Greek History 1 and 2
The Group Analytic Approach at the Open Psychotherapy Centre
Ioannis K. Tsegos, Athanasia Kakouri- Basea
Introduction
The Open Psychotherapy Center (OPC) was founded in 1980 in Athens with main objective the outpatient treatment of patients with serious, mainly, psychiatric disorders. The activities of the three Training Institutes of the Centre[1] as well as the activities of the Institute of Group Analysis (Athens) were housed in the same premises. It is, therefore, a complex and multi-faceted organisation, the operation of which is characterised, amongst other things, by a number of innovative applications, both in terms of treatment as well as the training of therapists. This innovative intention, in addition to being a general feature of the Centre’s philosophy, is also an inevitable consequence of its therapeutic purposes, such as the one mentioned earlier. More specifically, and because we are referring to patients with serious disorders, the Centre’s therapeutic orientation could only be clinical and pragmatic, that is, be shaped on the basis of what is effective, each time, for each patient. It is obvious that this particular therapeutic approach excludes theoretical one-sidedness and divisive treatment options (eg. drug prescription or psychotherapy). On the contrary, it promotes flexibility, fosters creativity and common sense, and demands the combination of therapeutic schemes which are, after all, most appropriate for the majority of patients at the OPC (WHO, 2012). Finally, we could assert that the Centre’s operation, which spans over forty years, is a constant effort to seek more suitable ways of psychiatric treatment with group psychotherapeutic methods, Group Analysis being one of them. Historically, group-analytic therapy was the first method we used and one of the most commonly used at the Centre, either as an autonomous form of treatment or in combination with other group approaches, as described below.
Our Initial Therapeutic Choices
The choice of group-analytic therapy dates back to the initial establishment of the OPC and it occurred, one could say, out of necessity. Given that this was an original project, with no prior example in Greece, we were seeking a method of group psychotherapy combining the socio-dynamic and psychodynamic dimensions of treatment. From the limited knowledge that we then had, group analysis seemed the most appropriate.
At the same time, we were looking for a method that focused not only on the “patient” aspects of an individual, but, primarily, on the “healthy” ones, which we consider to be the basis for the individual’s personal development, but also for the decrease of their symptoms. Group Analysis, enabling the equal and active participation of each individual in the therapeutic process, and mitigating the role of the coordinator, seemed the most useful and appropriate for our therapeutic needs.
All of the above were clearly articulated principles and beliefs, but there was no adequate training of the staff yet, which we considered — and continue to do so — as the prerequisite for the psychotherapeutic task to occur. We were, however, fortunate enough to have Ioannis K. Tsegos as the driving force behind the Centre, whose training at the I.G.A. in London proved invaluable. Tsegos undertook the training of the other members of the initial staff group, and thus the foundations were laid for the gradual establishment of the Training Departments of the Centre and the I.G.A. of Athens.
It is important to mention the above in order to demonstrate that the starting point of Group Analysis, as applied in the OPC, can be traced in specific therapeutic and training needs. Therefore, it makes sense that we would have to make various modifications in terms of the usual group-analytic practice in order to meet these needs, but also to be more compatible with the Institution’s principles.
Convergence with the Therapeutic Community
So far, we have established that Group Analysis was initially the only available solution. Quite soon, however, the number of patients increased and it became apparent that we needed to enrich therapeutic activities with other approaches that would promote the social element of relating to others and to reality, in order to strengthen the therapeutic process. We decided that socio-dynamically oriented groups were the most suitable for this purpose, as they fulfilled our therapeutic goals. As an example, we had patients who, although required to participate in group activities, for various reasons they were unable to function in a group-analytic setting. We also noticed that many patients — usually the most disturbed ones— found it difficult to verbally express themselves and to interact with the group. Once again, Tsegos’ experience with the British Therapeutic Communities was crucial as he took initiative and urged us to turn to socio-therapy and the Therapeutic Community (TC).
This was how the first weekly Therapeutic Community was designed and implemented and a little later, a secondTC started, which occurred every two weeks. TC procedures involve members of groups more actively and more specifically, they enhance the rotation of roles, encourage spontaneity and responsibility, and facilitate creative expression and contact with reality (Tsegos, 1982; Karapostoli, 1989).
