HEALTH SCIENCE JOURNAL VOLUME 8 (2014),ISSUE 3

SPECIAL ARTICLE Keywords: inpatients group therapy, psychotic

patients, psychosocial interventions, group
Group therapy in psychotic therapist

inpatients Corresponding author: Koukourikos Konstantinos, Pilea

Thessaloniki, e-mail : kokaea @yahoo.gr, tel 6977220814
Konstantinos Koukourikos1 , Eleni Pasmatzi2
Introduction
1. RN, Lecturer in Nursing, Alexandreio
Technological Educational Institute of The recent changes in Psychiatry, mostly after
Thessaloniki, Greece 1970, have made clear the attempt to drive the
2. RN, Mental Health Nurse, MSc, General care of psychiatric patients from longitudinal
Hospital G. Papanikolaou, Thessaloniki, treatments and institutionalism in psychiatric
Greece hospitals to short-term treatments in psychiatric
departments of general hospitals, as well as out
Abstract hospital settings.1
The treatment of psychoses, particularly of
schizophrenics, occupies a special place within The revolutionary changes in
the evolution of psychiatry and psychotherapy. psychopharmacology, the abandonment of old
Group therapy has come to play an important therapeutic methods and the adoption of novel
role in the treatment of psychotic disorder and it ones, and finally the participation of a mental
is a part of hospitalized patients therapeutic health team have given drive to the creation of
experiences. new treatment methods. Among them group
The goals of each group vary but they all have therapy can be included, having though been
common purpose to increase patients submitted to necessary changes comparatively to
awareness of themselves through interaction the traditional one.1
with other group members who provide Group therapy is that type of psychotherapy, in
feedback about their behavior, to provide which carefully selected patients are being placed
patients with improved interpersonal social skills in a group lead by an instructed psychotherapist,
and decrease isolation. in order to stimulate the patients to help each
The purpose of this article was to provide a brief other and cause changes to their personality and
description of the implementation process of behavior.2
inpatients group therapy on the psychotic
patients. The majority of psychiatric departments
Inpatients group therapy is effective when employs group therapy as a complement to their
applied and considered as a part of a well general therapeutic approach and has developed
organized and complete therapy aggregation, some type of groups, such as: interaction groups,
made up of: a) medical surveillance, (b) family music therapy groups, social capabilities group,
information, therapy and sensitization, (c) self- analysis group, relaxation group, gardening group,
supportive psychotherapy and (d) psychosocial art-therapy group, medicine-instruction group.1
restoration. Group Therapy should not be seen
as a panacea, but as a therapy process whose In the United States of America the group
role- instructing and supporting- are of high therapy is used in more of the half psychiatric
therapeutic importance not only for the patient, departments of general hospitals. Is should be
but for his close family environment as well... noted that in American society there is a misuse
of group therapy, with people forming groups on

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any subject, including healthy people.3 mimesis, in the frame of the group, in pretty
helpful in finding new, healthier and more
INPATIENTS GROUP THERAPY correct conducts.
Group therapy is an important part of hospitalized 4. Universality. Patients feel that they are not
patients therapeutic experiences. Groups may be the only ones living with a problem and that
organized in many ways in a ward. The goals of many other people may be suffering as they
each group vary, but they all have common do.
purpose to increase patients awareness of
themselves through interaction with other group 5. Group pressure. It helps constructively in the
members who provide feedback about their change of the group members inadaptable
behavior, to provide patients with improved conduct.
interpersonal social skills and decrease isolation.4
6. Coherence. The members feel acceptable to
The groups size in this type varies from 5 to 12 each other, useful for the team, in which they
members, while the best is 6-8 people. Group work collectively to achieve common goals
sessions vary from once to twice a week, with and aims.
duration of 60-90 minutes Groups may be open or
closed. In closed group, the goal should be made 7. Interpersonal cunning. It aims at the
explicit in the first session. In open groups, the modification of the interpersonal conduct.
goals should be reviewed at the beginning of a 8. Interpretations. They may be given by the
new persons first session. Patients are selected therapist, or even better by the group
after proper history taking and detailed mental members.
status examination.5
9. Emotional relaxation and catharsis. They
Another important aspect is selection of topics make up an important experience for the
for discussion. The topic selected for discussion patients, who learn how to express their
should be congruent with the goal. Ideally, a feelings in a manner which is not painful for
patient begins a session by introducing an them.6
appropriate topic, all members relate that issue to
their own situation and then start sharing coping THE CLINICAL SETTING
strategies.5
The clinical setting of the inpatients groups shows
The therapeutic principles developed in the group some particularities and special interest as well. In
therapy, traditional and inpatients Group Therapy the frame of a ward, the demands of the group
are: therapy change and there are revolutionary
changes in its application techniques too.
1. The reality orientation. Through their contact
with others patients may improve their reality There are two main factors affecting this
perceptive conception. modification, and are related to needs of the
psychotic patients:
2. Transference. This may be varied concerning
the different members of the team and the The nature and deduction of cognitive
therapist or even collective as far as the group function,
is concerned.
The insight of the numerous social
3. Identification. Other peoples behavior stimulants received.7

