos peligros: ver a los nuevos miembros anteriormente durante algunassemanas; facilitar el desarrollo de un concepto de "grupo como una totalidad" y proponer, en ciertoscasos, una terapia individual o grupal simultnea.

Otras opiniones desfavorables subrayan dificultades tales como la tendencia excesiva a laidealizacin y a la dependencia, favorecida en ese contexto, Con el fin de establecer un "milieu

teraputico" con orientacin de "comunidad teraputica", en las unidades de cuidados en las quehemos trabajado (Bilbao, Barcelona y Ginebra), desarrollamos durante los ltimos veinticinco aosun programa en "bloques" para la enseanza interdisciplinar (psiquiatras, enfermeros ypsicosociales). Nuestra objetivo era ofrecer una experiencia de participacin personal no slo a ungrupo, sino tambin a una "comunidad didctica" que permita vivir ciertas experiencias propias a lascomunidades teraputicas. Los cursos se desarrollan a lo largo de uno, dos o tres aos medianteseminarios.

En el plano clnico y en el plano personal, el paralelismo entre el medio didctico creado entre losestudiantes que han seguido el curso y el "medio teraputico" que se desarrolla en las unidades dehospitalizacin breve gestionadas como lo hemos descrito anteriormente, es indudable. Estasimilitud podra, en parte, provenir del hecho de que el personal teraputico y didctico formabaparte del mismo equipo en las dos experiencias: adems, se desarrollaron de manera sncrnica.

SUMMARY

This article reviews the methods used for the training of group therapists during the last decades.Inall group psychotherapy training centres the candidate is expected to undertake a a personal groupexperience, and in some centres a training in individual psychotherapy is required. Observation andco therapy are considered to be one of the most effective methods for teaching group psychotherapyand it features in most programmes . Another essential training activity consists in psychotherapygroup 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 therapydeveloped 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 theneed for a certain number of minimal theoretical and practical imperatives in the training of futuretherapists. The range and quantity of techniques proposed in recent years complicates the task oworking out a training syllabus to cover all of these. Regardless of the approach, however, mostgroup processes present the same features. A psychoanalytical orientation is not an absoluterequirement 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 fortherapists with such orientations, analytically oriented programmes are the most valid to acquirebasic training.

PERSONAL QUALITIES AND THEORETICAL PREPARATION REQUIRED OF THEPSYCHOTHERAPIST

Professional qualifications

Our view is that only candidates who are members of the traditional professions in the field omental health should be admitted for training i.e. psychiatrists, psychologists, social workers andpsychiatric nurses. We consider it ill-advised and even dangerous to train people in psychotherapywho 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 towork with groups: spontaneity, which over time one learns to use as a technical means ; selconfidence and confidence in others ; the ability to act, sometimes allowing one's inner self to


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appear ; the fortress of the ego, capable nonetheless of changing roles depending on the patients, asense of humour, to avoid infantilising the group unnecessarily, and allowing patients to see thetherapist 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 reactspontaneously to its effect ; the ability to accept one's technical mistakes ; the ability to act not onlyas 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 exemptfrom conflict (activity-passivity, masculinity-femininity, enthusiasm-restraint, masochism-sadism,tolerance-intolerance, patience-impatience, etc.) which may not appear in individual analysis. Thesecharacteristics may be of no importance in individual analysis, but in group work, they may prove tobe crucial. The supervising psychotherapist whose group contains a future group psychotherapistmay try to help him/her modify his/her attitudes or in some cases, advise against continuingtraining.

Theoretical training course

Candidates should undertake some courses of theoretical training, the syllabus comprising not onlythe actual techniques of group psychotherapy, but also the science of normal and pathologicalbehaviour. The modalities of these theoretical courses vary according to the training centres. Insome, 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 inindividual psychotherapy. On the other hand, a number of group psychotherapy supervisors -particularly those with group analytical orientation - consider individual experience as potentiallynegative in training as a group psychotherapist, as it encourages resistance. Indeed, the sameprofessionals had the most difficulty accepting the idea that the group has therapeutic potentialwhich is beyond the scope of individual psychoanalysis. As most of these therapists had extensiveexperience 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 inpsychotherapy. No therapist can work with too many different models and in any case, the fact olearning a technique which requires transforming the conceptual model demands a change ocoordinates which is very difficult to achieve.