As we have already underlined, the pursuit and design of different ways and combinations of methods in order to improve therapeutic results has been an integral objective for the Centre since the very beginning. Thus, having already the experience of small group-analytic groups, we began to gradually introduce group-analytic elements to the communal process, through regular “trial and error” practices. More specifically, we introduced elements that relate to the notion of the “group as a whole” and the group analytic way of conducting the group. Similarly, we found that the social dimension of the group-analytic group could be strengthened with elements “borrowed” from the Therapeutic Community, such as the alternation between different roles, or the mobilisation of the individual’s “healthy” aspects, etc.
This early, initial convergence of the two approaches was crucial to the overall development of the OPC. First, it led to the creation of an original model of a Psychotherapeutic Community: the Group-Analytic Community (Tsegos, 1982).[2] Moreover, it contributed to the creation of an innovative treatment scheme, in which the methodology of group analysis is combined in an equal and complementary way with that of the TC. A large number of patients participate in the scheme which on a case-by-case basis includes psychodrama and the group-analytic model of family therapy, and it has been shown to be particularly effective (Tsegos et al., 2007, Kakouri, 2012). This particular program requires the patient to participate in groups of different size and orientation; the treatment is modified according to each patient’s therapeutic course, combined at times with medication if that is deemed necessary. For example, the patients in their initial stages of treatment, may participate only in individual therapy sessions; later on, they may participate in socio-therapeutic groups and/or in the Large group of each of the two Communities —or the Psychodrama— and then, group-analytic therapy may also be added to to their treatment. This schedule would be weekly if the patient is a member of the Daily TC and fortnightly if they are a member of the Fortnightly TC.
In regards to group-analytic Psychodrama, it should be noted that is another original application of the OPC. It incorporates typical psychodramatic techniques within the functional basis of the group-analytic process, making use of the notion of “group as a whole” and of the group matrix (Papadakis, 1984.).
It is clear that the group analytic approach, either by itself or in conjunction with the Therapeutic Community, is the “central core” of the operation of the OPC, as it has influenced the way training activities are organised, while also informing the Centre’s administrative function.
Describing the innovative applications concerning the training of therapists in greater detail could be the subject of a separate article, however, we will presently refer — albeit very briefly — to the group-analytic model of supervision, which was formulated by Tsegos and described in detail in the book “The Third Eye: Supervision in Analytic Groups”, edited by Meg Sharpe (1995 a). This model has proven to be particularly effective in terms of supervising the clinical practice of trainees. It makes use of an original, clearly structured, supervisory process and is based on the weakening of the role of the experienced trainer, which strengthens the potential of the “peer group” and supervising group “as a whole”.
If we were to form a more general comment in evaluating our long-standing group-analytic experience, it would be that we have succeeded in fulfilling the coupling of two approaches, which can by no means attributed to chance. In fact it was a “convergence of things”, as characteristically noted by Tsegos (2012), as the two approaches, although following separate paths, have common historical origins. After all, the “Northfield Experiment” (Bion 1962, Main, 1946, Foulkes, 1948) was the starting point for both, and Foulkes’s prophetic remark about the experiment, as stated in 1946, is indicative of this basis, as he notes that “the relationship and mutual penetration of the two fields of observation (psychotherapy and socio-therapy)… is a fascinating study of great practical importance”.
This “ipso facto convergence”, however, did not occur only for historical reasons, as both Group Analysis and the Therapeutic Community emerged from direct observation and experience, and then the corresponding methodology was systematised and the theoretical framework formed. As such, they lack any theoretical dogmatism that characterises other approaches; this makes them more flexible and non dogmatic, and therefore more adaptable to the various clinical and other challenges, each time.
General Notes and Examples
What has been stated so far might be difficult to understand entirely or even be seen without scepticism as there is no direct contact with the activities at the OPC. Perhaps a way to further clarify the implementation of the group-analytic approach at the OPC is by referring to some indicative examples.
A key differentiation from the usual group-analytic methodology concerns the composition of analytic groups. Participants in these groups are patients, for whom group analysis is the sole treatment, but also patients who are members of the TC groups, where they know each other member. This particularity can of course lead to questions regarding the formation of subgroups, the cohesion of the groups and, generally, the observance of boundaries. By and large, boundary issues arise frequently and are expected to do so, as a significant number of patients participate in various groups at the same time.
