Irvin Yalom called psychotherapy groups a 'social microcosm' [Irvin Yalom 2007, p.32]. Psychological support groups and closed psychotherapeutic groups are especially important for patients in psychiatric institutions. The article substantiates the value of group work in psychiatric institutions; describes the main forms of group interaction; the features of interaction with patients in Russian psychiatric hospitals are analyzed. The proposed concept of care and work with patients is based on the ideas of positive and transcultural psychotherapy by Nossrat Peseshkian. The purpose of this article is to actualizethe importance of group forms of work with patients for specialists in helping professions.

Irwin Yalom called psychotherapy groups a "social microcosm" [Irwin Yalom 2007, p. 32]. Psychological support groups and closed psychotherapy groups are particularly important for patients in psychiatric institutions. The article substantiates the value of group work in psychiatric institutions; describes the main forms of group interaction; analyzes the features of interaction with patients in Russian psychiatric hospitals. The proposed concept of patient care and work is based on the ideas of positive and transcultural psychotherapy by Nossrat Pezeskian. The purpose of this article: to update the importance of group forms of work with patients for specialists of helping professions.

The relevance of this topic is due to the increase in public interest in psychological forms of work with patients of psychiatric institutions. In addition, neurological hospitals increase the number of jobs for medical psychologists. And also, the number of specialists undergoing training in psychotherapeutic methods is increasing. At the time of writing, in a pandemic, most medical facilities prohibit patient visits; which leaves people in even greater isolation without the direct support of loved ones. As a result, the importance of group work with patients increases.

Unfortunately, many medical psychologists have to deal with the lack of involvement of psychiatrists, heads of departments, middle and junior medical personnel in deep cooperation.   According to my observations, this is due to a lack of interest and understanding of the value of the inner world of patients. Often, the process of treatment is reduced to the relief of existing symptoms; And about the attitude towards patients, in some places, it is anti-therapeutic.

The writing of this article is based on the experience of working in a psychiatric institution and studying the experience of European countries. In the article "Reforming the psychiatric service. The experience of the USA and Europe" of the Independent Psychiatric Journal, L.A. Tsyganok reviews and analyzes the experience of the psychiatric movement in European countries and the United States [Tsyganok L.A., 2007].  It underwent a detailed study of WHO prescriptions for psychiatric care.

An analysis of the theoretical and historical material before andafter the reforms introduced by the French physician Philippe Pinel allows us to trace the importance of a humane and flexible approach to the treatment of patients.

The analysis and theoretical development of an effective way to help patients inside hospitals were based on observation, own experience in a neuropsychiatric hospital and interaction with specialists in various fields. Much attention was paid to the ideas of Positive and Transcultural Psychotherapy. The works of Irvin Yalom and his artistic description of the process of psychotherapeutic work also made a great contribution to the writing of this article.

Outcomes

From the point of view of modern ideas about humanity and treatment, initially, the goal of psychiatric hospitals was set incorrectly. The first psychiatric "cures" aimed to "isolate" the patient; not to "cure" or "help." As we remember, Philippe Pinel, a French psychiatrist at the Salpêtrière hospital, in 1795 decided to remove the chains and shackles from the mentally ill, which had already led some patients to recovery. Now we cannot say that patients are openly violent. However, its passive forms, interfering with recovery, in the form of stigmatization, restriction of rights and freedoms, isolation, rudeness - are found everywhere in Russian psychiatric practice. 

High workloads on medical staff, strict protocols, and staff shortages exacerbate the disinterest of medical personnel in the inner world of patients.

As a consequence of disinterest, there is a habit of "stigmatizing". That is, to try to adjust the state of a person to a certain framework, clearly and clearly describing what is happening to him. Yes, it helps the doctors and the institution. This is really easier in terms of documentation and pharmacotherapy. However, this does not benefit the boys themselves. For doctors, too, these are diagnoses based on rapid diagnosis, which is especially often observed on medical commissions (the so-called overdiagnosis). For psychologists, this is an attempt to "insert" a person into certain patterns, supposedly describing how the inner world of a patient is arranged, for example: "hysterical", "epileptoid", "schizoid", "demonstrative", "narcissistic", etc. However, the use of these concepts, from the point of view of benefits for the patient, practically does not make sense without involvement in the external world and interest in the individuality of each individual.

