"" | Introducing Group Therapeutic Activities at a Traditional Russian Psychiatric Hospital: Resistance and Change

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Introducing Group Therapeutic Activities at a Traditional Russian Psychiatric Hospital: Resistance and Change

Tore Sorlie, Jurate Lazinskiene, Sigita Asvydiene, and Oleg Ponomarev

The study tookplace at three acute psychiatric wards at a large psychiatric hospital in northwest Russia. Previously, there had been no systematic group activities for the patients and limited multiprofessional cooperation. During a 2-year period, multiprofessional staff groups were trained in the use of groups as integral parts of the milieu therapy. The following factors promoted the success of the training: the support of the leaders and their participation in the program, trainers' knowledge in Russian language and culture, and supervised clinical group experiences. In addition, it appeared particularly fruitful that participants, through their participation in an experience group, were able to see the parallels between their here-and-now reactions to the trainers and aspects of their relationship to authority figures in the hospital. The exploration of these transference reactions made them aware of their projected feelings of anger, self-criticism, and worthlessness and facilitated creativity and cooperation with their leaders. The program was evaluated as successful and was continued for new staff groups.

KEYWORDS: Experience group; group therapeutic activities; psychiatric hospital; Russia;
transference reactions.

1 The study was financed by the Nordic Barents Health Programme and was supported by the
Regional Psychiatric Hospital No. 1, Archangelsk; the Northern State Medical University, Arch-
angelsk; the University Hospital of North Norway; and the University of Tromso.
2 Department of Clinical Psychiatry, University of Tromse. Correspondence should be addressed
to Tore Sorlie, MD, PhD, Department of Clinical Psychiatry, University of Tromso, 9291 Tromso,
Norway. E-mail: tore-sorlie@unn.no.
3 Kaunas University of Medicine, Institute of Psychophysiology and Rehabilitation,.
4 Lithuanian Group Analytic Society, Vilnius.
5 Mental Hospital of Arkhangelsk Region, Talagy, Russia.

ISSN 0362-4021 2007 Eastern Group Psychotherapy Society

During a 2-year period, multiprofessional staff groups were trained in the use of groups as integral parts of the milieu therapy at a traditional Russian psychiatric hospital. The article describes the implementation of the training program and the process of change in participants' professional attitudes, in their interactions with patients and coworkers, and in treatment routines. The main factors that influenced change are discussed.
Following the radical democratic changes of Perestroika, there has been greater economical, social, and political instability in Russia (Collins, 1995). This new situation has created major reform processes in Russian psychiatry (Polubinskaja, 2000). Politically motivated restrictions on the ideological content of psychiatry have been abolished. Central goals are to strengthen the social psychiatric approach and social support systems, develop new methods of rehabilitation, and integrate psychiatry into general somatic medicine (Poloshij & Saposhnnikova, 2001). Treatment standards have been elaborated, and regional health authorities monitor their implementation. There are, however, great regional differences (Rezvyy & Parniakov, 2001).
The study site was a large psychiatric hospital with 1280 beds situated in the city of Archangels in northwest Russia. Its catchment area has 1.3 million inhabitants. The current hospital leaders were of younger age than their predecessors and oriented toward improvement of the treatment system. Over time, there had been several projects in cooperation with partners in other countries.
Still, there were limitations in treatment capacity and quality, particularly for psychotic patients. The community-based health care system for psychiatric patients also had limited resources. Some public social welfare services were available. However, patients needing practical help and support when living outside the hospital had primarily to rely on their families.
There were nine acute psychiatric wards, each with 60 patients. Compared to Western psychiatry, the staffs were small (each ward had 12 nurses, 20 nurse assistants, 3 psychiatrists, and 1 social worker) and the material conditions poor. Each acute ward consisted mainly of one large living room, including one part that was used for dining, and three large, 20-bed dormitories. The patients could not keep personal belongings at the ward. There were no small group activities within the ward and only limited activities going on outside the ward. In particular, there was no organized occupational therapy.
Although psychological, social, and cultural aspects were considered in the evaluation and treatment process, professional practices were mainly psychophar-maceutical. The same tendency is seen also in acute wards in other countries, where the patient load is high compared to available time and treatment resources. A main task for the nursing staff was to observe patients' behavior following their medical treatment and report to the prescribing doctors. A multiprofessional milieu therapy was not developed.
The patients were spending most of their time in the wards' large living rooms. No time was used for small group activities. Distance and control characterized the staff-patient relationship.