Undoubtedly, there have been cases where disruptive phenomena, such as acting out, can occur and even result in a premature termination of therapy. Usually, however, the particular “culture” that is nourished in the group-analytic groups makes it clear that the preservation of the group as an entity is a responsibility of the whole group and not just of the “avenging” conductor. When such cases occur, we often find that if the therapist is able to acknowledge his or her own fears about the possibility of the group collapsing and trusts the group, then boundary issues can foster a dialogue within the group and contribute to the process of creating personal boundaries and to the process of the personal differentiation of each patient (Tsegos, 2012, Petropoulou, 2008).
The peculiarities concerning the structural elements of group-analytic therapy also include the frequency of group sessions. In some cases, and for various reasons, the frequency of treatment was not on a weekly basis, and also, the number of patients residing outside of Athens increased and weekly attendance was difficult for them. We thus decided, despite our initial reservations, to modify the frequency of therapy, forming fortnightly group analytic groups as well as the Fortnightly Therapeutic Community. We were surprised by the fact that this actually facilitated and enhanced the therapeutic process. Today, almost half of our group analytic groups are fortnightly. Their members are not only individuals attending from other cities, but also patients for whom the “distance” from the therapeutic environment is beneficial, for diagnostic and other reasons, (eg. patients with personality disorders). The creation of fortnightly groups has given us the opportunity to identify some of these therapeutic benefits but also the difficulties that sometimes arise, particularly during the early stages of their formation. Moreover, it has given us the opportunity to study the therapeutic significance of “intervals” between sessions. We consider “intervals” between therapeutic meetings to be an active — and not an inactive— element of the therapeutic process, contributing to the strengthening and stabilisation of therapeutic changes (Markezinis, 1996, Tsegos et al. 2007).
A presentation of the group-analytic practice at the OPC would be incomplete without a reference to the issue of the role, or more specifically, the attitude of the group conductor. It is well known that group-analytic literature emphasises the importance of the psychotherapist’s personal qualities. For example, Grotjahn (1978) clarifies that the therapist’s personality traits are an important therapeutic factor, while David (2016) focuses on the therapist’s “personal style” and his/her influence on the effectiveness of psychotherapy. The question then is how and to what extent the various group-analytic institutes shape a trainee group analyst’s “personal style”. At the IGA (Athens) and the OPC Institutes we have responded to this by introducing the Communal mode of Training, applying our therapeutic principles to our training activities (Tsegos, 1995 b). As demonstrated by our long experience, this training model seems to be particularly helpful in highlighting the psychotherapist’s personal characteristics, weakening possible authoritative tendencies, and enabling [the therapist] to participate in a personal and spontaneous manner in the group, combining this spontaneity with an ability to protect the therapeutic process, when necessary. (Tsegos, 1993, 2002, 2007).
As an appreciation of the contribution of Group Analysis, we should note that this was for us the starting point in order to eventually reach the conclusion that the small group analytic group is an effective means for the emergence of the personal qualities and of the personal characteristics of each individual. Then, in conjunction with the TC, it gave us the opportunity to “discover” the importance of role and strength in therapy. Thus, and as our clinical experience increased, we attempted to identify the therapeutic factors of the group-analytic approach, as applied in the OPC. The distinction of the personal qualities from the role/part and of the strength from power, the relating being in contrasting relation to insight, are only some of these factors. These concepts have been studied in detail by Tsegos and have been discussed in a number of articles and publications (eg. Tsegos, 1993, 2002, 2007).
Finally, Group analysis is directly linked to the history and evolution of the OPC. It is also linked to the history of Group Analysis in Greece, as the OPC was the organisation that “introduced” it as a therapeutic method and established it through the IGA (Athens). At the same time, its early “meeting” with the Therapeutic Community resulted in thiscoexistence, i.e a dynamic field of experimentation and creative changes demonstrating the extent of its therapeutic potential and the range of its implementations. In terms of effectiveness, this is exemplified by the overall course of the OPC to date. Moreover, it has been presented and analysed in numerous research theses that are available upon request.
