Esta es la versión en Inglés del mismo trabajo que está en Castellano y en Francés. Se trata de un texto presentado en el año 2003 con motivo de unas Jornadas sobre la formación grupal en Ginebra.
17 years training course of Group Psychotherapy in Barcelona: a training experience in evolution.
Dr. J.M. Sunyer
Este texto ya fue publicado en 2004. Eur.J. Psychiat. Supplement (33-43)
Introduction
In Bilbao in 1975 Prof. Guimón started to become interested to training professionals in Group Psychotherapy. In doing so, he organized a introductory course of group psychotherapy in 1977 in collaboration with some group analysts coming from Bilbao and others parts of Spain and England. Since this moment, a large number of professionals linked by different psychiatric Hospitals, Mental care centers and others structures like Day Hospital etc, have participated in these courses. From the beginning the courses were organized by the OMIE Foundation with the support of the University of Basc Country. Some time later, this programmes had the support of the Deusto University. These programmes are still being organized in Bilbao, Geneva and Barcelona.
The program is based in personal analysis in group psychotherapy, large groups, theory and supervision of clinical activities, and, during the first years had the influence of the Institute of Group Analysis of London ( M. Pines, Fdo,Arroyabe, M Patalán, M. Marrone), but also from others Spanish group psychotherapists (L. Illà, J.L. González Ribera, P. O’Donell, and J. Campos), and finally, the influence of our clinical practice in Hospital Psychiatric settings with all kind of pathology. At this moments, we have our own way to training professionals coming from our experience accumulated during this time, our clinical practice and also, the results of our own discussions and professional evolution. For University reasons the program take three years, and the four formative blocks had been modified to eight week-ends per year. The team was formed by groups psychotherapists with clinical experience. This program has been constantly modified over the last 17 years.
In Barcelona started from a time of supervision activity that was organised by Prof. Casas at the Toxicomanies Care Centre of Saint Pau’s Hospital, and conducted by Dr. Guimon. In doing these activities, it became apparent that the staff were in need of training and guidance in group psychotherapy; but because was very difficult that all staff members travelled to Bilbao to be trained in these courses, the idea of a block training program appeared. As a result, in 1986 a preliminary four week-ends program began in Barcelona. And this was the start of the current course of groups, led by Prof.. Guimon and later, by Dr. Ayerra
The team is formed by group analyst that have clinical experience and dynamic or psychoanalytic training. To be accepted we have only one criteria: professionals that are interested in Group Psychotherapy and that accept to be training in the arena of group analysis or, at least, with the dynamics principles. But if these aspects are important, we also need a degree of commitment, the capacity to articulate different forms of group analytic understanding, and to accept a leadership. This provoked a natural selection of professionals that form the team. By the other hand, the candidates that have been accepted take part of a structure formed by members that are in their second or third training year.
This program consists in a 24 week-end blocks of 24 hours training program during 3 years. The present team is formed by six group analysts that are the conductors of six groups of 8 people. In total, each annual course have 50 professionals training in group psychotherapy.
The formative equation.
We consider that the formative equation is formed basically by the professionals who want to be trained and the team of teachers who lead the training program; but also by the observers, the boundary person, and occasionally by teachers who comes to made some conference or lesson.
The trainees.
During all this 17 years our program had trained approximately 300 mental health professionals that basically are psychologist, physiatrists, nurses and social workers. Also, others professionals, likes teachers and lawyers had been accepted. The candidates must apply for being accepted, and during the interview we give all information about the course, their characteristics, the necessary commitment, and the basic norms to be in the group. We do that to avoid the idea of a “typical” university course in that no personal implications is needed.
Basically they are Spanish professionals but also people coming from others countries are welcomed. In this sense we have 3 o 4 professionals coming from Latin-American countries. All professionals are form 24 to 50 years old, most of them women, and practically all, working in Mental Health and Drugs Centers.
