day hospital and other halfway houses in which group psychotherapy
is the basic therapeutic instrument, are indispensable structures
for maintaining severe psychiatric patients in the community.
During the last 25 years, programmes of milieu therapy in a
certain number of short-stay units have been organised and a
pleasant and supportive atmosphere was created in the wards.
In traditional psychiatric hospitals a specific 'milieu' can
be created thru group programs playing a therapeutic role for
some particular patients.
The use of principles from the so-called milieu therapy, based
on the experiences of therapeutic communities organised into
inpatient units, day hospitals, halfway houses and sheltered
workshops, have improved the clinical prognosis and socio-occupational
adaptation of chronic schizophrenics
práctica psiquiátrica clásica tiene poco
valor para la Asistencia primaria. En cambio, el psicoanálisis
puede ser de gran ayuda para formar a los médicos generales
en técnicas psicoterapéuticas sencillas y sobre
todo para favorecer la capacidad de contención de los
médicos de cabecera y los pediatras. En Atención
Primaria se pueden aplicar también nuevas estrategias
asistenciales como psicoterapias breves y focales, entrevistas
de contención, entrevistas de elaboración de duelos
concretos, seguimientos psicológicos, los procesos de
flash psicoterapéutico. Hay técnicas mixtas con
referencia psicoanalítica utilizando elementos técnicos
conductistas, cognitivos conductuales o psicodinámicos:
protocolos para la enuresis funcional o para la autonomización
progresiva o para las técnicas de relajación.
urgencias psiquiátricas deben estar incluidas en las
urgencias de los hospitales generales y se ha demostrado que
la existencia de camas de estancia muy breve para la observación
y el tratamiento agudo (entre 24 y 72 horas) de parte de estos
pacientes puede evitar numerosas hospitalizaciones psiquiátricas.
En este sentido, en el futuro, aumentará el número
de servicios de urgencias hospitalarias que funcionen como verdaderos
"centros de crisis", con personal específico
y bien formado.
"intervención en los momentos de crisis" (crisis
intervention) idealmente exige detectar precozmente a los sujetos
susceptibles de descompensarse, para establecer a su alrededor
una verdadera red humana que les ayude a superarla.
La Hospitalización psiquiátrica en el Hospital
General ha contribuido a atenuar la estigmatización de
los pacientes psiquiátricos y de los profesionales de
la Salud mental y al desarrollo de la Psiquiatría biológica
. Por otro lado, la entrada en un hospital general presenta
también para el enfermo la ventaja de ser menos traumática
que una hospitalización en un centro psiquiátrico
monográfico. Además, las hospitalizaciones en
un hospital general tienden a ser más cortas que las
estancias en un hospital psiquiátrico tradicional, con
independencia del tipo de paciente tratado, y se sabe que los
pacientes hospitalizados por estancias breves presentan mejor
evolución ulterior que aquellos que son hospitalizados
por períodos largos.
En cambio, se ha subrayado que este marco terapéutico
favorece en exceso el enfoque biologista en detrimento del modelo
de intervención relacional. Además, los profesionales
que trabajan en los hospitales generales tienden a desarrollar
cierta actitud omnipotente, persuadidos de que un tratamiento
biológico a corto plazo es extremadamente eficaz, cuando,
en realidad, lo que ocurre es que, con demasiada frecuencia,
no son testigos de la evolución crónica de estos
pacientes en el exterior.
Aunque numerosos países, sobre todo occidentales, hayan
realizado enormes esfuerzos tendientes a la desinstitucionalización
de los enfermos y a su retorno a la comunidad, gran parte de
las camas de los hospitales psiquiátricos en todo el
mundo siguen estando ocupadas en permanencia por pacientes que
presentan más bien discapacidades sociales que enfermedades
el futuro, gran parte de estas personas deberían poder
vivir en establecimientos financiados y dotados de manera conveniente
por los organismos sociales más que por los organismos
de salud. Pero, a pesar de esto, siempre habrá cierto
número de pacientes, aquejados sobre todo de psicosis
funcionales crónicas, de síndromes demenciales,
etc., para quienes serán necesarias estancias prolongadas
en hospitales psiquiátricos, que tendrán entonces
que ser reajustados para poder ofrecer actividades terapéuticas
eficaces. Si no, habrá que crear nuevas instituciones
para responder a estas necesidades .
cuanto a la hospitalización parcial permite un puente
entre la comunidad y la hospitalización total. Sin embargo,
el porcentaje de pacientes admitidos para hospitalización
que podrían alternativamente ir a un hospital de día
no es mayor del 30-40% por lo que son deseables unidades integradas
que ofrezcan una u otra alternativas.
En el futuro se realizarán algunos programas como alternativa
a la hospitalización en casos de descompensaciones agudas
en forma de tratamientos de crisis de uno o dos meses.