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The various group therapy programs are designed him problems during his treatment and
and applied based on these factors. It is, thus, focuses on the help he is going to receive in
easy to comprehend that during the first phases order to untie them effectively.
of the disease (the incisive phase), some therapy
models are not effective, and only the h) The group therapy in the department is not an
pharmaceutical treatment (P/T) is really crucial for autonomous and selection therapy, but makes
the patients course. In the second phase, up a part of a therapeutic whole.
however, Group Therapy is able to provide i) In Group Therapy, the staff takes part in it
corrective meddling to the cognitive and social periodically, as a therapist. Consequently,
performance lacks. there is neither the possibility nor enough
There are two patient categories which shape the time for the same therapist to prepare the
G/T program: patient for his participation in each session
and always figure out the groups makeup.
a) Those who, after the first psychotic incidence
and the proper pharmaceutical treatment, j) The coherence makeup in these groups is
show low cognitive deduction and function often.
satisfyingly to very well, not only socially but k) Finally, the interpersonal approach of the
professionally as well, and patients conduct is not requisite, because of
b) Those who recover with low rates and present the time limits.10
heavier symptoms of residuality, and thus, GROUP FORMATION
strong social deduction caused by the
persons adaptability to the social practices The group formation can be done in two ways:
before the initial stage of the disease.8,9
1. The level approach, where patients are
The clinical setting of inpatients group therapy, as placed according to the function level:
already mentioned, is different from the
HIGH: (sick, non disorganized with good social
traditional Group Therapy and is recommended
and cognitive function) with sessions up to 75
when it comes to the modification of the
minutes, which stimulate the groups stability
traditional Group Therapy techniques. More
without conflicts and eruptive situations,
specifically, there is:
viewing on orientating and defining the
c) Non requisite patients mobilization (some of patients problems which will establish his/her
them take part involuntarily and have no faith post-hospital remedy.
in the Group Therapy usefulness).
LOW: (sick regressed and disorganized) with
d) Presence of continuous patient rotation (the sessions up to 45 minutes, which are mainly
residence in the group is brief- up to 3 weeks). supportive and enhancing the construction of
the patients orientation.
e) Non completion of a group therapy frame
(low number of sessions during the patients The advantage of this system is the
treatment). maintenance of a proper and balanced for the
needs of the participants level, so as to achieve
f) Lack of homogeneity of the
the level group goals. However, in them, patients
psychopathological cases.
are clearly distinct in categories of functional and
g) The patient lives intense and insuperable to non functional, which may cause tenseness.

