1. The care facilities of the Psychiatric Unit for Mental Development.

It is impossible to speak about group therapy or group in the optic of mental disability without considering the therapeutic context into which these activities are inserted.

The Geneva canton decided and this as far back as the seventies to dedicate a specific psychiatric care for the intellectually disabled, when needed.

Parallel to this, thanks to the family associations possessing a specific political will, have developed living and working environments, where activities are both occupational or leisurely, and which following a “built to fit” measure have tried to meet the different needs of this extremely diverse population.

Therefore in Geneva, parallel to our unit, there exists a “mental retardation network”, that is to say a socio-educational structure which is both vast and well organised, of which both private and public institutions receive important canton and/or federal subventions.

To come back to our own psychiatric unit for mental development, we have for tools for cure.

The two clinical units, which give a total of 18 beds, allow for cures in which recovery is truly necessary.

On the ambulatory side our consultations follow approximately three hundred people, as well as the families if they wish it, there is also a day hospital and a mobile team.

The day hospital receives people in pre- post- crisis, prepares the still hospitalised people for adaptation to future activities of the day hospital, it enriches the people for whom leaving the hospital in the short term is not predicted but whom can benefit of a relative opening to the external word with rehabilitating exercises.

The mobile team has to main orientations: help staff in diagnosis of crisis and sustain especially difficult departures from the hospital unit.

2.            Indications and Effectiveness

The presence of intellectual disability has often been considered a problem with regards to classic group therapy.

Without wanting to refute this point of view, it seems inevitable, on the contrary to use this technique within the curing framework when the population we are treating with presents intellectual disability and psychiatric pathology.

Obviously this approach presents characteristic aspects linked to the type of population considered. With patients possessing a relatively high verbal level, we can still make reference to Yalom's work on the theoretical level, especially when referring to intra-hospital patients, which means that they present severe pathologies.

Considering other situations instead, possessing acute characters and with patients possessing non existing or very low verbal levels, we inspired ourselves from Brenner's work, taking into consideration the important macrosocial limitations, and transferring into a group dynamic the evolutionary development from the sensorial to the cognitive right up to the microsocial.

Balint's work on regression was of help to us regarding less verbal groups, more closely linked to a population having important cognitive limitations for communication.

A part from the more typically theoretical and clinical aspect, we realised that a therapeutic approach in the Day Hospital, could not, on the administrative level cannot do without the extensive use of groups in this care facility, even if complementing other more classical individual therapies.

Our Day Hospital structure is a mixed structure which maintains certain typical characteristics of day time programs, and therefore specifically rehabilitative, but having to satisfy even the demands of short therapy centres, by this we mean the facilities of responses to psychiatric emergencies, this always in an optic directed towards our specific population.

The fact of having to take in patients in emergency cases (less rapidly for rehabilitative support) the day of the call, and in any case immediately after having placed the indications (with the eventual help from the mobile team) makes modular and group organisation necessary, in such a way as to allow first and foremost the most an evaluation and an indication as fine and as precise as possible regarding other group or individual therapies.

When other care facilities are considered, the hospital and consultation units, we will find more classic group therapies, with in-patient groups, and on the other with groups of the verbal type although adapted to our population.

Regarding criteria of exclusion, we can retain as valid (although in quite a broad sense) criteria of classic group therapy when referring to verbal groups and with relatively stable patients: autonomy, motivation, and capacity to understand and accept group rules.

When looking at classic intra-hospital groups, which take place within a containing framework, we use classic criteria of maximum inclusion, with a ‘ad personam' follow up if necessary (in maniac phases sever behaviour disorders, and close surveillance) on the part of the staff

In little or non-verbal situations or with severe patients, the criteria of need and/or urgency becomes the most important one and an “a posteriori” approach will be needed.

What seems to us as being important to underline is that, oppositely to what we could have thought, the group situation remains, in a very large majority of cases, a therapeutic approach remains a first level therapeutic approach, very containing, highly re-organising, which nonetheless allows moments of regression which are easier to pilot than they are in individual therapy.

We have been able to appreciate in our practice the presence of a typical group dynamic, that is to say a psychodynamic or underlying mechanism, in each one of our groups, even in those of a more educational and behavioural type. From this point of view Neri's work has helped us a lot in the understanding of the concept of group matrix and its application in clinical practice.

