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Psychodynamic Group Psychoterapy in the Early Intervention Program for Patients with Psychosis

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Psychodynamic Group Psychoterapy in the Early Intervention Program for Patients with Psychosis Psychiatria Danubina, 2018; Vol. 30, Suppl. 4, pp S198-202 Conference paper © Medicinska naklada - Zagreb, Croatia PSYCHODYNAMIC GROUP PSYCHOTERAPY IN THE EARLY INTERVENTION PROGRAM FOR PATIENTS WITH PSYCHOSIS (RIPEPP) Branka Restek-Petroviü1,2,3, Nina Mayer1 & Majda Grah1,4 1Psychiatric Hospital “Sveti Ivan”, Zagreb, Croatia 2Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia 3Faculty for Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia 4University of Applied Health Sciences, Zagreb, Croatia SUMMARY Psychiatric Hospital "Sveti Ivan" in Zagreb, Croatia, offers an outpatient Early intervention programme for patients with psychotic disorders (RIPEPP), consisting of psychoeducational workshops and group psychodynamic psychotherapy. Psychodynamic group psychotherapy presents a unique conceptual format not offered by other types of psychotherapy, and it is especially useful for population of patients with psychotic disorders. During group work, gradual establishment of communication and interactions, and creating a network of relations through experiences of corrective emotional symbiosis, affect the constellation of internal objects and relationships between members, and their restructuring. The function of group psychotherapy is not only to offer relief, support, and elements of education, but also to enable internal changes. Therapeutic factors contributing to the improvement of people with schizophrenia include supportive aspects such as universality, acceptance, cohesion, hope and altruism. This paper contains vignettes from inpatient and outpatient group dynamics. Key words: early intervention - group psychotherapy - psychosis * * * * * INTRODUCTION 1992). The group helps members understand how long lasting inner conflicts and non adapted behaviour affect Psychodynamic group psychotherapy and its speci- their lives, in order to reduce the difficulties and ficities, such as its realistic and democratic setting, pre- improve the functioning of the ego. sents a unique conceptual format not offered by other Specific therapeutic group factors such as cohesion types of psychotherapy, and it is especially useful for and mirroring can also positively affect personality struc- the population of patients with psychotic disorders ture stabilisation by creating opportunities for corrective (Gonzales de Chavez 2009). Patient in the group has the symbiotic experiences and forming a more stable self opportunity in the here-and-now situation to meet and which could in turn contribute to lowering the risk of share therapeutic space with other patients, to establish psychotic episode relapse. Therapeutic factors contribu- communications with them under stable and nurturing ting to the improvement of people with schizophrenia in- conditions, and to share experiences and learn from clude supportive aspects such as universality, acceptance, them (Restek-Petroviü 2014, 2017). cohesion, hope and altruism (Yalom 2005, Gonzales de Group psychodynamic psychotherapy of patients Chavez 2009). Cohesion ensures a sense of wholeness, with psychotic disorders actualizes the dynamics of unity, positive group climate and therapeutic alliance, and object relations in a 'here and now' situation, and makes it may well be an important factor contributing to creating it visible and accessible. This means that the gradual opportunities for corrective symbiotic experience (Urliü establishment of communication and interactions and 1999a, 1999b, 2012, Restek-Petroviü 2017) which is of creating a network of relations, through experiences of great importance for a number of people with psychotic corrective emotional symbiosis, can affect the constel- disorder. The group also helps reducing anxiety by lation of internal objects and relationships between them therapeutic factor of universality when patients in the and their restructuring (Urliü 2012, Štrkalj Iveziü & group realise that they have experiences similar to others. Urliü 2015). By establishing a group matrix in a long- The group experience encourages people to stay in lasting group process, primitive object relations and therapy and take an active role in fighting demoralisation, primitive defence mechanisms become actualised and self-stigmatisation, social exclusion and low self-esteem. accessible to analysis and scrutiny, while the corrective The group has an empowering effect for its members emotional experience of good symbiosis in the group through creating capacity for recognising their own opens the way to more mature and stable interpersonal feelings and helping others which in turn increases relations (Urliü et al. 2009, Urliü 2010, Štrkalj Iveziü & sense of self-worth and gains acceptance and respect Urliü 2015). Group-as-a-whole can act as a "good from others. Therapeutic group needs to be a place that mother", a person who cares and helps group members allows safe containing of different contents, including to integrate their split parts of the self (Roberts & Pines projections of incomprehensible psychotic experiences. S198 Branka Restek-Petroviü, Nina Mayer & Majda Grah: PSYCHODYNAMIC GROUP PSYCHOTERAPY IN THE EARLY INTERVENTION PROGRAM FOR PATIENTS WITH PSYCHOSIS (RIPEPP) Psychiatria Danubina, 2018; Vol. 30, Suppl. 