Thus, despite the existence of a strict formal structure, there was minimal structure available that could assist the patients in relating to and organizing the variety of influences that they were subjected to from other patients and treatment personnel. There is impressive clinical evidence that unstructured groups, with minimal organizational structure and no clearly denned task relating that group to its environment, tend to bring about an immense regression toward the activation of defensive operations and interpersonal processes that reflect primitive internalized object relations. In particular, this is the case in individuals with a low degree of maturity and psychological integration such as those with severe character pathology, borderline conditions, or psychotic syndromes (Kernberg, 1987).
Use of groups has been advocated as an important part of the therapeutic community environment (Hansen & Slevin, 1996; Oldham & Russakoff, 1987) and represents a major tool in promoting a humanistic perspective within custodial institutions. Groups should be used as integral parts of this social structure and the treatment program of the hospital and not be inserted as foreign bodies (Kibel, 1991).
On the initiative of the director of the hospital, multiprofessional training in group-therapeutic activities was organized for staff groups at three selected acute wards during a 2-year period (2003-2004). The training took place during four blocks, each lasting 2 weeks. Two Lithuanian group analysts who speak Russian fluently conducted the training.

DATA COLLECTION

The first author participated in the planning process and in supervising the implementation of the training program. Together with the remaining Norwegian project group, he had yearly evaluation meetings with the participants of the program. The second and third authors collected their information as conductors of all parts of the training program (participating observation). They systematically made process notes from the workshops, which subsequently were discussed with the first author. The fourth author, who is the director of the hospital, contributed with information about the hospital and contemporary Russian psychiatry. He also contributed with information about the effects of the program within the hospital.

THE PLANNING PROCESS

The program was planned in cooperation with representatives of the leadership of the hospital (the director and the chief nurse) and north Norwegian partners and was supported by the ministry of health in Archangelsk oblast (county). It was financed by the Nordic Barents Health Program. During the first workshop, a local organizing committee with representatives from all participating wards was established to strengthen local involvement, motivation, and responsibility for the program.

PARTICIPANTS, STRUCTURE, AND CONTENT OF THE TRAINING PROGRAM

Seven or eight staff members were selected from each participating ward: two psychiatrists, four or five nurses, and one social worker. One member from the hospital administration participated in one group, two in another, and none in the third group. From all wards, the head doctor and nurse participated. The daily structure included one theory lecture, one supervision session for each ward staff group, and one experience or training group for all participants (N= 26). Both trainers conducted the supervision group where there was no administrative member. The other supervision groups had one trainer. Both trainers attended the experience group.
The lectures covered psychodynamic aspects of mental illness, milieu therapy, teamwork, group psychology, and group therapy of psychiatric patients with varying degrees of problem severity. During the second year of the program, the lectures gradually developed into technical seminars, in which participants presented their own clinical work for supervision by peers and conductors.
In the supervision groups, verbal presentations and written reports were used. Goals, structure, role differentiation, and technical issues in different working groups were discussed as well as participants' fears and resistances connected to different aspects of their group experiences. Especially in the beginning, the trainers modeled how to approach the presented material with a respectful and exploring attitude. Over time, peers' active involvement in the supervisory process increased.
Monthly theory seminars were arranged locally, and a reading list was elaborated. The conductors brought relevant literature to be studied. Most literature was in English, but some was translated into Russian.
The goal of the daily experience group meeting was to study large group processes and to collect and process information that might enhance the progress of the program. The interaction was verbal, and there were no thematic restrictions. Participants were invited to a free-floating group discussion modeling the free association of psychoanalysis.
The task of the trainers was primarily to create and maintain a culture of inquiry, mainly by modeling an analytic attitude (Foulkes, 1986). This means to be nondirec-tive, to receive all communications as potentially meaningful, to use verbal methods (clarification and interpretation) to communicate about and analyze the relationships that develop between members and between participants and the trainers, and to understand the trainers' position as transference figures and treat the interpersonal relationships in light of this (Lorentzen, 2004). Participants' thoughts and reactions as participants in the program were verbalized and explored. They were invited to express how the program influenced attitudes, roles, behaviors, and routines in their clinical work. Interactions within the group and border incidents (irregular attendances and dropouts) were addressed and analyzed. When similarities were
obvious, parallels between group dynamics and dynamics within the wards as well as in the hospital system were addressed.
Between sessions, the trainers were systematically sharing their experiences to develop an understanding of the dynamics of the groups and to restore their own emotional equilibrium and sense of reality. They had a couple of supervision sessions with another group analyst (T.S.).