Whatever the case, even allowing for this relative deformation, in most group psychotherapy trainingcentres the candidate is expected to undertake training in individual psychotherapy The AGPArequires those with university qualifications in medicine, psychology or social work to have at leasttwo year's experience in their respective professions. Thus this organisation requires candidates tohave completed a certain number of hours of supervised individual psychotherapy before starting thetraining course and a total of four hundred hours before finishing the course. Personal experience inindividual 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 theexperience of a therapeutic group to be necessary ; ten years later, in a similar survey all thepsychotherapists polled agreed with the conditions demanded by the AGPA, in considering it asentirely advantageous, and no one doubts its benefits today. Most authors see no difficulties raisedby experiences of this kind, considering the group process as in no way precipitating or exacerbatingthe candidates' emotional problems. However, some authors have reported a number of risks incarrying out group psychotherapy with candidates who work together in everyday life, indicating thepresence 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 tothe appearance among some group members of " decompensation which is so great that theirbehaviour 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 asupervision group, and suggest that arrangements be made so that the candidates experience thesecond 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 areassuch as relationships in the couple, the family, and in relation to authority, providing valuable


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experience of the group process. Even so, in addition to their intrinsic difficulties, groups of this sortcan 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 asobserver-recorder, or by studying sessions recorded onto video. Observation, in its variousmodalities, 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 forrelatively short periods of time in group sessions, as this may disrupt their usual procedure. In theirview this risk disappears if the presence of the observers or observer -recorders continues for acertain length of time. The variable introduced into a group by being observed through a mirror orby video recording is understandable. If this were merely used as a teaching experience, the ethicalimplications would need to be examined , considering the interferences which certainly occur in thetherapeutic process. Nevertheless many authors stress the potential benefits of observation and thetechnical study of these recordings

Our own experience has been that given the relatively limited number of candidates in training, theirparticipation 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 itsuniversally recognised advantages , this therapeutic modality is of particular value in trainingtherapists. Apprenticeship of this kind gives the best results when an experienced therapist acts ascotherapist to a novice therapist, enabling the latter to gain personal experience without anintermediary and to have his/her task supervised directly. Another modality [6] is used by certainauthors, whereby cotherapy is carried out by two residents having undergone similar preparation. Amore experienced therapist supervises the task, being present at the session, observing it on videoor listening to an account of the session. Rosembaum calls attention to the possible dangers ocotherapy. As group psychotherapy becomes increasingly common in psychiatric assistance, hewrites, so administrators are increasingly favourable to rapid group therapy training, andincreasingly use cotherapy as the most effective method. In such cases, administrators must clearlydefine 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 tocontent him/herself with "sitting at the master's feet". Or else, he adds, what is even worse, after acertain 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 ocotherapy, both therapists need to have similar clinical experience ; in this way the therapists workwith one another, rather than one for the other. If this is not the case, he says, the quality otreatment diminishes, and thus from the patient standpoint, this particular type of technique shouldbe 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 doneindividually or as a group; the person supervising receiving the information concerning the sessioneither verbally through the therapist's report, by observation through a mirror, or by watching asession 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 (Guimn, 2001), to improve their performancein conducting groups which meet weekly or once a fortnight for an hour and a half, we introduced ainnovative seminar in which those conducting the groups could undergo supervision of their work, ingroups bellow.

Team supervision ("The process group ").

A process group is generally held to be a training group for students or a group experience aimed atimproving staff relationships. Process groups are also formed to teach group dynamics and conceptssuch as norms, roles and authority. But when such groups are introduced into institutions, their mainaim is usually to modify the way the staff operates. Authors who write about process groups supportthe 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 leadershiptechniques in order to harmonise aspects of the process group, which differ from those of apsychotherapy group.