As a last note, any therapeutic success or failure is valued, by those who come to the OPC, that is the patients. We do not claim to have “discovered” a therapeutic practice that is a unique or the most effective intervention in the field of mental health, as we are aware of its limits and limitations. Neither do we claim that the OPC can function as a paradigm. It can, however, offer a different example as to how Group Analysis can contribute to the emergence and strengthening of the personal characteristics of an individual, which still is the main purpose of any psychotherapeutic method.
Dr. Ioannis K. Tsegos, Psychiatrist, Group Analyst, President of IGA Athens, Director of the OPC.
Dr. Athanasia Kakouri – Basea, Psychiatrist, Group Analyst, Director of the Therapy Department of the OPC. igaa-opc@otenet.gr
References
Bion, W.R. 1961. Experiences in Groups. London: Tavistock Publications, 1980.
David, M. 2016. «The Group Analyst’s Role when Facing the Group». Group Analysis, Vol. 49, pp.249-266.
Foulkes, S.H. 1946. «Principles and Practice of Group Therapy». Bulletin of the Menninger Clinic, Vol. 10 (3), p.p. 85 – 89.
Foulkes, S.H. 1948. Introduction to Group Analytic Psychotherapy. Studies in the Social Integration of Individuals and Groups. London: A. Wheaton and Co. Ltd, 1984.
Foulkes, S.H. 1975. Group Analytic Psychotherapy. Methods and Principles. London: Interface.
Grotjahn, M., 1977. The Art and Technique of Analytic Group Therapy. New York: Jason Aronson.
Kakouri. A. 2005. “A Multifactorial Approach for Severely Disturbed Patients”. Annals of General Psychiatry 2006, 5 (Suppl 1). International Society on Brain and Behaviour: 2nd International Congress on Brain and Behaviour Thessaloniki, Greece. 17–20 November 2005
Karapostoli, Ν. 1989. «The Importance of the Levels’ Interchange in the Therapeutic Procedure of the Psychotherapeutic Community”. Diploma Dissertation. Institute of Psychodrama-Sociotherapy of the OPC. Athens.
Main, T.F. 1946. «The Hospital as a Therapeutic Institution». Bulletin of the Menninger Clinic, Vol. 10, p.p. 66 – 70.
Markezinis, Ε. 1996. «On the Intervals in Therapy and the Frequency Issue in Group Psychotherapy». Diploma Dissertation. Institute of Group Analysis Athens.
Papadakis, Th. 1984. «Group Analytic Psychodrama». Diploma Dissertation. Institute of Group Analysis Athens.
Petropoulou, Μ., 2008. «Boundaries and Rules of the Open Psychotherapy Centre Psychotherapeutic Community». Diploma Dissertation. Institute of Psychodrama-Sociotherapy of the OPC. Athens.
Tsegos, I.K. 1982. “A Psychotherapeutic Community in Athens”. Vth Windsor Conference. Windsor, 1982.
Tsegos, I.K. 1987. «A Foulkesian Synthesis: Group Analytic and Therapeutic Community Principles in Group Analytic Training.» Presentation at the Scientific Meeting of G.A.S. London, May 1987.
Tsegos, I.K., 1993 . “Strength, Power and Group Analysis”. Group Analysis, 26 (2):131-137.
Tsegos, I.K. 1995 a. «A Greek Model of Supervision». In M. Sharpe (Ed.) The Third Eye: Supervision of Group Analytic Groups. London: Routledge.
Tsegos, J.K. 1995b. «Further Thoughts on a Group-Analytic Training» Group Analysis, Vol. 28(3), p.p. 313-326 .
Tsegos, I.K. 2002. The Disguises of the Psychotherapist. Athens: Stigmi Publications.
Tsegos, I.K. et al. 2007. Open Psychotherapy Centre (1980-2007). Activities and Peculiarities. Athens: Enallaktikes Publications.
Tsegos, I.K. 2012. The Psychiatric Communalism. Athens: Armos Publications.
[1] Institute of Diagnostic Psychology
Institute of Family Therapy
Institute of Psychodrama—Socio-therapy
[2] For more details, see also Karapostoli’s article at the same issue
The Group Analytic Therapeutic Community
Ioannis K. Tsegos, Natasa Karapostoli
Introduction
The psychotherapeutic practice of the Open Psychotherapy Centre[1] is based on the principles of group psychotherapy, and more specifically on Group Analysis, the Therapeutic Community and Psychodrama. This particular preference is not an occurrence of financial calculations or obsessive ideologies but the outcome of the now strong belief that the treatment of mental disorders requires on the one hand a multifaceted therapeutic intervention, while on the other, and this is particularly crucial, the active participation of non-professional, such as the members of a group.