En cualquier caso, la desinstitucionalización de los
pacientes psiquiátricos sólo tiene éxito
cuando existen los recursos comunitarios adecuados, puesto que,
en caso contrario, puede ser contraproducente por provocar,
a la larga, una resistencia en la población a la aceptación
de estos enfermos en su seno.
grupal, instituciones de salud mental
Therapy, mental Health institutions
remedicalisation of the psychiatric profession has provided
new specialists with solid training in neurobiology, and given
them access to the new substances developed. While this biological
approach has led to considerable advances in psychiatry over
the last 20 years, it has also substantially weakened the relational
approaches, particularly the psychoanalytical.
With the changes that have taken place in psychiatric practice
in terms of cost containment ( managed care) primary mental
health services, emergency psychiatry, crisis intervention and
consultation-liaison psychiatry take on added importance. Alternatives
to psychiatric institutionalisation such as short stay units
in general hospitals, day centres and residential units are
developed. Different types of group interventions play a primordial
role in the therapeutic armamentarium of these programs .
CARE, EMERGENCIES AND CRISES
is common knowledge that most people presenting mild or moderate
psychiatric disorders are seen by general practitioners who,
while they fulfil a fundamental role, often fail to recognise
these problems. ome emergency services are on the increase in
big cities, and have already proved to be successful. Crisis
centers as alternatives to hospitalisation have been successfully
developed in some countries (Alanen et al., 2000) and a Cochrane
Review on the effect of these interventions for people with
severe mental illnesses (Joy et al., 2002) concludes that home
care crisis treatment, coupled with an ongoing home care package,
'is a viable and acceptable way of treating people with serious
mental illnesses'. In all these activities group therapy plays
an important role thru the provision of an adequate containment.
((Bion, 1959; Winnicott, 1971) is defined as the ability to
be faced with anxiety, to comprehend it and project it in a
fashion to rob it of its negative power. There is internal containment
(dealing with one's own object representations), microsocial
containment (the mother, the original family unit, the analyst)
and external containment (social networks). The formal systems
(health care workers, family doctors ) and several informal
groups ( social networks, sporting clubs, the clergy) can serve
as containers until they are overcome by pathology or by social
discord arising from the disorder and mental h health professionals
are called upon to act. Some group activities (Balint's groups,
"process" groups, etc.) can, in any case, favor the
containment element provided by family doctors, pediatricians,
APS nurses, mental health teams and non-professional centers
in the population.
OUTPATIENT CARE AND HALF WAY FACILITIES
of severe psychiatric patients in community-oriented settings
has been the most important contemporary development in mental
health planning. Sectorisation, which emerged from the French
post-war 'sectorisation' policy and American psychiatry in the
1960s, has rendered a valuable service to psychiatric care by
allowing the deinstitutionalisation of many psychiatric patients,
and by avoiding hospitalisation for many new cases. Sectorisation
has made possible the continuity of care between the hospital
and non-hospital services, particularly in catchment areas of
under 200,000 inhabitants, where there are smaller-sized teams
and more fluid communication.
that the optimism born 30 years ago from the efficacy of medication
has diminished, much of the general public considers the deinstitutionalisation
of severe mental patients as a threat to the security and the
well-being of the population, and this increases opposition
to their departure from hospitals even further. The day hospital
and other halfway houses are thus indispensable structures for
maintaining these patients in the community. In a day hospital,
group psychotherapy is the basic therapeutic instrument. Some
day centres treat patients from the very first manifestations
of their disorder through to complete remission, whereas others
focus on rehabilitation of patients following treatment in hospital.
a day hospital we have created in Geneva (J Guimón, 2001)
both types of patients are accepted, in different but complementary
programmes. The first therapeutic function of this day hospital
is to offer the patient a setting, which allows him or her to
shore up internal checks and balances, and to receive psychiatric
attention. A second function is to furnish emotional support,
so that the patient's self-esteem is reinforced. The group dynamic
seeks to create an atmosphere in which 'pathogens and pathogenic
ties' can surface, and then be addressed and modified.
In a day hospital we have created in Geneva (J Guimón,
2001) both types of patients are accepted, in different but
complementary programmes. The first therapeutic function of
this day hospital is to offer the patient a setting, which allows
him or her to shore up internal checks and balances, and to
receive psychiatric attention. A second function is to furnish
emotional support, so that the patient's self-esteem is reinforced.
The group dynamic seeks to create an atmosphere in which 'pathogens
and pathogenic ties' can surface, and then be addressed and
The programme includes the prescription and control of medication,
the organisation of psychotherapeutic activities based on the
comprehension of the dynamic factors that intervened in triggering
the illness, and the techniques which aim to combat the symptoms
characteristic of schizophrenic deterioration: difficulties
of an intellectual type, apathy and libidinal objectal withdrawal,
isolation in the patient's introverted world. The days begin
with a coffee break and include lunch and three small groups
a day, which comprise verbal psychotherapy (dynamic and cognitive)
twice a week as well as group activities in the form of discussion
(free, on medication, on social information, on daily life)
and various activities (artistic expression, theatre and video,
body movement, cooking, games). In addition, there are two median
groups: general assembly (which unites all caregivers and patients
once a week) and the multifamily group (which unites all patients,
their families and caregivers) once a month.
the therapeutic team, in varying percentages, can be found psychiatrists,
psychologists, social workers, occupational therapists, and
psychomotor therapists. Professionals have in general received
training in individual and group psychoanalysis, and possess
a certain amount of knowledge regarding family therapy and social
networks. Communication between therapists is in the form of
meetings of working groups.