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Cohn (Cohn, 1994a) describes his experience in leading a training group of mental health workerswho would go on to lead groups of chronic patients. The elements to focus on using objectrelationship methodology, include the effects of projective identification on different continentenvironments. Understanding and using the counter-transfer responses of the course leader helps toreveal the unconscious objectives of chronic patients in perpetuating their internal and interpersonallives through their effect on the group leaders working with them and on each of them. This insightcan 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 andtrainees has become increasingly unpopular as a resource , while the need for such groups hasincreased. Cohn (Cohn, 1994b) believes that the reason why process groups are not used moreoften is a combination of a failure to understand the nature of these groups, and the inability todistinguish between process groups and traditional psychotherapy groups. The author defines theprocess group in the institutional setting as " a group which is set up to use its own process in theaim of studying and developing a person in his professional role within the institutional or clinicalsetting ". According to this definition the person and the professional role are understood assomewhat different, but as experiences and aspects of identity which are equally authentic. This ideastands in opposition to the more traditional point of view whereby " the real person " keeps histruest 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 aresomewhat different, each person's professional role is an authentic part of his identity which needsto 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 operatesprofessionally, 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 fromcontact with the patient and the impact of the system of treatment identified for an individual , andthe 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 lessinclined to develop process groups due of the lack of qualified leaders and disquiet about violatingethics such as double relationships (personal communications).

Many authors would say that the main aims of process groups and psychotherapy groups differ inthe 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, theauthor's experience is that the individual always joins a process groups in the expectation, hope andfear 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 anintense 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 programmeis essential for the programme to function well. The activity is systematically included in oursyllabuses, as a blocked unit and in the integrated seminars on clinical group supervision. Butanother form of experience supervision has proved to be particularly useful in our trainingprogrammes.

This involves introducing different qualified observers for each seminar, who are successivelyintroduced into the different activities of each unit and participate later in intervision meetings. Thefrontiersman, as this type of participant is referred to in London, is a " senior " person, outside thetraining team, who at the end of a block of training draws up a report describing how he/she saw theexperience.

TRAINING COURSES IN GROUP PSYCHOTHERAPY

The partial aspects reviewed in the preceding paragraphs were taken into account when designingthe training syllabuses in the various centres. Courses vary in the range of subjects offered. Theyalso vary in terms of the importance placed on participating in a psychotherapy group, the point atwhich 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 individualpsychotherapy.. 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 individualpsychoanalysis. Some Associations have laid down their requirements for group psychotherapycertification. It would seem to be quite reasonable to suggest that a future psychiatrist hasexperience in the area of awareness groups or training groups, to observe groups, participate incertain activities as cotherapist, to have had responsibility at some stage of leading a psychotherapy


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group under the control of a supervisor and to have a certain theoretical grounding all of whichauthorises 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 favourof extending psychotherapy to professionals who do not work in the field of mental health. It is clearthat some people have particular personal qualities in the area of communication; despite this, wethink that it is only possible to begin training in psychotherapy after having undergone thispreparation. But this in no way prevents us from proposing awareness programmes open toparticipants from awareness groups, members of the community who are particularly involved with apopulation exposed to mental illness: teachers, members of the clergy, etc.

On the other hand far more demanding programmes exist for the training of group psychotherapistswith full psychoanalytical orientation. (the Postgraduate Center in New York). In this case, theexperience of analytical group psychotherapy comes after individual psychoanalysis, thus avoidingthe simultaneity of the two techniques which, for many authors and as reflected by our ownexperience, gives rise to difficulties of transfer, unless both treatments are undertaken with thesame therapist. In his last years, Foulkes (Foulkes, 1975) was said to consider it unnecessary for thefuture analytical group therapist to undertake individual psychoanalysis and suggested that, on thecontrary, 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 individualpsychoanalysis.