For the above reasons, patients and their relatives, in recent years, have increased their attention to non-state psychiatric care institutions. According to the statistics of the private psychiatric clinic "Clinic Rosa", the growth rate of patients with mental disorders in the non-state psychiatric service of Moscow increases annually, increasing over the past 7 years by an average of 20% per year (by 24%, 81%, 28%, 4%, 7%, 20 %, respectively) [Filashikhin, Avedisova].

The importance of improving the level of education among doctors, as well as junior and secondary medical personnel, is undeniable. In particular, this applies to the study of the psychological aspects of mental patients.  In my opinion, it is very important to organize assistance to medical personnel in understanding their own style of interaction with patients; the possibility of obtaining timely psychological assistance and the prevention of emotional burnout.

Approaches to mental health care

Approaches to the provision of psychiatric care in different European countries differ, but not too critically. All European states follow the requirements of the World Health Organization (WHO). Accordingly, it is possible to trace the general directions of development.  [Kolpakova, Tarasova]

1. Deinstitutionalization. Pimplies the closure of public psychiatric hospitals or the reduction of their inpatient departments, by reducing the number of beds and funding. This approach allows the private sector and non-governmental organizations (NGOs) to set up residential care facilities where treatment takes place in a more homely environment and atmosphere.
2. Decentralization of mental health care.  It means the transfer of inpatient units for the mentally ill from specialized hospitals to citywide ones. This policy is primarily aimed at the inclusion of psychiatry in the general health care system, the integration of mental health with primary care, and the development of residential institutions.
3. Increased community care.  This approach calls for delegating some of the authority to provide assistance to social groups and organizations located in the area of residence of the mentally ill. These may include communities of patients or their relatives, as well as NGOs.
4. Increased attention to non-drug therapy.  Psychotherapy began to be engaged not only by psychiatrists, but also by other specialists. Including a non-medical profile.
5. Implementation of legislative reforms to ensure the civil rights of patients. That is, the formation of a legal framework for mental health policy. In particular, the tasks include: regulating involuntary hospitalization, providing adequate treatment conditions, fighting for non-discriminatory jobs and education, developing social support, and ensuring the right to privacy and family life.
6. Destigmatization. Psychiatric patients are severely stigmatized, which leads to loss of social status, discrimination, unemployment, isolation, and reduced life opportunities. To reduce the negative impacts, as part of the work to develop community care, programs and strategies are being created to reduce stigma and change stereotypes associated with PS.
7. Focus on improving the quality of life of patients.  Over time, this principle has become an important concept of the modern model of medical care. Psychological and physical well-being and social participation have come to the fore, not just symptom reduction or survival.
8. Involvement of family members and loved ones in the process of treating patients. It is important that along with involvement, there is an awareness of the burden that falls on the shoulders of caring relatives. They also try to provide support.

In Russia, they strive to follow the European vision and the WHO prescriptions. However, these prescriptions are often formal. Changes that are implemented in existing systems take place without proper training of specialists. In addition, there is the problem of remote regions, which should also fall under the influence of changes, but often remain without due attention.

"The law, first of all, takes care of reducing the negative consequences for the state - meaning the reduction of cases of disability and disability, crime, unsuitability for military service, etc." [Tarasova A.Y.] The rights of patients are mainly taken into account in the regulatory documents on inpatient treatment, but what happens to people outside and inside the hospital often contradicts the original goals of the created enterprises.

The value of group work with patients in psychiatric hospitals

Analyzing my own experience in a neuropsychiatric hospital, I deduced a diagram of the most effective interaction between the members of the therapeutic process to help patients. This scheme is based on the unity of specialists helping professionals among themselves, with the patient and with his close environment.

Fig 1. Effective interaction between staff and patients in medical institutions:

As can be seen from Figure 1, almost all elements of the system must interact with each other for comprehensive and comprehensive patient care. Unfortunately, in the Russian realities of medical institutions, we can observe the absence of such interaction. The links of care are either separated from each other, or the medical staff, and especially the doctor and psychologist, speak "different languages."

Also, as can be seen from the proposed scheme, a rather important element is the interaction of patients with each other. That is why, one of the most important and effective forms of treatment are psychotherapeutic groups.