LEARNING PROCESSES WITHIN THE TRAINING PROGRAM

Experience Group Processes

Initially, the trainers experienced that they were met in a polite and somewhat pleasing way. Underneath this surface, they experienced a lot of hidden insecurity and ambivalence. Previous experiences made participants expect lectures and not any personal and long-lasting commitment, where their own relational experiences should be focused.
Instability and unpredictability characterized their participation. In every new workshop, and also within each workshop, people just disappeared and new ones appeared without any spontaneous good-byes or welcoming attitudes. Changes in the hospital organization and leadership that occurred between the first and second workshop contributed to this instability. Several individuals in central positions were exchanged. Some of those who originally attended the program as representatives of the administration disappeared, and new ones appeared. Some continued in new roles.
When addressing these irregularities and encouraging the participants to express their corresponding reactions and thoughts, a lot of insecurity and criticism toward the leaders were displayed. When participants were encouraged to explore the meaning of these feelings here and now in the group, the responses were initially dominated by silence. The participants were passively waiting for any initiative from the trainers and had little courage to speak up independently. Lack of cooperative attitude made the trainers feel isolated and uneasy. When the silence was explored and participants were asked to express their thoughts and worries in this tense situation, it appeared that the trainers were supposed to take care of all decision making, without any need for participant involvement.
When the participants gradually realized that they had projected authoritarian attitudes onto the trainers and interacted as if these attitudes were real, this became a corrective relational experience. A safer atmosphere emerged, and more open expressions of their here-and-now and daily fantasies and fears were displayed. This openness also helped them acknowledge the defensive nature of their submissive and irresponsible roles, both in the group as well as in their daily work. They could also realize how their submission had made them feel weak and vulnerable and thus contributed to the conservation of the system they were now reacting
against. By not taking responsibility for their own negative feelings and thoughts
and projecting them onto their leaders, they had made themselves passive victims
without any responsibility.
Over time, when the group became livelier, its dynamics also were characterized by subgrouping and rivalries between the three ward staff groups, but also between the different professional groups across the wards. On one hand, subgrouping may have represented a defense against anxiety in the median group setting and against direct interaction with the trainers. Rivalry was expressed through comparisons between the staff groups and appeared to express a wish to be the preferred sibling. On the other hand, subgrouping and rivalry also appeared to represent a striving toward autonomy and competence.
When feeling more responsible for their own situation, critical comments toward their leaders diminished. They realized that external enemy expectancies and experiences had created internal enemy pictures that easily were activated and projected as a part of a self-suppressing mechanism.