The Group-analytic Psychotherapeutic Community is an original scheme, which is part of the multifactorial approach of the Centre’s Therapeutic Sector.[2] We believe that Group Analysis and the Therapeutic Community[3] do not fundamentally constitute different and separate approaches, but complementary therapeutic methods; the 41 years that have passed since the establishment of OPC (1980) have exemplified that in practice. From the start we decided not to copy any pre-existing communal model from abroad. That simple principle was indeed wise and crucial for the gradual formation of the Centre’s philosophy which was based on a clinically effective direction. The result was that thecommunal element permeated the proliferating activities, intensified the theoretical reflection, and lead to the following definition: “Therapeutic or Training Community is a method of psychotherapy / training, which mobilises and uses the healthy and real part of Ego, both of the Patients and of the Therapists, the Students’ and the Trainers’, for personal development as well as the smooth operation of the organisation; what is pursued is the maximum knowledge and experience, based on forming relationships and the constant role alternation, clearly, responsibly and with adjustability”(Tsegos, 2002).
The combination of Communalism and Group Analysis became an advancing and creative factor, both for the Group Analysis and for the TC. We could now say that, “such a Therapeutic Community constitutes a protective factor for Group Analysis, so that it does not slip towards the “scientific” fields of linear rationalism and the Manichaeistic nature of psychoanalysis; conversely, Group Analysis constitutes a levee factor for the Therapeutic Community, so that it does not drift in the saviour course, or to suffocate in the unproductive areas of collectivism” (Tsegos, 2002, p.43).
We will therefore reflect on certain theoretical, but also practical answers, which we have given over the years, and which characterise the conjuction of group-analytic and therapeutic-communal principles.
Realistic Orientation and Flexibility
Historically, the two approaches, Group Analysis and the TC, are almost peer, with Group Analysis being slightly older.[4] It is crucial that the initial Therapeutic Communities, as well as the initial implementation of the Group Analysis, was not designed by “services in charge” or sectors, and they are not based on an already formed ideology.[5]
The same applies on the clinical activities of OPC[6]. The choice of Group Analysis and TC was intentional. They are both group-oriented, suitable for multifactorial schemes and with significant results in the treatment of severe psychiatric disorders (Tsegos, 1995, Kakouri, 2005). The free and non-dogmatic use of theories and practices as well as our non-condescending views regarding common sense, have lead to a series of changes, readjustments, innovations, definitions and applications, not just in the areas of therapy and training, but also in the organisational operation.
We believe that in its essence, group-analytic principles, fosters flexibility and creative adaptation. These after all are characteristics that permeate Foulkes’ work, who notes: “Indeed, it is an intrinsic part of a group-analytic approach that rigid organisation and institutionalisation are avoided so as to allow maximum flexibility to ever-changing conditions… Arrangements should … be hand-made and on the closest possible contact with the realities of the conditions“ (Foulkes, 1964, p. 238).
Movement or Method: the Necessity of Specialists’ Training
The Therapeutic Community falters to this day between being a Movement or a Method. Rather than delve into the study and use of its social dimension, utilising the small groups, and especially the analytic ones, it opts for activism, idealisation of spontaneity and especially the devaluation or even dismissal of the necessity of trained TC workers, which results in caricature versions of TCs and discredit of the method. All forms of psychotherapy need specialised professionals, and not followers or converts (Tsegos, 2012).
Historically, the TC came to mean so many and different things, which lead to indefinite, misleading and euphemistic conclusions. After WWII, it spreads and is linked to other groundbreaking movements (social and cultural), reflecting the spirit of the time. Everything had to become more accessible, less mysterious, less rigid, less standardised (Clark, 1974). The international “movement” of the TCs for psychiatric patients (in contrast to the TCs for addicts), while it went through a period of excitement and expansion (1950-1970) it begins to wither. Many TCs close down or barely function, dependent on budget cuts of public mental health systems, as well as the deadlocks which the same model had fallen into.