As described earlier, training in the form of " block sessions " has become widely developed inEurope over recent years, through the GAS and EGATIN, as well as in response to the participationof analysts from the London group in the training courses in other European countries. The viewspublished 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 theresistance 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 isone 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 theUniversity of the Basque Country, we set up training in group psychotherapy, oriented to analysingthe individual within the group, and developed with the help of Dr. Ylla, who as part of thedepartmental team, travelled up to Bilbao from Madrid each week. He was later seconded for twoyears by Dr. Carlos Gonzalez from Madrid. Most of the psychiatrists who participated in this trainingexperience had individual psychoanalytical training. Mandated to set up a plan to reorganisepsychiatric care in the Basque country, the author set up a training programme to guarantee fullerimpact on the Institutions. Our consultant, Dr. Campos from Barcelona, helped to establish contactswith 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 aweekly basis or in the form of " block sessions ".

In (Guimn, 1986, 1989; Guimn et al., 1985) the aim of offering mental health professionals theopportunity of examining their interpersonal relationships, a general course devoted to Group Workwas 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 theAutonomous Basque Community participated in this first course. The course is run according to twomodalities: either as an Introduction to Group Work, which is scheduled every Friday afternoon, astwo one and a half hour sessions over 32 weeks, or else as a series of seminars in which eachseminar offers an experience of 18 hours covering the last three days of the week, 4 to 8 times ayear. The course has since been run every year on a weekly basis in Bilbao, followed by a full threeyear training course.

We then incorporated a number of techniques from non analytical theoretical models with directsupervision, as used by Pacho O'Donnel, (an Argentinean psychodramatist), Olga Silberstein (familytherapist 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'sdegree from the University of Deusto. Training has since been extended to Barcelona and Geneva.

The course in Barcelona


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Thanks to the impetus provided by Dr.Sunyer activities identical to those described above were setup in Barcelona. The course is run as a series of six intensive seminars for training as a " Specialistin 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. Over1,000 professionals have participated in training in Spain.

The course in Geneva

In 1994, after meetings between with some Geneva group therapists we decided (Guimn, 1998) toset up an introductory course at the Department of Psychiatry at the University of Geneva during theacademic year 94/95.Example 80 . To establish a " therapeutic setting " with a " therapeuticcommunity " orientation, we developed a "block" programme for interdisciplinary training(psychiatrists, nurses et psychosocial workers) in the care units of our Department. Our aim was tooffer 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 stafincluded all those cited above, three consultants from the OMIE Foundation and a number of othercollaborators from the Department of Psychiatry. Their respective roles (group leader, observer,group work supervisor, reading group coordinator) were attributed after group meetings. DeustoUniversity 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 worksupervision.