This kind of program have been shown efficacious. A recent Cochrane
Review (Marshall et al., 2002)(Marshall et al., 2002) compared
day hospital versus outpatient care for severe psychiatric disorders,
and found that there was evidence from one trial suggesting
that day treatment programmes were superior to continuing outpatient
care in terms of improving psychiatric symptoms. On the contrary,
another Cochrane review (Catty et al., 2002) did not find any
randomised trial evaluating the effects of non-medical day centre
care for people with severe mental illness.
IN THE PSYCHIATRIC UNITS OF THE GENERAL HOSPITAL
the past 30 years most Western countries have set up small,
short-stay psychiatric hospital units within general hospitals.
Admissions to general hospitals have contributed to reducing
the stigmatisation of psychiatric patients and mental health
professionals, and to the development of biological psychiatry.
On the other hand, it has been argued that this type of procedure
weighs excessively in favour of the biological approach, to
the detriment of the psychosocial model of intervention. Moreover,
professionals who work in general hospitals tend to develop
a certain all-powerful attitude, with the impression that short-term
biological treatment is highly effective, whereas they lack
any feedback on the chronic evolution of these patients outside
The trend towards shorter stays has encouraged the use of biological
rather than psychodynamic treatments in these units. In order
to minimise this bias, group-analytical programmes have been
established at some short-stay units(Yalom, 1983). During the
last 25 years, we have organised programmes of milieu therapy
in a certain number of short-stay units. In one of our studies,
the results of the programme organised at Bilbao University
Hospital over the last 25 years were viewed as positive from
a clinical standpoint (Guimón et al., 1983). We contend
that these positive effects were the result of the atmosphere
created in the wards through the organisation of a variety of
groups, we now describe .
group meets for half an hour early in the morning, from Monday
to Friday, with all available personnel attending. The goals
are to gather and share information on the evolution of the
patients and problems arising in the ward since the last meeting.
Interpersonal problems among the members of the staff are also
occasionally taken up. This makes for a better understanding
of the ward atmosphere, and a more comprehensive approach to
the patient. Interpersonal difficulties and interprofessional
competitiveness are often dealt with under the guise of theoretical
disagreement, and become manifest at times in the form of lateness,
absence or rationalisations.
group's meetings are held early in the morning during the week,
for periods of 45 minutes. All patients are urged to attend,
and do so unless exceptional circumstances intervene. The sessions
are conducted by a skilled group analyst. Approximately 40 chairs
are arranged in a circle with the conductor seated always in
the same position. Most of the personnel attend, and usually
sit close to the more disturbed patients. The goals of this
'quick medium-size open group' are to facilitate the integration
of the incoming patients to this new environment, the discussion
of the situation of the outgoing patients, and to encourage
the patients' active involvement in their therapeutic plans.
Although a psychoanalytic reading of the communication is, of
course, undertaken later by the staff, the interventions are
carried out in a psycho-educational vein.
The conductor actively encourages each patient to participate
in an open discussion. Patients are asked to talk about the
tensions and conflicts arising among themselves and with the
staff. Attempts are also made to show them how these reactions
are often distorted by the psychopathology itself. They are
invited to talk about their general condition, contrasting their
assertions with those of the other patients. They share objective
and subjective feelings about their symptoms. The therapist
in charge conducts the group bearing in mind some ubiquitous
topics: reluctance to take medication, side effects, unawareness
of the illness, fears of being discharged, and so on.
Suggestions, protests and the patient's initiatives are worked
out through structuring the group by giving the members responsibilities.
Thus, once a week, the meeting takes the form of an administrative
session, in which a president and a secretary of the assembly
is elected by the patients from among themselves, and in which
a plan of activities (plays, mural work, etc.) is organised.
All of this contributes to the development of the healthy and
creative aspects of the patient that otherwise would go unnoticed.
With this group, we try to guide the patient all along from
the abstract to the actual, from the delusional to the real.
We foster communication and interpersonal relationships. We
try to integrate patients into an atmosphere that provides information
concerning the many aspects of their lives, family, and friends.
The presence of staff members in these groups enables the patients
to have a closer relationship with them. This dispels persecutory
feelings and resolves conflict that would otherwise persist.
This environment fosters the transparency and directness of
both patients and the therapeutic team. Resistance arising in
the patients, such as fears of criticising others or being punished,
tends to disappear soon. Irregular attendance on the part of
the doctors arises during certain periods, under the pretext
of overwork, but in reality reflecting a devaluation of the
group approach, which can spread to the test of the team. This
generally depends on the attitude of the ward leader towards
group or milieu therapy. On the other hand, excessive nursing
staff rotation results in sporadic attendance and a lack of
commitment to the group. This is often fomented by the institution
itself, which is reluctant to have its auxiliary personnel involved
in these kinds of 'specialised' activities.
These problems are best worked out through the participation
of the staff in the postgroup meeting created for this purpose.
This meeting is, besides, a valuable means of sharing information
about the patients.