Group Analysis on the other hand is clearly a method of psychotherapy, which very quickly organised the training of specialists. The happy occasion of the operation of the Training of Group Analysts (IGA, Athens) in the same premises with the OPC quickly leads to the necessity of the Training in Psychodrama and Sociotherapy, which began in 1985 and continues, to this day, being the only four year training for TC Workers. Unfortunately, many communal therapists are persuaded by the belief that a communal approach is not compatible with an organised training, because such thing would suppress excitement, spontaneity, and the interest which are all essential for a sociotherapist, and would turn hin/her towards only technical knowledge. The answer we provided to the above dilemma is that the training of the specialist in a Training Community not only does not suppress, but on the contrary nourishes the above characteristics, which are indeed necessary (Tsegos, 1996, 1999, 2012).
The Importance of the Framework: Intermediate Institution
The communal approach emphasised organisation and framework. It is important to keep in mind that Foulkes, who actively participated in the Northfield Experiment[7] crucially captured the importance of the dynamics within the larger group: “The author’s placement in Northfield… aimed to gradually place the group at the centre… and to turn the emphasis away from the smaller group… towards the ward and the hospital as a whole… This was possible after the whole hospital became progressively a therapeutic field, since we knew that digging the tunnel from one end would lead us halfway through the route of those digging from the other end… (Foulkes 1946, p. 89). It is a pity that Foulkes stopped his engagement with what became known as the Therapeutic Community after Northfield (Tsegos, 2012, p. 71).
After the end of WWII, TC needed the appropriate framework of operation. Its basic principles are in direct opposition to that of an asylum. That is how the idea of a psychiatric day hospital (outpatient care) which can be linked to a psychiatric or general hospital was born. The communal model also paid attention to the basic principles of social organisation, such as democracy, communalism, the embellishment of the hierarchical pyramid, the size; but it failed to deepen and organise its theoretical background. Confusions were inevitable: democracy oftentimes is identified as voting and the embellishment of the hierarchical pyramid leads to an implicit hierarchy. Even the very notion of communalism gets often mixed up with that of collectivism. Collectivism is characterised by the control of shared living and working environment, as well as the shared bedrest, and communal dining. On the contrary, Communalism is characterised by the participation of everyone in the decision-making process regarding its maintenance and operation, as well as the nurturing of its unique culture, but also, privacy and the individuality of personal, private living (home, family etc.) (Tsegos, 2012, p.139).
At the OPC[8] we have provided some practical answers to the above questions. It is a therapeutic unit that belongs to the intermediate institutions and which, in terms of size, administrative organisation and economic costs, is classified between a residence and a large hospital. The intermediate institution is the most suitable in order to treat pathological phenomena which are more related to the particular psychopathology of the patient and the conditions of his/her institutionalisation and less with the illness or disorder itself. This is because it minimises the primarily social – real or imaginary- dimensions given to a disruptive event either because of the influence of the family institution or because of the influences by the therapeutic process imposed on the individual within a big therapeutic institution, such as a hospital, wherein the individual usually becomes institutionalised, which also affects the staff too (Tsegos, 2012).
It would therefore be at least strange not to utilise the communal approach, which the Institution bases its therapeutic and training methodology, on its mode of organisation and administration. All the more so as it is an institution providing mental health services, where there is an accumulation of pathology (not so much amongst the patients but rather the therapeutic staff). This means that the theoretical and methodological innovations are not only relevant to its therapeutic and training activity, but also its very structure and organisation (Tsegos, 2002).
Weakening of the Roles – the Emergence of the Prosopon and the Importance of the Around-Ego
The Therapeutic Community principally questioned established roles (healthy-patient) and strengthened the depletion of the dominant role of the doctor-therapist. The questioning of the submissive role of the patient, which prevailed in the medical, as well as the psychoanalytical model until then, is one of the most important contributions of the communal approach. But questioning on its own does not lead anywhere.
Here too, the contribution of Group Analysis was crucial. Since very early on, Foulkes made groundbreaking statements, such as “… the art of a psychiatrist rendering himself redundant” (1946, p. 86), or later, Group Analysis is as ‘a form of psychotherapy by the group, of the group, including its conductor” (1975, p. 3).