The experience has been renewed each year, under the coordination of A. Fredenrich and S. Tissotand 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 Genevaexperience. The psychiatrists who participate in training, work in the canton of Geneva for the mostpart whereas for the other health professionals a higher percentage come from other cantons. Thepsychiatrists work mainly in the intrahospital services, but also in ambulatory psychiatry in the publicsector. A few come from private practice, geriatric psychiatry, mental development services andsubstance abuse units. As regards the duration of training, most participated for a year althoughsome 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. GonzalezPinto and in Geneva by V. Vucetic. In the course of the first study, the evolution of certainsymptomalogical variables was studied in relation to SCL-90, social adjustment, SAS, attitudes tomental 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 rarelysignificant, which may be explained by the low level of sensitivity of these instruments in apopulation of people " with no psychiatric pathology ". During the 1999 Geneva training course,participants were presented with a battery of self evaluation questionnaires, designed to evaluatecertain aspects of the group process and the changes perceived in both professional and personalterms. The evaluation was carried out in such a way that the anonymity of each participant wasrespected. As the results are still being analysed, we can only present the preliminary results, basedon evaluations made at the beginning and end of the course, as regards the satisfactoriness of theperceived 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 6small groups of 11 to 12. The level of non-response to questionnaires varied from 7.4% to 14.7% atthe beginning and end of the course, respectively. Practically all the participants at the start of thecourse expressed a certain level of expectation in relation to the dual aspect of training, at bothprofessional and personal levels. A high degree of satisfaction was expressed in relation to the lastseminar as a whole. Only two participants declared a certain degree of dissatisfaction. The level osatisfaction is particularly high in the case of the small experiential groups. Participants placed lessvalue on the teaching modules (supervision and theory groups). The satisfaction expressed duringthe first seminar can virtually be superimposed. At the end of the course we asked participants toassess the effects they perceived at the outcome of training as a whole. Practically all those whoreplied recognised having derived certain benefits both in professional and personal terms(Guimn etal., 1988). Insight into group dynamics and self awareness are the most common elements listed ashaving improved to a considerable extent. Changes were perceived more in terms of understandingthan in improving therapeutic practice. A comparison between the doctors' group and that composedof 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 trainingwas a positive subjective experience for almost all participants. The emotional impact of groupcohesion, common for this kind of intensive seminar, is likely to exert an influence on the degree osatisfaction and the evaluation of effects which prove to be very high. Participants confirm the


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subjective importance of apprenticeship through experience, placing particularly high value on theexperiential modules (small groups) as compared with the pure teaching modules (Guimn 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 termsof developing emotional insight (" therapeutic ", " self awareness ") is both different andcomplementary to the experience of individual therapy. Training of this kind involves the interlinkingof personal and professional aspects, as was evident both in the expectations and in the perceivedeffects expressed by the participants. Our impression is that the experiences in Bilbao, as inBarcelona and Geneva have brought about greater integration among health professionals in thevarious teams, by providing them with a meeting place and a common theoretical frame oreference, which is highly useful to all.

Differences were observed between the weekly courses and the intensive seminars. A number oquestions and fears attended the launching of block sessions, but the experience gained over theyears has shown that, despite certain disadvantages with this training modality, there are someextremely encouraging advantages.

Theoretical course

The theoretical course is at a clear disadvantage in the intensive seminars held at the end of theweek, for several reasons: there are far fewer lectures and seminars; in an experience of this kindwhich demands different forms of energy, intellectual receptivity is distinctly lower in terms oattention, memory, capacity to associate etc.; reading is not as effective if it is tackled indiscontinuous phases, with long intervening gaps, and by skimming the texts, as when time is setaside regularly.

Small group experiences

In regard to the awareness experiences, it is true that the university is not the most conducivesetting in which to offer professionals experiences involving the personal processes which lead to theemotional insight so essential to our clinical activities. But as time passed we were surprised todiscover a veritable process (including emotional development) taking place among the students inBarcelona who participated in the block sessions. There are several possible explanations for thisphenomenon: the experience is far more intense, defences are highly activated and exposed toruptures; these cannot be restructured from one group to the next because of the proximity in timeand 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 theexperience based on work throughout the week, after having approached the initial difficulties at theoutset, several months go by before envisaging the end, thus allowing the group to slow down theprocess and to easily develop the fantasy of a long duration; there is no need for haste in developingthe process, there are very long silences and a more marked tendency to function in a defensive andrationalising manner; in the intensive experience, there is no time to get bored, it takes less time towarm up and immobility is impossible as, before it can set in, the end is already in view, like amicro-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 adjacenteffects: travelling, staying in a foreign city etc. Logically, this permanent conflict is what essentiallyenables understanding, finding solutions and changing; the participants in the intensive experienceare more aware of the emotional and economic investment; it is important to take into account thatbesides the admission fees there are costs for travel, accommodation; they also have to give upSaturdays 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 ownexperience leads me to think that they are not just on a par, but can even be more useful ascorrective experiences for professionals in the field of Mental Health, who all possess extraordinarilystrong 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 placeonce during each of the four days of each seminar. To avoid this space being contaminated by theemotional atmosphere generated by the " experiential " groups, we tried to change the compositionof the groups by introducing members from other groups. But this solution proved too complicatedto organise and we decided to maintain the same composition for both types of group. To avoid theemotional contamination referred to, we advised supervisors to actively ask participants take turnspresenting the real group experiences they had had or intended to organise in the near future. Theaim 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 whichencourages emotional content rather than risk or practices, we observed that supervision sessionstended to be poor, with somewhat conventional content and little commitment from participants.