In psychiatric institutions, the psychologist has to assemble psychotherapeutic groups "from what is." Taking into account the different length of stay in the hospital, diagnoses, stages, the patient's condition, it is necessary to adapt the group to those patients who are already on inpatient treatment.

According to my observations, being in an atmosphere of acceptance and support is the main factor in improving the well-being "here and now" among hospital patients.  But unfortunately, we have to deal with the fact that almost all the emotional manifestations of patients, whether it is crying or irritation, the desire for confrontation, perseverance in defending their own interests - are perceived by medical personnel as "abnormal". As if disobedience, even one that does not harm the well-being of the patient and the people around him, needs to be treated urgently. The message is given: "you can't show up and be yourself - you're pathological."  It happens that the words or actions of patients are taken by medical personnel "at their own expense", which entails abuse of power. And often, the very actions of medical personnel provoke various emotional and behavioral reactions in patients.

As a way out of this kind of difficulties, I see the organization of seminars and psychological training groups for medical personnel to develop an understanding of the importance of humane treatment of patients and the creation of an atmosphere of care and acceptance within the walls of a medical institution.  Such training and psychological groups in which medical staff could understand their way of interacting with patients, receive information and feedback; find and work out within themselves the reason that affects the way they interact with patients and rebuild their own forms of communication.

3.3 Classification of group PP in a hospital setting

As you know, groups according to the composition of participants can be:

- Homogeneous.  That is, collected on any grounds (gender, age, diagnosis, request, etc.)

- Heterogeneous.  A group in which the various prizes listed above meet.

I would single out two main forms of work with patients in a psychiatric hospital:

1. Psychological support groups.  They can be used for patients whose period of stay in the hospital is less than two months. That is, the period that is not enough for the development of gradual close and stable contact with other members of the group. These groups can be created for a longer period, to create an atmosphere of group support and accompaniment of patients for the entire period of treatment.

The most important thing that is formed in psychological support groups is the feeling that you are not alone. For a long time, I had to observe how there is no close contact between several dozen patients who are in the same department and general wards. Patients practically do not communicate with each other, and when interacting, they do not allow them to speak openly about their experiences. Open expression of emotions, medical personnel, most often, are regarded as an increase in symptoms.

The group is a great opportunity for patients to get close to each other in a safe and accepting atmosphere.  Almost all patients, after the first meeting of the group, become more united in the department. They seem to understand that the rest of the patients here are "the same as me", that is, suffering people who are in a difficult situation. Patients begin to communicate with each other, help in solving problems in the department or with advice in society. They begin to listen to each other and share experiences of similar experiences.

Since intrapersonal conflicts are formed as a result of a violation of a person's relationship with the world, and above all with people; From time to time, I bring interventions about group dynamics and relationships between group members into the process of support groups. This is done so that, along with receiving and showing support, patients have the opportunity to pay attention to the ways in which they interact in the group and gradually rebuild the established patterns of behavior and interaction.

1. Closed dynamic groups. It is very difficult to assemble a full-fledged dynamic group in a hospital in which patients would be motivated, could ask for help, would be critical of their condition, and had approximately the same period of stay in the hospital. But with luck to assemble such a group, the interaction turns out to be very, very productive.

Efficacy factors of inpatient therapeutic groups

I would single out several factors of great efficiency of dynamic and supportive groups in a hospital setting:

a) Level of critical experiences.  According to the postulate of positive psychotherapy about the development of primary actual abilities, they can develop in two main ways:  through example or through despair (through touching peak experiences). As a rule, patients who, according to their abilities, are permissible to participate in a dynamic group, are people who have reached a very acute level of experience (as a result of which they ended up in a psychiatric institution). And at the same time, they are able to gradually touch it. Patients, for example, with psychotic episodes or severe depression go through despair. At the same time, they participate in the group, getting an example of people and relationships through which, they can more fully develop the missing abilities. This is a very big driving mechanism for development. There is a possibility that both methods of developing actual abilities will be involved in a stationary dynamic group.

b) Availability intime.  As you know, for reflection and contact with yourself, you need a lot of temporary resources. This refers to the time to think, live, find with your feelings and emotions; what frank group interaction can potentially teach.

c) The feeling that "I am not alone." The patient, after her first group art therapy session, told me at our individual session that she had no idea what other patients were experiencing and thinking. Although, she always wanted to know about it.

d) Relief of productive symptoms with drugs.  The provision of medicines and control of their intake allows a person who touches difficult experiences to remain in contact with himself. However, often, medications interfere with conversational psychotherapeutic work.