A non-directional stance is not a matter of democratic veneer but rather an established belief that the conductor’s trust in the group fosters and promotes the group’s abilities and strengthens the healthy sides of the participants. It is only through trust that the members of a group will take initiative, operate at an adult level and participate actively in their therapy; in fact, particularly when these members belong to the so-called serious psychiatric disorders (psychoses, acute disorders, personality disorders etc.) which in the beginning of the therapeutic process, are characterised by passivity and withdrawal.
In our own approach, in the place of role, we paid close attention to the Person[9] and instead of the Super-Ego, in which the religious tones are obvious, while its usefulness is rather doubtful, we created the notion of Around-Ego; this is a more accurate, real and declaratory term for our approach. Around-Ego becomes the main regulatory factor in every group or communal scheme. It is cultivated and blooms with the strengthening of the active participation each and every person involved in the psychotherapeutic process, weakening the role of the expert, limiting guilt and reinforcing shame (Tsegos, 2012, p. 150).
In addition, in order to avoid any authoritarian tendencies of the staff, we established the regular (every two years) rotation of the coordinators of the therapeutic-community groups,[10] but also of the Leader of the TC.
Goals and Means of the Therapeutic Process
The absence of a main theoretical background had as an obvious effect the variety of the goal, depending on the theoretical orientation of each leader of a TC or its aim (change of personality, re-education, socialisation). The implementation and promotion of group activities is a trademark of the Communities. However, these often wear out in the implementation of practical tasks which involve the communal living, or the operation of the groups regardless of any, independent of the communal affairs, training of the personnel.
In our communal approach, the purpose is clearly psychotherapeutic. An extreme, ideal aim would be for all members of the TC (patients and therapists) to become authentic, spontaneous, stable and able in taking on responsibilities (Tsegos, 2002, p. 241). Foulkes understood the notion of health as a creative adjustment to reality, believing that mental illness cannot but be due to a distorted relationship of the individuals with their social network and, as such, the latter cannot be healed unless this primary relationship improves.
The TC has played a defining role in the development and systematisation of Sociοtherapy,[11] as it considered it to be a therapeutic approach of major importance, sometimes in fact as the only proper approach, even over psychotherapy. While TC was preaching a holistic approach to the individual, in its practice it did not avoid polarisation, reaching a futile confrontation between psychotherapy and sociotherapy (Tsegos, 2012).
In the TCs of OPC, the means of the therapeutic process is Group Analysis and sociotherapy, with the latter correspondingly instilled with the group analytic principles. We consider both approaches to be equal and complementary to one another. This effectively meant the existence of a cohesive training of Sociotherapists and the same rules applicable to the operation of psychodynamic and sociodynamic groups.
Instead of an Epilogue: Cost-Effectiveness
The long implementation of the Group-analytic model of the TC leads us to the conclusion that it is a cost-effective approach. The investigation of the effectiveness has been of great interest to us since the beginning. In addition to the international bibliography[12] and our clinical observations, there have been numerous research studies,[13] and findings which actually prove the efficacy of the communal approach. Especially for serious psychiatric disorders, studies show that a multifaceted approach, which includes communal therapy, is extremely efficient.
Moreover, it is inexpensive. According to our research regarding the cost of psychotherapy, we concluded that the TC is the most affordable therapy option for a patient, in comparison to other services provided by the OPC. It costs 5.3 euros/hour, whereas other individual group therapies cost 17.3 euros or one-one therapy costs 40 euros/hour (Polyzos et al., 2004, Karapostoli, 2012). The TC is beneficial, but only for those directly involved (therapists and patients). A personal, pragmatic therapeutic scheme is not easily steered into advantage by impersonal, bureaucratic institutions or other, irrelevant to the patient’s needs, conditions.
We should say that this is a brief description of our experience untill now. We hope that in the following years many improvements will come. A therapeutic model should always be an open system in close communication with the needs of the persons within (staff and patients) and the demands of the environment (community needs, special conditions). Preserving a living system is not an easy task and can not be achieved without mistakes, reality confrontation and common sense. It is a challenge in a challenging era.
Dr. Ioannis K. Tsegos, Psychiatrist, Group Analyst, President of IGA Athens, Director of the OPC. igaa-opc@otenet.gr
Natasa Karapostoli, Occupational Therapist, Psychodramatist – Sociotherapist, Secretary of the Training Committee of the OPC Institutes. igaa-opc@otenet.gr
References
Bridger, H., 2005. “The Discovery of the Therapeutic Community. The Northfield Experiments”. In Amando, G. and Vansina, L. (Eds.) The Transactional Approach In Action. London: Karnac Books.