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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 inthe form of blocked sessions evolved in a more positive manner than those who participated insessions throughout the year, but this is due more to the high continent capacity of the " teachingsetting " which developed during the intensive courses than to the high emotional content. There isan 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 werealso run simultaneously. But one needs to look beyond superficial remarks; a deeper analysis mightinvolve applying more or less objective scales for measuring atmospheres, such as those developedby 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 thecontext of training blocks has considerable limitations, in the context of institution supervisioncarried out at Belle-Ide in Geneva, the experience was completely different. A large number ogroups are developing in the different units at Psychiatry Clinic I with different theoreticalorientations, run by various mental health professionals. Since the beginning of 1998, supervisionseminars have been organised for these group activities. the sessions start on Wednesday afternoonand develop in four parts. In the first part lasting one hour, the staff in charge of the different unitsmeet with the clinic Director and the group activity coordinator (S. Ehrensperger) to discussdevelopments 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 madeto standardise and to some extent " manualise " the different activities so that they can beconsistently developed over time, despite the changes in group leaders. New groups are then formedin response to need. A theoretical session takes place for 75 minutes, involving a revision of thereference literature on the various group models, followed by discussion of the pros and cons andtheir feasibility of use in our clinic.

Supervision of the groups conducted in the various units by different therapists or leaders is carriedout in the form of a groups' group combining 5 to 8 group leaders under the coordination of asupervisor from outside the clinic and a co-supervisor. For an hour and a half, the different groupsare described and discussed by members. This sometimes entails presenting a new group for eachsession in turn. Other leaders prefer to let the group function through more free-floating discussionaround a particular line of thought.

At the end of the groups' group, the coordinators from each group meet for an hour in an inter-vision group where they discuss the contents of supervised groups, while respecting anonymity asfar as possible.

Supervision of the teams had been suggested as a part of the supervision seminars but was notsufficiently subscribed to. We therefore chose to carry out supervision in the care setting, for thesecond year (1999), at the point when the various teams change shift i.e. at 2 pm, the supervisormoving from one unit to another.

The supervision seminars have provided an overview of both the institution and the therapeuticteams. Our experience closely follows that of Frankel [25] who set up a training group for mentalhealth professionals who in turn conducted groups of patients. Basing his study on object-relatedtheoretical concepts, he looked at the effects of projective identification on various "containing"

environments. The fact of detecting the complicated game of mutual identification between theleader and the teaching group participants, improved understanding of the same phenomena withinthe care units.

Supervision of the therapeutic team

Systems of psychiatric care which are managed with a " community " orientation tend to providepatients with a series of " corrective emotional experiences ". The therapeutic team conceived as thepatient's " alter familia " is considered to be the main therapeutic agent of change. Thus the basictherapeutic 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 patientswho are seriously ill, psychotic transfer, through a game of projective identification and projective "counter-identification ", creates counter transfer in therapists, giving rise to multiple projectionswhich 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 ", whilemaintaining 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 leadsto 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


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need to be changed to form " good enough teams "(Guimon, 1985) capable (like Winnicott's goodenough mother) of coping with the needs of patients and avoid burdening patients with the team'sown 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 animaginary space or " illusion " (Winnicott, 1971) which in fact is the space for creativity andpsychoanalysis.

REFERENCES

Alonso, A., & Rutan, J. S. (1993). The experience of shame and the restoration of self-respect ingroup therapy. International Journal of Group Psychotherapy, 38, 3-14.