The trainers
The team which was initially led by Prof. Guimón and after that by Dr. Ayerra, was formed by some psychotherapist from Bilbao and Barcelona. There were different sensitivities, backgrounds and experiences; some had more Kleinian or Bionian references, others more Foulkesian or Freudian; but the real basis was their clinical experience with psychotic and very disturbed patients. It was imperative to join this variety of theoretical positions and the common point was the clinical view. Nevertheless, we needed a long period for organise our own idea about a training course, an experience that couldn’t be a reproduction of the Psychoanalytic training program, or only an experience to show a kind of special psychotherapeutic technique.
After the first four week-end training program, staff members started to think about the program; the differences in commitment they can take and the time table possibilities they had to maintain this program. This introduced some modifications in the member’s team and because of differences in the hierarchical position or training among members. This meant that our criteria had to include a minimum common level of experience, formation and compromise or responsibility. Finally, a team of professionals that basically had a good relationship, a great level of confidence and complicity were organised.
As a result of our efforts to implement a good team, we recognized that a post-activity-groups were needed. So we maintain our group time to consider what happened in the training groups, but also we have our own meetings during the course to organise, modify or change the aspects of the training program we considerer they can be changed. This group were essential in order to maintain a coherence between all staff members. In these post-groups activities staff members could change feelings, thoughts, theoretical positions and doubts which had appeared in the experimental psychotherapy group, or in the theory and supervision’s sessions. But also we try to establish a good relationship among us that permits a high level of confidence and complicity.
From this point, actually six are the staff members that have the responsibility to contain all anxieties, to maintain the capacity of thinking over the tensions that comes from the members, groups and structure. Time had showed us that we are not only a team that trained professionals in group psychotherapy during 24 week-ends, but we are a team that must maintain our capacity to understand what happen in the groups, to growth personal and professionally to give the opportunity to transmit that groups psychotherapy is something more than a technique for help people. For doing so we constitute a group of work that try to give some signification to all thinks happens in the training program. Is like a “good enough team”, using the definition that Guimon took from Winnicott’s papers, that wants to be closer to trainers but with a distance to allow them to growth in this area.
The observers.
The OMIE Foundation believed that one of the most interesting aspects for training in Group Psychotherapy were to allow some professionals be observers and cooperate with the conductor. This collaboration happens after group session when both could interchange opinions about what happened in the group and what were the feelings the observed has held in her self. This role was offered to still training staff members that work in the institutions we collaborate with, but this provoked some problems; further was offered to professionals that has been trained. In this point, reflections about this role showed us that would be better to admit observers who had been trained one or two years before: the transference aspect over the course had been more resolved and their have more possibilities to understand different staff positions, opinions and attitudes. Also we considered that if all observers belonged to the same training year period would be better because they can organised their own sub-group and be supported by this.
This figure represents the part of the group who can’t talk, who is out of the verbal communication level and who catches on all the affective elements that the group can not to speak, for being shared between conductor and observer. In this direction, conductor and observer become a team that works with all elements that appeared from the group, and also a complementary vision of the group to be shared by all staff members.
Person in the boundary
As you know group cohesion is one of the most important therapeutic factors (Yalom) but, at the same time, it could be one of the elements of the anti-group (Nitsum), which could paralyse the group work. That means that the group, members and conductor, must work hard to maintain a balance between the therapeutic factor and the anti-group element. The conductor could be strained by the powerful group forces that don’t permit the group to maintain an adequate level of work. The same happens in all structure: the team of trainers can be paralysed or strained by forces coming from the total experience. If we introduce an element that allows the group to be free to face this problem, we have the possibility to maintain a satisfactory group work level. We call this figure “the boundary person” who is a professional that is located in the boundary between the inside and the outside of the group
Because of their position this figure creates all kinds of reactions: they could be good parent who understand the members of the group better than the conductor; or persecutor who enters the group to destroy it, or the representative of the psychotherapeutic law who can analyse what the conductors do or say in their post-group meetings. They can say something or not in the different groups hi enter: in the seminars, or the supervision groups, with the staff meetings or in whatever of the experimental groups, large or small. However in any case, he allows us to keep open the training group program.
Actually one or two professionals comes to be “boundary person” in each academic year, and permits us to complement our vision about the groups and the total structure.