Clark, D.H., 1974. Social Therapy in Psychiatry. Harmondsworth, Middlesex: Penguin Books, Ltd.
Clark, D., 1987. “Group Analysis and the Therapeutic Community”. Group Analysis, 20 (1), 3–13.
Foulkes, S.H., 1946. “Principles and Practice of Group Psychotherapy”. Bulletin of Menninger Clinic, Vol. 10 (3), p. 85-89.
Foulkes, S.H., 1964. Therapeutic Group Analysis. London: Maresfield Reprints (1984).
Gale, J., Realpe, A., Pedriali, E. (eds.), 2008. Therapeutic Communities for Psychosis. Philosophy, History and Clinical Practice. London: Routledge.
Harrison, T., 2000. Bion, Rickman, Foulkes and the Northfield Experiments. London and Philadelphia: Jessica Kingsley Publishers.
Kakouri. A. 2005. “A Multifactorial Approach for Severely Disturbed Patients”. Annals of General Psychiatry 2006, 5 (Suppl 1). International Society on Brain and Behaviour: 2nd International Congress on Brain and Behaviour Thessaloniki, Greece. 17–20 November 2005.
Karapostoli, N. & Scandaliari, Th., 2007. «The Pschotherapeutic Comminities” in Tsegos, I.K. and Collaborators (Eds), 2007. Open Psychotherapy Centre. Activities and Peculiarities (1980 – 2007). Athens: Enallaktikes Ekdoseis (in greek language).
Karapostoli N., Polyzos N., Tsegos I.K., 2012. “The Cost of Therapy Services Provided by a Day Psychotherapy Unit”. Group Analysis, Vol. 45 (4).
Lees, J., Manning, N., Menzies, D. and Morant, N. (eds.), 2004. A Culture of Enquiry. Research Evidence and the Therapeutic Community. United Kingdom: Jessica Kingsley Publishers.
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[1] OPC henceforth
[2] More specifically, the OPC in close collaboration with IGA Athens, has established and developed seven Communal units (three therapeutic and four training): Daily Psychotherapeutic Community (1980), Fortnight Psychotherapeutic Community (1990), Summer Therapeutic Community (1988), Institute of Group Analysis (1982), Institute of Psychological Assessment (1984)), Institute of Psychodrama-Sociotherapy (1985), Institute of Family Therapy (1990).
[3] TC henceforth
[4] For the relationship between Group Analysis and Therapeutic Community, see also Clark, 1987, Lees, Haigh, Tucker 2017.
[5] At the OPC, the therapeutic orientation is decisively realistic (clinical), i.e there is always an emphasis on what is useful for the patient, after a complete personality evaluation has been concluded. The multifactorial approach, which was gradually formed, and based on experience, means the combination of therapeutic schemes, suitable for the specific person and at the specific time (individual, group, communal, family therapy, drug treatment, etc).
[6] For more details see also Kakouri’s article at the present issue.
[7] More information on the Northfield Experiments can be found, amongst others, in Pines 1999, Harrison 2000, Bridger 2005, Pearce & Haigh 2017.
[8] An autonomous, self-governed, non-profit Day Care Centre, which does not receive any grants or financial aid whatsoever by any organisation, institution or body, within or outside of Greece.
[9] Individual: concept with demonstrative properties and quantitative characteristics. The approach is realised through an experiment. Persona: signifies roles, representation, symbols. Person: is an idea, of being or becoming. It presupposes the presence of other persons, eye contact and experience (Tsegos , 2002 p. 120)
[10] Some groups are in fact conducted by patients.
[11]In clinical practice, sociotherapy is the active involvement of those who are treated in their actual treatment, through various activities, and with the aim of improving the relationship of the person with reality, as well as with others.
[12] See for example Lees, Manning, Menzies and Morant 2004, Gale, Realpe, Pedriali 2008, Haigh, Pearce 2017.
[13] See for example Terlidou et al, 2004, Tziotziou et al 2005, Karapostoli, Skandaliari 2007.