Clinical Group Experience and Supervision

Initially, there were no systematic group activities on any of the wards. However, already at the end of the first week of the second workshop, a weekly community meeting was initiated on all three wards, wherein all patients and staff members participated. A succeeding staff meeting was arranged. These meetings were later run on a regular basis. Small group activities were initiated on all wards following the second workshop. Initially, they were more sporadic and focused on both practical and informational issues. The regularity improved over time. Between the third and fourth workshop, some regular small group activities were initiated on all three wards.
During the staff group meetings (following the ward community meetings) and the supervision groups, the participants experienced the benefits of sitting in a multiprofessional team discussing their professional lives as equal partners. Previous culture had been dominated by the instructions of powerful doctors, which had been executed by powerless nurses and other staff members. These roles had created a lot of rivalry and conflict between different staff groups, which had not previously been discussed openly. However, by expressing and exploring thoughts and feelings in the supervision groups, it appeared that even the doctors had felt powerless and restricted by the hierarchical structure of the hospital and felt helpless in coping with all the power they had been attributed by the remaining staff. Previously rigid professional roles were softened, and they could relate to each other as ordinary human beings being mutually dependent in striving for common goals. They gradually realized each other's strengths and weaknesses. The doctors could acknowledge the competence of the nurses and social workers and felt relieved by
sharing responsibility with them. At the same time, the nurses and social workers showed more initiative and responsibility as decision makers. The basis for mul-tiprofessional teamwork was emerging. During their ward community meetings, the humanity of the severely mentally ill patients became more apparent. By communicating directly, staffmembers realized that the patients had healthy parts with which they could identify and communicate. One of their disturbing fears had been that direct contact with groups of patients would create uncontrollable and violent behavior. It was a surprise that patients in the community meetings, and in the small therapy groups as well, were quite polite, listened, and had a capacity to regulate and normalize each other's activity. Another disturbing fantasy that was corrected was that patients who were allowed to cry would cry endlessly and uncontrollably.
The protective aspects of the participants' ideas about the patients became obvious. When they were given the opportunity to share their own painful feelings, a better differentiation between their own and the feelings of the patients as well as improvement in their emphatic capacity occurred. Gradually, they realized that the patients were motivated for their own treatments and healing processes and even should be main participants in this process.

DISCUSSION

The interpersonal focus of the program strongly provoked the existing biologism and the hierarchical relationship between staff groups. The fact that the program was started on the initiative of the director, with an ambition to change practice within the hospital, made participants look on the program and its trainers as a prolongation of his authority. This created a lot of ambivalence and resistance toward trust and openness within the program, which was displayed and handled in the daily experience group. Training programs addressing the needs of the individual trainee in independent training programs are much easier to conduct, but their impact on change in health care systems and practice are more uncertain. At the end of the program, teams were functioning on a formal level on all three wards. Weekly community meetings and weekly small working groups took place on all wards. Change in professional attitudes and interplay with patients and coworkers as well as in treatment routines were significant. Most important was that the staff had an increased feeling of support from their leaders, both on the wards and on a hospital level. They felt more responsibility for individual patients, and daily work had become more challenging. They were now to a much greater degree aware of the experiences of the patients and their own reactions and thoughts as well. Open disagreements and discussions were more commonboth with patients and colleagues. They had to rely on the patients and on each other, risking unpredictable reactionsand change. All participants wished to continue the program beyond the 2-year period. What were the main factors that influenced this process of change?

Leadership's Involvement and Support

From the very beginning, the director and the chief nurse had been directly involved in the planning of any aspect of the program. They also participated in some of the program's experience group meetings. Their acceptance and participation was essential in establishing the legitimacy of the program, in motivating for participation, and in encouraging for change. The legitimacy of the program was also strengthened by being in accordance with the reform process in Russian psychiatry (Polubinskaja, 2000) and by the support of the health authorities of the Archangelsk oblast.
The rapid initiation of community meetings and small group activities was a direct response to the recommendation of the director.
Despite the fact that the director had initiated the program, he was subjected to participants' projections of their internalized pictures of unpredictable and authoritarian figures that were based on tradition and their previous individual experiences. During the first couple of workshops, this criticism made the director doubt the usefulness of the program. However, when similar transference reactions also were reproduced and processed in participants' relationship to the trainers in the experience group sessions, the skepticism of the director gradually diminished.
More continuous information about the dynamics of the program and support for the director and his staff probably would have improved the progress of the program.