The external visitor
Occasionally we decide to introduce a special visitor who is a group psychotherapy professional in any of the different flows of group psychotherapy thinking to make a conference about a particular subject. This experience is interesting because it introduces some theoretical o experimental elements that we cannot offer. This person breaks the traditional atmosphere of our training course adhering an element that allows us to be more in touching in the real world of the mental health, and also with connection for the university.
The training structure
All these people, conductors, observers, external visitors, person in the boundary are the docents’ group. But to become a team we need personal commitment: to organise a group with open communication, the capacity to share all the difficulties we have, to discuss our different theoretical positions and to recognise all transferencial aspects that the group and their members provoke in each member of the staff team, and the team as a whole. This way of thinking comes, basically from three sources of clinical and personal experience:
1. the psychoanalytic training: the majority of staff members had had a psychoanalytic training period. That means that the conductors have had his own personal analysis and have assisted to theory seminars and clinical supervisions period. It is true that not all staff members agree to this point: the necessity to be analysed, but I am convinced that this experience offers a complementary possibility to be more closer to any problem the member or the group and the structure can provoke us.
2. the group analytic training. If the individual training is important, to have had a personal experience in group analysis is fundamental. This means to have participated in small and large group experiences that permits to understand group life not as a complementary vision of psychoanalysis applied to group, but a new form of human vision: the nodal point of a complementary network of conscious and unconscious communication.
3. the clinical experience in Mental care centres. Specially with the therapeutic community form or view. This allows us to the importance of the team, of the communications between members, the differences and complementarities from all kinds of psychological interventions; but also about the primary psychic mechanisms like splitting, regression, schizoid and paranoid position, etc.
This personals experiences learn us about the necessity to maintain a meeting group with all de conductors and observers, after each group session with the members in training; these after-session group is a basic moment to integrate all the circumstances have been appeared in the groups, whatever they are. In the Bion’s interpretations, this group becomes the container of all the aspects that members inject in the group and in the conductor and the observer. And allows us to be like the group “good enough” as Winnicott said who permits the members express her self in all different aspects they are. So the training group experience is more than a training course, is an offer to have a personal experience in group therapy to attend their own personal characteristics whatever good or bad they are, and a possibility to understand our personal and professional network, the complementary of the external world and the internal one. To do that, the training course is divided indifferent areas:
Small group. In each week-end, each member have their personal experience in group psychotherapy constituted by eight members, the observer and the conductor. The groups meets six hour and a half times for week-end, during 24 weeks who takes the total course, 8 weeks for academic year. Each group is composed by professionals, women and men, form different parts of Spain, different professions and ages. At the beginning we organized 7 small groups per WE, but recently we reduce to 6 groups for increasing the number of large groups in each WE.
Large group. This is another important part of our training program. At the beginning we have 2 large groups for weekend. From the beginning we have had the experience of large groups led by conductors that they had an passive attitude, following the different movements the group made, and taking an analytical position. From this way, we can see groups that were plenty of confusion, chaos, aggressive tendencies. In this sense we try another way to conduct, more facilitators than analysts, taking interest in clarify and contain. We observe that the first large group were more tensioned, with difficulties to stay, to think and to talk; meanwhile the second were more peaceful, clear, with a more tendency for thinking and to put into words all the aspects of our experience. We also observe that these groups were basically the part of the structure that contains all the aspects and problems that had appeared through the Weekend and who were linked by the total experience. Two members of the staff, who also were conductors in the small groups, conducted these groups. All the staff members assist except the observers because we believe that all participants can speak in the large groups, but the observers will be in an ambiguous position. To eliminate this ambiguity we decided no to include them
Our experience showed us that with two large groups, members couldn’t be more involved in this particular space and we wanted to know what will happen if we increase in one more the number of larges groups. The results were an increasing of the large group work, allowing members to talk about more social aspects that we have been talk before. The group, composed by more than 50 members, have an increasing level of intimacy and, simultaneously, members can discus about social and institutional situations: violence, terrorism, nationalism, immigration, racism problems and so on.