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2. The team approach, in which all the curative factors and where confidentiality and
newcomers in the clinic are introduced in non judgmental approach can be
13,14
2-3 groups periodically and in sessions of communicated to the group members.
45-60 minutes for certain time periods.
These groups do not have homogeneity
and may accept patients of all levels and GROUP THERAPY PROCESS
diagnosis, being although under the same
stressful events.11 The clinical instructions refer to the patients
preparation, the group formation, the groups
THE ROLE OF THE THERAPIST structure, the training and supervision of the
The role of the group therapist is mainly special techniques application:
attributed to mental health nurses and less often 1. Patients Preparation
to psychiatrists and psychologists, as well as other
therapists such as social workers and work- The therapist initially focuses on the
therapists. Because of the short duration of the indispensability of the G/T and its aims. The
inpatients groups, the group therapist should therapist mainly notes:
have the following characteristics: he should be
2. It helps to the change of conduct, the
energetic, quick, effective, supportive, structured
comprehension of the disease and its
and pellucid.12
prognosis, the possibility of mutual
The therapists aim is: opinion exchange, as well as to active
mutual aid.
The therapist should actively structure the
discussion in a way that encourages the group 3. The training and comprehension of the
members to stay in a topic. simplicity that characterizes the rules of
the team.
When members interact spontaneously
around an appropriate issue, the therapist 4. The compliance with the teams rules
should be quiet and allow the patients to feel (working hours observance, stopover to
a sense of mastery. the sessions, acceptance and respect of
the other people of the team.5
Therapist should try to include all members in
the group discussion by asking each one to 5. Formation
express their views and feelings. Therapist
The groups coherence and identity are being
should assist silent members to speak and
insured. The group is made up of people with
should understand their reasons for silence.
similar psychopathology diagnosis, introduced
When there is conflict between members according to their functionality and balance
then therapist should not take sides rather concerning social, cultural, ethnical and racial
encourage whole group to discuss issue in a origin, the gender and age.15
way that leads them to understand why
6. Structure
conflict has arisen.
More specifically, there are inpatients groups,
The therapists task is to help the group
where the patients succession is continuous (new
develop into a cohesive unit with an
patients after the incisive phase enter these
atmosphere conducive to the operation of
groups, while others leave it). The groups consist

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of 6-8 members who meet in one or more aggravation of their condition, the ways of
sessions of 60-90 minutes duration.15 avoiding reversion, the identification of
positive symptoms and the need to comply
7. Leader-Therapist with the P/T. In groups, thanks to interaction,
Usually, two therapists participate, namely the the members communicate their experiences
leader and the co-therapist- assistant. The on how they live with the problem, how they
presence of the assistant aims at helping the come over their psychotic condition elements,
therapist in chief to maintain the reality the encouragement and the course of their
inspection, to conform patients having swelter disease.
and eruptive tendencies, and generally to ensure - Maintain the discussion on recent and timely
the congruous function of the team, restoring the issues of living: the patients discuss over
balance in it. What is more, he takes part in the subjects which are directly related to
model-roles, settlements and exercises everyday life. They refer to problems that
instruction.16 engross them, such as family, work, their
8. Clinical education and Supervision relation with their co-patients and how they
get on with each other.
It is requisite that exist: a) the coexistence of a
therapy couple, consisted of a beginner and an - Focus on the positive side of the themes
experienced therapist, (b) the groups supervision discussed: the discussion is rolling on the
by a person specialized in psychotic patients so as positive points of the narrations so that the
to intervene if there is no improvement in the goals of the team be more feasible and in the
team, if the therapist- chief is let down by the realms of reality. These goals are mutual
interventions result as well a if there are conflicts support, encouragement and mutual aid
and confrontations between the therapy couple, through consultation.
(c) the use of several supervision means, such as - Focus on the groups orientation: a) towards
video camera, mirror etc.17 interaction and (b) towards social education
9. Special techniques application in Group depending on the patients functionality. In
Therapy interaction groups, patients are encouraged
to express their emotions and problems, and
- Prevent the patients from being exposed to they are rewarded for this. Within the groups,
many stimuli: as already mentioned, a patient they recognize their problems, find solutions
in the first and incisive phases of the disease, and answers through their in between
as well as disorganized patients of low relationship, while they receive consultation
functionality are not allowed to participate in and moral solidarity and support by the other
interaction groups. The methods employed members. The patients live confidence and
evoke to the patient aggravation condition are not obliged to refer to very personal
and total isolation. The gradual adaptation, issues. They learn to manipulate anxiety
where the patient gains more resistance to through the team, and therefore the social
anxiety is a correct and suggested technique. and professional relationships. Everything
happens within the therapy environment is
- Education and Reality inspection: the
employed as an example by the therapist,
members instruction lies upon the general
who asks and seeks after the members
information about their sickness, its
annotation and opinion over these themes.
prognosis, the reason which lead to the