On the other hand, we have had to also admit that a solid personal training and good knowledge allied with an experience of personal experience of group psycho-dynamic are necessary for the staff in order to work with the patients' group material, whether it be verbal or non verbal, for whom the non verbal is on the front line.

As far as effectiveness of treatment in-groups or by a group is concerned we used several different types of scales and evaluative tools.

With an intellectually disabled population, we generally use the French version of the ABC (Aberrant Behaviour Checklist), supplied to us by the authors; with a questionnaire which avvale of the collaboration of a “proxy” or third participant, it is possible to observe behavioural disorders over one month time periods which can be reduced to one week.

The CARS (Children Autism Rating), the PEP (Psycho Educational Profile), and the APPEP (Adult Adolescent Psycho Educational Profile) are usually used for evaluations of autistic characteristics of the patients, and they give us a picture of the evolution over considerably long time periods of time.

3.         The groups in treatment facilities.

Generally, the principal difficulties our patients meet concern communication, maintenance, or referencing (in time, space, of the social or affective type), the handling of stimuli, socialisation, handling of affections, physical well being, and sexuality.

Going in further detail, group approaches depend the needs of each patient, needs which make him be directed into certain situation of which the facilities and tools for treatment are judged to be most appropriate.

Even when taking into account the real difficulties of the patients, the staff try to measure, as far as possible (and impossible) to take into account the desires of the patient, in order to reach the most useful and pleasant compromise.

In a characteristic way to our population, there may be a very easy and frequent movement between different facilities, and different groups and this on a more or less long period of time, depending on the patient's situation.

At the consultation two verbal groups of a more classical psycho-dynamic take place, once a week, of the “slow open” type, of which one is for patients of up to 30 years of age, the other one for older patients. They last 45 minutes each, with a post-group.

A new group, known as the “Treatment” group started in may 2000, and is built on a unit made up of 5 psycho educational type groups.

Bridging over between hospital unit and day hospital, and parallel to the “Treatment” group of the consultation, another group on the same team has been created, lasting 1 hour and a half, differently from its homonym, it is an open group, without duration limits in the medium tem.

Considering other groups of the hospital unit, there is essentially in-patient. They take place on Mondays and Fridays, and last 30 minutes plus a post group.

The rules of the group are announced at the beginning and can be reminded in case of slips. These groups have a containing function with regard to conflicts belonging specifically to the hospital unit and allow the purging of punctual crisis.

Now going over to the day Hospital, the groups which take place there have mixed participation, as we alluded to previously, in the sense that the participants are ambulatory patients, hospital patients on the way to departure, and of patients who will still need hospitalisation on the medium term.

As a general rule, group therapies are parallel to individual therapies and the common goal is to allow the maintaining of the patients capacities, of avoiding complete hospitalisation or at least of limiting its length, and this in the more general vision of maintaining patients living and/or work environments.

Out of the different groups, which take place in the Day Hospital, the ones which have the most social, light, and quiet atmosphere, and which precisely for this reason are the most difficult ones for the staff, can receive patients for which the intervention has urgency to it. As we have said before, it is precisely these groups, which allow an observation period, and simultaneously allow us to receive “au pied levé” patients who would otherwise risk, if not accepted immediately at the Day Hospital, a severe crisis and a complete hospitalisation. These groups therefore allow the ‘levelling' of patients.

In our clinical practice, we realised the importance of meals in the therapy. Meals are a fundamental moment for hygiene, pleasure and socialisation. This is why during meals, to a therapeutic aim, the staff eats with the patients in small groups, in different places: the Day Hospital, in the cafeteria of the Belle Idée grounds, at McDonalds, in restaurants around the city.

The more ‘technical' groups are oriented towards maintenance and amelioration of competence in patients. The different groups do, in reality, cover more than one demand, but in the general sense we will say that the group takes into consideration one main goal on one hand, and eventually the sub-population determined by verbal capacity and clinical situation. On this point, it is important to underline that the determination of a sub-population is not always needed and that sometime a broad spectrum of patients puts at work the group's dynamic.

Without making a list, we will use certain as example a few exemplary groups.

The group “Accueil”, that is to say more or less: “of the Hello”, opens the patient's day in the morning, and serves to give points of reference in space and time, and it is open to the vast majority of the patients.