Theory seminars. Being true that a good part of the training program is the personal experience in group Psychotherapy, this doesn’t means that the theory is not important. Because that, in our program we have two forms for giving theory. The fist year one of the conductors gives some conferences following a theory program in which we include the history of group psychotherapy, the basic notions of psychoanalysis and group psychotherapy, the basic assumptions of Bion, the principles of Group Analysis, and the applications of groups psychotherapy in clinical and organizational area. The two following years, the conference system is modified and we prefer the structure of seminars around some papers, books who were discussed by the members of the group seminar conducted by one of ours staff conductors’ A long of this two years we take some articles or books from Raoy MacEnzie, Foulkes, Bion, Grotham, Kissen, Kreeger, Yalom, Nitsum, Anzieu, Kaës, Agazarian, P. de Maré, M. Pines, Schwartz, Scheidlinger,, Shilder, Skynner, Garcia Badaracco, Pichon Riviere, and some Spanish autors.
During the seminar session, the conductor can observe some resistances or difficulties to do the work they had to do. In this cases his intervention points out the difficulties in relations with the small group of psychotherapy, and try to differentiate what depends on the small group or the seminar’s group. This shows how the affective difficulties can destroy the work they had to do and invite the members to discus this difficulties in her small group, and to follow the seminar work.
The clinical reflections space. Actually this means the supervision space, but we think that this word, in group context, is not very suitable. The group itself try to establish a series of thoughts about the clinical work presented by one of the his members. This clinical work could be a group psychotherapy session, a group psychotherapy program, a family therapy session (to be seen like a group)or an organisational structure.
And like in the theory seminars, the conductor can observe some difficulties that arise the group from the personal experience in small groups. His function is to clarify and to maintain the objective of the group and to remit the relationship problem to his own personal space.
The final thesis. To increase the level of our training program we ask for a paper about one of the aspects of group psychotherapy that would be interesting for each participant member. This paper could be a bibliography revision, or a investigations about some aspect of his group practice, or a revision of a group program they want to improve, etc.
The pre anti-group aspects of the training program
All this training experience has been in a permanent evolution from the beginning in that the program was a project to show what group psychotherapy is, and to training professionals in this “technique” to a present moment in that group psychotherapy is more than a technique but a major instrument to allow people, understand his life in connexion with others and the society.
If in the first years we have had a Psychoanalytic model to be applied to group psychotherapy, later we understood that Group analysis is a particular psychoanalysis form to include the inner world formed by a dynamic mental reality with partial objects, the self, affects and their representations that represents externals relationships and all their dynamic network, and that are joined together through the language and their symbolic representations and that includes the pathogenic structures coming from their primal groups experiences (family group) and that will be seen in the small group; but also, the symbolic links that take in to the society and that conforms our social dimension.
This has been un important point to modify our training program, and permit to think mores in a “community therapeutic – training program I group analysis” than in a “training program form group psychotherapy”. If we think like a “community training program” that would be means that all circumstances around the training process are important to understand not only the individual dynamic as a member in the group setting, but the dynamic of all groups, including staff group, in the context of our society in a given moment.
With all this different points of view, we can consider the inner world, the network each member try to establish in his small group, the network and their significations the small group (with the conductor and observer) establishes with his own and with the structure, and the significances that link all phenomena, conditioned by invisibles loyalties and for the reproductions (transpositions) of the external and social world. In this equation all forms of creativity are working, but also all forms of destructiveness. For this we need to understand the anti-group dynamics (Nitsum) that try (or want) to destroy this individual and group processes.
It is true that Nitsum showed us a very interesting panel of elements that provokes anti-group activities in the group life. We want to consider some pre anti group situations that needed and need a very great effort from staff to modify the lethal activity and to be became a creative potential form group and structure.
· Desertion of members. Is one of the most important and dangerous moments in the group’s life. Members, that have had an very important level of anxiety decide abandon the experience. This provokes a very important movement that can be destructive by itself: the guilty about our capacity to understand or contain the tensions in a member, or the group capacity to be more sensitive, or the capacity of the conductor or the staff members to understand what happened. All this aspects increase the difficult to take some decisions if the group has been extremely reduced and we need to joint two groups in a new one.