Experience Group Processes

The strong tendency to silence any conflict or unpleasant feeling that initially was displayed in the experience group was similar to previous experiences within a group analytic training program in Vilnius (Lorentzen, 2004). This collective defense mechanism, probably inherent in the culture, did inhibit the development of a culture of inquiry during the first year. According to Brown (2001), the social unconscious can manifest itself through different collective defensive mechanisms that protect the group members against anxiety and counteract attempts at making people aware of social connections. The silence probably also reflected the fact that the trainers invited the participants to disclose and ventilate their more secret emotional domains, which would make them even more vulnerable. Previous treatment culture had not emphasized the importance of the emotional reactions of the staff.
It also appeared that the participants were expecting the trainers to take all responsibility for the activity in the group. This projective mechanism in groups was already pointed out by Freud (1921) in "Group Psychology and the Analysis of the Ego," where he suggested that a leader can occupy the role of superego for members

of a group, who are thus freed not only of responsibility for decisions, but also of burdens of self-criticism and doubt.
When the participants were expressing their insecurity and criticism toward their hospital leaders in the experience group, it was quite crucial that the trainers assisted them in exploring the meaning of their experiences and recognizing similar feelings toward them here and now in the group. Any tendency in the trainers to identify with the participants' criticism of the director and his staff would have been seriously counterproductive. Free associations and disclosure of vulnerable individual experiences helped participants realize how they habitually had been projecting their internalized punishing and persecutory superego parts on their leaders, and on the director, in particular. This repetition in the experience group setting of patterns of social interaction belonging to their ordinary working situation is consistent with Hopper's (2002) theory of group transference or repetition compulsion. Here Hopper postulates that people from a given culture, through acts, fantasies, object relationships, and feelings, will have a tendency to recreate earlier situations within new group constellations.
When participants gradually reinternalized their superego functions, they also realized how they, through their previous passive and submissive roles, partly had been responsible for reproducing the authoritarian system they were now reacting against. This process of reinternalization made them more aware of their own responsibilities and capacity to influence their own job situation.
A more continuous training program (not in blocks) may have improved the possibility to recognize this tendency as a pattern and, consequently, its cultural and dynamic functions and roots.

Trainers'Knowledge in Russian Language and Culture

Both trainers were speaking Russian fluently. Thus there was no need for language translation. Their group analytic training took place in a block training program in Vilnius (Lorentzen, Maar, & Sorlie, 2002a). In this program, where the group was used as the interpreter, the use of English had created a lot of difficulties in the translation and interpretation process (Sorlie, Maar, & Lorentzen, 2000). Greater language problems were encountered in a block training program run in Russia, where a language interpreter was used to establish communication between Russian-speaking participants and English-speaking trainers (Lorentzen, Maar, & Sorlie, 2002b).
The trainers recognized cultural similarities between the study hospital and psychiatric hospitals in which they had been working in Lithuania. This facilitated their capacity to grasp the individual, professional, and cultural meaning of the communication and dynamics in the training groups and in the hospital as well.

Group Experience and Supervision

The rapid initiation of ward community meetings on all three wards was due to the encouragement of the conductors and to the recommendation of the director. By communicating directly with the patients, staff members learned to know better their healthy parts and their cooperative ability. The participants also had to encounter their countertransference reactions, which they previously had controlled by keeping distance from the patients. As a result, a biological perspective on mental illness and treatment was gradually exchanged with a biopsychosocial perspective, where they also realized the importance of the individuality of the patients and their role in their own treatment processes.
During the staff meetings that followed the ward community meetings, the participants experienced being partners of a multiprofessional team who could mutually benefit from each other. Previous culture had been dominated by the orders of powerful doctors, which had been executed by powerless nurses and other staff members.

CONCLUSION

The success of the program was supported by the leaders' involvement and
belief in the training program, the trainers' knowledge of Russian language and
culture, and supervised clinical group experiences. In addition, it appeared par
ticularly fruitful that participants, through a daily experience group, were enabled
to see parallels between their here-and-now reactions to the trainers and aspects
of their relationship to authority figures in the hospital and in the society as well.
The exploration of these transference reactions made them aware of their projected
feelings of anger, self-criticism, and worthlessness and facilitated creativity and
cooperation with their leaders.
Following this program, another 2-year program for the staff groups of three new wards was initiated in spring 2005. The number of trainers has been extended to three, and a support group for the director of the hospital and his staff has been established. In addition, the initial training group is being followed up with supervision sessions and theory seminars.

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