Battegay, R. (1976). Group psychology and group dynamics. In S. Krauss (Ed.), EncyclopedicHandbook of Medical Psychology. London: Butterworths.

Campos, J. (1998). Una historia de la AIPG: hechos y hallazgos. Barcelone: Grfiques MAES.

Cohn, B. R. (1994a). The process group in institutional settings: special techniques for anendangered species. International Journal Of Group Psychotherapy, 44(3), 333-347.

Cohn, B. R. (1994b). Recycling Yalom: using a system analysis to facilitate work in inpatient groups.Group Analysis, 27, 407-418.

Foulkes, S. H. (1954). Group-analytic observation as indicator for psychoanalytic treatment.International Journal of Group Psychotherapy, 35, 263-266.

Foulkes, S. H. (1975). Group-Analytic Psychotherapy: Method and Principles. London: Gordon &Breach.

Grotjahn, M. (1971). The qualities of the group therapist. In H. L. Kaplan & B. J. Sadock (Eds.),Comprehensive Group Psychotherapy (pp. 757-773). Baltimore: Williams and Wilkins.

Guimon, J. (1985). El equipo suficientemente bueno. Rev Asoc Esp Neuropsiquiatr, 5, 501-505.

Guimn, J. (1986). La formation du psychothrapeute de groupe, La formation en psychothrapie degroupe et psychodrame (pp. 59-77): Ed. Argot.

Guimn, J. (1989). Group Psychotherapy in Spain. Review of the International Group PsychotherapyAssociation.

Guimn, J. (1998). Thrapie groupale dynamique intensive et brve. Psychothrapies, 18(1), 15-21.

Guimn, J. (2001). Introduction aux thrapies de groupe. Paris: Masson.

Guimn, J., Ayerra, J. M., & al., e. (1985). La formacin en psicoterapia de grupo en Bilbao:descripcin de una experiencia de 11 aos. Revista de Psicologia General y Aplicada, 40(4), 811-820.

Guimn, J., Erehnsperger, S., Weber, B., Fredenrich, A., Vucetic, V., Zanello, A., Zinetti, A., &Maercker, A. (2000). Evaluacin de la psicoterapia grupal en la asistencia psiquitrica : la Batera "

Bel-Air ". Psiquis, 21(6), 277-287.

Guimn, J., Gonzalez-Pinto, A., Sanz, C., & Gonzalez-Ceinos, M. (1988). Efectos terapeuticos en unprograma de sensibilizacion grupal. Psiquis, 1, 11-28.

Guimon, J., Luna, D., Totorika, K., Diez, L., & Puertas, P. (1983). Group psychotherapy as a basictherapeutic resource in psychiatric community care from the general hospital. In J. J. Lopez-Ibor Jr &J. Saiz & J. M. Lopez-Ibor (Eds.), General Hospital Psychiatry (pp. 95-100). Amsterdam: ExcerptaMedica.

Guimon, J., Sunyer, M., Sanchez de Vega, J., & Trojaola, B. (1992). Group analysis and wardatmosphere. In F. P. Ferrero & A. E. Haynal & N. Sartorius (Eds.), Schizophrenia and affectivepsychoses. Nosology in contemporary psychiatry (pp. 157-166): John Libbey CIC.

Redlich, F. C., & Astrachan, B. (1969). Group dynamics training. American Journal of Psychiatry, 125(1501-1507).

Rogers, C. R. (1970). Carl Rogers on Encounter Groups. New York: Harper and Row.


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Sacks, M., & Carpenter, W. (1974). The pseudotherapeutic community: an examination oantitherapeutics forces of psychiatric units. Hospital Community Psyhiatry, 25(5), 315-318.

Sunyer, J. M. (1990). Evaluacion de la atmosfera en las Salas Psiquiatricas Espanolas. UniversidadAutonoma, Barcelona.

Winnicott, D. W. (1971). Playing and Reality. Londres: Tavistock.

ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516

CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (Espaa)Copyright 2002

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