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In the second groups of social education efficacious for lasting internal patients and for
through roles and models function, which the day hospital patients, thanks to the
therapist himself represents, the patients are development of cognitive functions and
asked to improve their sociality and abilities. They conductive practices.21
are taught the indispensability of communicating
with people, of perceiving their false thoughts and The Group Therapy aiming at interaction
social conducts, the reasons that lead to these mainly helps the lasting external patients
conducts, ones actions consequences, and (particularly the institutionalized ones)
through the team they seek for alternative improve their social conducts and
solutions so that the dysfunctional conducts can communication, and thus, deduct their social
be altered. The group therapy context ensures the isolation. Moreover, for inpatients with high
protection and safety of its members, gives the functional level and mild psychotic symptoms,
impression of family and home atmosphere and the G/T application is a convenient therapy
encourages the members to stay in touch approach being much more effective if
independently of the sessions.17,18 continued and after the hospital remedy. In
contrast, for lasting external patients, its
RESEARCH STUDIES application does not give encouraging results
of efficacy.20, 22
Several studies19,20, 21,22 have been made on the
effectiveness of Group Therapy for patients with When Group Therapy is orientated to
schizophrenia. During these studies, the interaction through social education, it may
therapeutic bid of G/T was evaluated, through the turn out to be effective for lasting external
application of several methods on different patients. The results reach their peak for
patient groups. So, there are studies on either these patients either with homework
internal or external patients, who are either in the entrusting, or with education on problematic
incisive or the remission phase of psychotic situations, similar to those patients might
elements, and who are subsumed in groups with affront in their everyday life.20
specific focus and orientation, such as social
education, supportive, and empathy. Based on the findings of studies, and taking into
account the appearance of cognitive functions in
Their results are written down as following: schizophrenia, it is safe enough to gather the
following:
The Group Therapy which is empathy
orientated does not always lead to positive Group Therapy in the incisive phase of the
results for patients in incisive occurrence of disease causes an aggravation of the patients
schizophrenia, while it is thought as useless clinical and psychotic condition, because of
and inefficient for institutionalized patients.19 the warped perceptive functions, and should
therefore be excluded. Their introduction in
The Group Therapy which is interaction
groups evokes anxiety and confusion to them,
orientated, when made through a long period
as they are not able to respond satisfyingly to
of time (up to 60-80 sessions), may help
social situations.
supportively the mobilization of the
hospitalized patients concerning their social Thus, Group Therapy can play an important
and interpersonal conduct.20 role only when it comes to patients whose
psychotic elements are in remission, and always
The Group Therapy aiming at teaching social
under the sleepless eye of the leader- therapist of
abilities and problem settlement is reasonably

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the team, so that a reappearance of some positive phase of his clinical condition each time, and
element is conceived betimes. With this method, particularly his anxiety and his cognitive level at
the patient is orientated to a more supportive and the present appearance of the disease.
focused on the problem Group Therapy.23,24
Group Therapy should not be seen as a
The less psychotic patients and those who are panacea, but as a therapy process whose role-
of high functionality respond better to the instructing and supporting- are of high
Group Therapy, and mostly to the interaction therapeutic importance not only for the patient,
caused by the group. This happens thanks to but for his close family environment as well. It
their good pre-morbid situation, to the quick should not be forgotten that Group Therapys goal
improvement of their psychotic condition, to is the patients social incorporation and the regain
the moderate up to good maintenance of the and maintenance of his sociality, the healthy
cognitive functions, and these patients ability expression of his emotions and his return to
to satisfyingly manipulate their social and reality.
professional relations anxiety. In Group
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