One of the main reasons why specialists fail to assemble psychotherapeutic groups in a hospital setting is the excessive emphasis on the selection criteria for the group. I am very sympathetic to Irvin Yalom's criteria for working with inpatients, described in the book "Theory and Practice of Group Psychotherapy":

1. Ability to speak;
2. The ability to hold your attention for 80 minutes;
3. Acknowledging your need for help.  [Yalom I]

As we can see, the criteria are quite simple. By selecting participants for inpatient groups and guided by these criteria, the interaction was effectively productive. As we can see, Irvin Yalom does not focus on the diagnosis. For example, in many sources they say that it is not necessary to take patients diagnosed with "mental retardation" (or "intellectual development disorder" according to ICD-11) in the group. In our groups, there were cases when patients with intellectual development disorders themselves manifested They wanted to join the group and contributed to the group work process. However, there were also difficulties with such patients, which led to acute group conflicts. Therefore, each case and each patient, from the point of view of his ability to be in a group, must be considered individually.

Lack of warmth, care and support from medical staff blocks the ability to Contact in patients, due to a feeling of mistrust. The group, here, is the "saving" place for patients, in which there is an opportunity to feel, manifest and develop Trust. Also, in the group, great emphasis is placed on Hope. Given the severity of the patient's condition, Nadezhda is an important link in the process of help. For patients who are desperate, it can be very useful to understand the reasons that have led to what is happening in life at the moment. Understanding the reasons makes it possible to make a choice.  "We are controlled by what we are not aware of." It gives you the opportunity to analyze and take a step in a different direction; which adds hope for change in the future. Also, the group perfectly develops Contact and Openness. And as you know, one of the main reasons for the formation of psychopathology and a factor that greatly aggravates the condition is the patient's inability to express feelings and block them. Acceptance is also one of the most important abilities developed in group relationships.

As can be seen from the actual abilities I have highlighted, most of them are primary abilities. I focus on them because the presence of psychopathology, in most cases, presupposes a deep deficit in the structure of emotional needs (for example, in acceptance). And it is in the psychotherapeutic group that we can contribute to their development.

Carl Rogers spoke about the 3 basic principles of interaction between people that underlie treatment: [Rogers K]

1. Unconditional acceptance. Which coincides with the capacities for acceptance and patience in positive psychotherapy;
2. Congruence. Which is similar to the ability to openness and trust in positive psychotherapy;
3. Empathy. Empathy involves the ability to contact.

The indisputable principles of Carl Rogers confirm the importance of primary actual abilities. This can be compared to the foundation on which the treatment and adaptation of the patient is built.

The ability to openness, in a hospital setting, is of paramount importance among secondary AS. If we are able to develop it in hospital patients, then we help them release the many experiences and feelings that lie inside, which led a person to psychopathology. However, it is very important to maintain a balance of politeness and openness in the setting of inpatient treatment. Often, I have had to observe how the open expression of emotions (for example, crying) was perceived by the medical community. Ersonal as a deterioration in the person's condition and he only added a dose of drugs. Therefore, it is very important to help a person find a way and place to express emotions that will be safe for the patient and will give him a sense of relief. For example, in psychiatric groups or in individual psychological sessions.

We can say that through the development of contact and primary abilities, in hospital patients, there is a development of the ability to Love. By developing the capacity for love, in this case, I mean the growth of a warm, accepting and empathetic attitude towards oneself and others.

The peculiarity of the stages of interaction (merger, differentiation and separation), in this case, is that it is extremely difficult for hospital patients to track them and understand the degree of relationships with other people. Some patients find it difficult to enter the fusion stage, as it is automatically associated with danger. Such patients need more time. At the stage of differentiation, some correspondence may be observed. separation; attempts to cling to the merger with the group. Which can be expressed in the frequent occurrence of feelings of resentment, protest and even increased severity of symptoms. I would say that in the conditions of inpatient treatment, where the average period of stay of non-compulsory treatment patients is 2-6 months, psychological support groups are needed, rather than full-fledged closed groups. In support groups, the main interaction occurs at the merge stage; However, it is not as deep as in closed dynamic groups.  A support group guides a person through a deep mental and emotional crisis.