The group “Arbres” which means “Trees”, receives mainly autistic non-verbal patients, works on the handling of stimuli and socialisation: patients go for a walk to touch a tree, then they draw it and mime it, the staff does the same.

The “Sonar” group (“Sonar”) also mainly receives autistic patients, has a thematic very similar to the group “Arbre” of which it is somewhat of an offspring, and in which the handling of stimuli. The groups “Sonar” is carried out with music, in and out of water, using immersed loudspeakers exactly as in synchronised swimming.

The groups “Logomotive”, which means “Logomotive” allying psycho-motricity and logopedia, receives a low verbal levelled population with medium and severe mental retardation, and works on communication.

Communication and socialisation have a position of first importance in different groups. “ Mobilisation et Découverte” (“ Mobilisation and Discovery” discovering the city and the countryside), “Ferme” («Farm”, walks to discover the Belle Idee farm), “Tombola” (“Lottery”, similar to the classic game), « Pâtisserie » (“Bakery” where pastries and salads are prepared to be offered to the whole Day Hospital) and « Vidéo » (“Video”, watching and commenting a video), these groups have a broad population and this helps interaction.

They are especially oriented to the handling of affections: “Café et Biscuits” (“Coffee & Cookies”), “Comment Faire?” (“How to do it?”), where the groups tries to feel, and understand emotional movements, to then be capable of handling them, eventually by miming difficult or funny situations. These are groups carried out with patients possessing a relatively high evolution and good verbal level.

The groups “Percussions” (“Percussions”, in this groups there also is an important work on emotions), “Danse” (“Dance”),”Aqua” (“Water” in a swimming pool), “Gym” (“Gym”), “Oxygène” (“Oxygen”) dedicate themselves to the physical well being and the physical self-image.

The group “Hommes/Femmes” (“Men/Women”) is specifically dedicated to the knowledge and handling of sexuality.

In the general sense, verbal groups and groups which need a relatively stable group matrix are called “very slow open” or “closed”.

When a very difficult population is approached, that is to say with an absent or extremely limited verbal capacity, with behavioural problems (hetero- and self-aggression) or with severe psychiatric pathologies, groups are closed but over a limited time period (for example four months), renewable. We cannot speak of a short therapy, quite on the reverse, we should speak of a “resistance therapy” What we want to avoid is the feeling of exclusion for patients which must nonetheless leave the group, allowing the entire group to participate until the end of limited period. We want also to avoid the burnout of the caretakers, which can be reassured to have to “hold on” for a reasonable amount of time. Furthermore, with this time period system a slow renewal of patients can be carried out.

The more accessible groups, with a lower verbal level and less technical demands are used as an observing space for patients who have only recently entered the Day Hospital. It is important to underline that these “accessible” groups, “warming up” groups open themselves to heterogeneous and instable population, as it is often said close to crisis and which therefore are more difficult to lead and which prove themselves to be harsh on the containing capacities of the staff.

The ratio between the staff and the patients varies between 1:2 and 1:3, an inferior ratio, taking into account the possible unexpected absences of the staff, could de-stabilise the group given that the containing presence of the staff is absolutely necessary to assure a relaxed and therapeutically effective framework.

4.            Conclusions

Our group work with intellectually disabled populations started a little more than 8 years ago from classical verbal groups.

From 1995 onwards, our Psychiatry Unit for Mental Development adventures itself in a new area of group work, open to a little or non-verbal population, elaborating pilot groups, to then continue with a more day-by-day practice integrating the groups into different treatment facilities.

The observation we made was the group structure adapts itself well to our population even is non-verbal thanks to its containing and re-organising nature.

Individual treatments result enriched and they are reciprocally complementary, serving as a preparation to groups, or being the groups a preparation to individual treatments.

Our patients are interested in participation to groups and show a greater tolerance (than we expected) to group situations.

An important point that is shared by the majority of our psychotherapeutic techniques is the necessity of finding objective methods with regards to the evolution of our patients, objectivity rendered even more difficult in a limited or non- verbal population like ours.

From the clinical point of view, our patients seem to have found an obvious satisfaction from taking part in our group activities, dropouts being few and attendance relatively faithful.

The final review that we can draw up is positive and encourages us to continue in this type of therapeutic work.

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