· De change or adapt setting. During these 17 years we have changed three times of our institutional space form work. But also, some times, the rooms we have had are not so grateful for working all week-end, and we needed to change. In other moments, the institution that give us some spaces needed them and we must change to have another local. This provokes some reactions that showed that we are not capable to maintain our setting, to face the institutional pressure. If we are not capable to understand and to modify the criticism capacity form a creative one, the possibilities to introduce some anti-groups movements are important.
· Psychic ?? It is not normal, but it is possible that in a structure with more than 50 members, working personal aspects during 24 week-end training course, a member could not be capable to contain his or her capacity and balance and be seriously emotionally disturbed. In this moments the capacity of the conductor, the staff members and the structure is tested. If the conductor has clinical experience and the staff team is “good enough” to maintain the capacity to understand, to contain, to increment their therapeutic capacity, all this situations had been resolved. And always, when members saw the capacity to contain and to understand what happened, the trust in the staff and conductor had been increased.
· The absence of the conductor for illness or personal situation. It seems to be true that we, the conductors, are normal people. That we can be ill or can be involved in a familiar or personal problems that doesn’t allow to takes our responsibility to conduct a group during a week end. These situations provokes all kinds of reactions and proves the staff capacity to react and to improve solutions in a very few moments. Normally, the observer becomes conductor; but if we have not observer, we decided that the same group organises his own group session, and after that, in an other space (theory or supervision) a member of the staff takes the possibility to share the experience with this group. Normally, if this staff member accepts to take all the aggressivity the group has, the experience became a good moment for the group and the staff.
· Break down of confidentiality. One of the basic norms is to maintain the confidentiality about all people says in the context of the group, but sometimes, and due to the level of anxiety, this norm is broken. Is a particular moment that all aspects of the training experience are en danger. Who is that brakes this norm? What we can do? How long is the conductor or staff responsibility? What about the meetings the conductors have between them? And what we can do if this norm is broken in the large group context? The capacity of the conductor and the small group, or the ability to manage this situations by the members of the staff or the conductors of the large group are tested by all trainers members. How to do with it, and to some extend we can consider this aspects in a social contexts, are problems we need no resolve.
· The modifications of the structure. During these 17 years working with this programme we have considered some many possibilities to modify the structure. May be, two were the most important modifications during this period: to increase the numbers of week-end par year which means that some many people had to increase the training period; and the modification of a number of large groups and, consequently, the diminution of small groups number. Others modifications like the change of one of the conductors, or to accept the presence of a complementary and specific group psychotherapy course during our course, were moments of important tensions that force us to re-equilibrate our capacity of containing tensions and problems.
· Social situations. Always we work in a society context. And we can not refuse or impede the real presence of social tensions in our structure. Basically in the large group, but also in the small ones. Problems like nationalism, language, terrorism, strikes, fanatism, immigrations or racial problems, etc., are in the large groups and we need to take and talk about. These situations can do to a situations very particulars: for example, when we have the Iraq problem, just half of the members of the large group doesn’t assist, and provokes a serious problem, not only in the staff members that discuss how long we have to be members of the training course and political members of a society and a particular moment of our life. Only the capacity to maintain our capacity to think and to talk about, the normal acceptance and respect of individual positions allow us to maintain the training course and to take this aspects for increasing the structure capacity for be more closer to members and their circumstances.
· The individual professional evolution. An aspect that had be important during our program is to accept the individual and professional evolutions of the staff members. Not all members are in the same ideological position for ever. Our personal and professional experiences lead to a modifications in our point of view about group processes. There are moments in that the positions of the conductors are different; but our mutual acceptance and the personal commitment to maintain our differences in our post-groups meetings, are crucial
All these circumstances made a training course in permanent evolution. The capacity to integrate differences, to maintain our commitment, the crucial desire to offer a model of group work that allows professionals to increase their personal and professional level, are the result of the Dr. Ayerra and the team effort, and the consequence of the seminal philosophy Dr. Guimon had given always
Thanks.
Barcelona 15 august 2003
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