3.5 Examples from the practice of conducting groups in a hospital setting

Let me give you an example of one of the patients. Elena (not her real name). 31 years. Observed with a diagnosis of "Paranoid schizophrenia" (F20.0). Hospitalization, during group psychotherapy, 14th. At our individual therapeutic meetings, as well as at the first group session, the patient was fenced off, and her statements concerned the overvalued ideas of the attitude of others towards Elena. She sat the entire first group pushed away from everyone else, in a small corner. During the first meetings, she behaved in a similar way, as in individual psychotherapy: talking about herself and trying to show all the severity of her situation, the patient almost completely fenced off from the possibility of receiving support, care and warm attitude from other members of the group. Gradually, the group members began to develop anger and a desire to correct the perception of Elena. Some participants openly expressed their criticism. Gradually, I made interventions about the feeling of helplessness, arising in a group and causing anger and a desire to correct a person. And also, about the fact that we ourselves periodically find ourselves in such a state of desire that we deny any possibility of help and support from outside. The group quickly moved away from attempts to criticize Elena. Participants began to trust more and share their own experiences. Gradually, after 5-8 meetings, Elena gradually began to trust the members of the group. Yes, she still didn't know how to accept care and support; But even despite the short period of time spent in the group, she stopped exposing hard walls in response to warm feedback. Instead, she began to look around and try to translate the topic. But she stopped reacting with hostility to the desire of others to help her.

The clash between a deep need for help and support, together with a strong conviction that it is impossible to get it for oneself, creates an intra-functional conflict in which the actual abilities for openness, trust, acceptance, and contact can be developed in interaction in a psychotherapeutic group. Gradually, leading to the possibility of rapprochement with others and the formation of emotionally significant wearing.

Another patient fell in love with support groups so much that she went to them throughout the entire period of compulsory treatment (1.5 years). She looked forward to each meeting, saying that this was the only thing that brought her help, interest, feelings about community during her stay in the hospital. She analyzed herself and her own past with deep interest, listened to the experience of other patients and shared her own.

There was an experience when patients who established close confidential contact on a group psychotic therapy continued to support each other outside the walls of the hospital, exchanging personal contacts and helping to solve emerging social problems.

As we can see from Scheme 2, the 

ability and need

 for contact is placed in the center, as the most significant and necessary while in hospital. It is close open contact with other patients and specialists that can develop those relevant abilities that will help the patient increase his rehabilitation potential.

Fig 2. The main relevant abilities developed in inpatient group psychotherapy and psychological support groups:

1. In Russian psychiatric practice, a radical revision of both the goals of the functioning of psychiatric institutions and their words is necessary. It is important that the main goal is not to isolate patients, but to help them. A transition to a more humane attitude. And the conditions should satisfy the needs of the patient, namely: in care, in a warm attitude, in hope and help.
2. The psychological service of psychiatric institutions, first of all, should give a person the opportunity to build a new way of relating to people around him and himself. Namely, through individual and group psychotherapy of patients, interested interaction with doctors and relatives. That develops a person's ability to further socialize, adapt and integrate into society.
3. For many inpatient patients, especially during a pandemic and isolation, group forms of work are important in compliance with the necessary protective measures.

Conducting group work with patients, from the point of view of the method of positive and transcultural psychotherapy, allows a sufficiently comprehensive and conscious approach to the leadership of the group. In stationary conditions, there is an opportunity for the development of both primary and secondary actual abilities. A positive concept of a person allows you to discern in each patient his resources and abilities.

Statements

Limitations of the study

The main limitation was the coronavirus pandemic, which significantly hampered the possibility of holding both therapeutic groups and psychological support groups. However, on the other hand, the epidemic has helped to understand the importance of group interaction for patients. During the period of exacerbation of the infection, group work with patients was not carried out, during periods of decline in incidence, groups were only in some departments with a very limited number of patients and the application of protective measures.