4, pp 198-202 There is scarce experience in application of psycho- GROUP PSYCHOTHERAPY dynamic group psychotherapy in the early intervention IN RIPEPP PROGRAM programs in the world. Group therapeutic format is frequently used, but mainly in the more structured form The therapeutic team of group analysts in the (CBT, psychoeducational or supportive groups) with RIPEPP program generally accept that group psycho- time-limited frame (Addington & Addington 2006, therapy combined with antipsychotics is an effective Woodhead 2008, Restek-Petroviü et al. 2015). method of treating psychotic disorders (Kanas 1996, Gonzales de Chavez 2009). EARLY INTERVENTION PROGRAM Group analysts in our therapeutic team accept the FOR PATIENTS WITH PSYCHOTIC conceptual position that psychotic disorders are a conti- DISORDERS (RIPEPP) nuum of mental disorders, among which the psychoses are the most severe (Schermer & Pines 1999, Urliü The Early Intervention Program for patients with 1999a, 1999b, Štrkalj Iveziü & Restek-Petroviü 2012), psychotic disorders (RIPEPP) has existed at “Sveti Ivan” and they are optimistically oriented towards the possi- Psychiatric Hospital in Zagreb since 2005. It was desig- bility of attainment of higher levels of object relations, ned and financed with hospital resources, and is based on inter-subjectivity, and empathy. The function of group the psychodynamic theoretical framework of understan- psychotherapy is not only to offer relief, support, and ding psychotic disorders, years of experience in the ap- elements of education, but also to enable internal plication of modified group analysis in treating psychotic changes. Patient groups are not designed to be solely disorders and the international experience in the applica- places for “adaptation training” – for the construction of tion of group techniques in early intervention programs. a more functional and adaptable false self (Schermer & The program includes patients in early phases of Pines 1999, Winnicott 1965) that is better suited to com- psychotic disorders treated both at the hospital and in munity norms – but also a place where the psychotic outpatient treatment, which are within the “critical experience is transformed, where early traumatic expe- period” of five years from the first appearance of riences and primitive fantasies are discovered and psychotic symptoms. The RIPEPP program is intended analysed, and where psychological defence mechanisms for patients with acute psychotic disorder, schizo- are developed, leading to integral clinical and social phrenia, schizoaffective disorder, delusional disorder, or recovery (Restek-Petroviü 2008). bipolar affective disorder with psychosis, and it includes Group psychotherapy in RIPEPP program for both patients and their family members. The goal of the majority of patients is applied in two settings and program is complete clinical and social recovery of the according to the level of therapeutic intervention in two patient through the attainment of insight into the stages: disorder and the acceptance of treatment, as well as the 1. Inpatient group psychotherapy – an atmosphere prevention of relapses (Restek-Petroviü 2012, 2017). of safety, support and empathic acceptance is created The RIPEPP program encompasses several thera- within which the psychotherapy process begins (Mayer peutic activities: et al. 2017). Work is performed on initial insight into Psychoeducation - carried out in a series of 15 inter- the nature of the disorder, as well as into triggers that active workshops led by psychiatrists, cognitive- led to mental decompensation. A therapeutic alliance is behavioural therapists, with the cooperation of forged with patients and their families, and patients are psychiatrists who are group analysts. The 60-minute motivated to join the long-term, outpatient part of the workshops are intended for patients and their family RIPEPP program. The level of therapeutic interventions members and are held every two weeks as a large is supportive, aimed at cohesion building, mutual open, task-oriented group. The workshop topics vary support and understanding. and cover a wide spectrum of information on the Vignette 1 disease symptoms, their aggravation, ways of moni- toring, pharmacotherapy, relapse
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