Patients’ Characteristics and Treatment Outcome in a Group-Analytic Psychotherapeutic Community

Patients’ Characteristics and Treatment Outcome in a Group-Analytic Psychotherapeutic Community

Tziotziou A., Katsouri I., Livas D., Karapostoli N., Tsegos I.K., 2005. International Journal of Therapeutic Communities, Vol. 26 (3): 245-260.

ABSTRACT : The aim of the present study is the recording of the characteristics of all patients treated in the Psychotherapeutic Community of the Open Psychotherapy Centre (OPC) from 1980 untill 1999 (N=816) and the discussion of the parametres which, according to the findings, influence the outcome. It is a retrospective study, based mainly on the archives (records and documents search, psychological tests and re-tests, therapists’ and patients’ outcome evaluation) of the therapeutic sector of the OPC.  The data recorded concerns the epidemiological characteristics: demographic, (sex, age, education, profession, family situation, father’s occupation) and the psychiatric/clinical (time of onset of the disease, former hospitalization(s), diagnosis, medication, duration of TC therapy, treatment outcome). The findings of this extensive study indicate some factors which are statistically correlated to the outcome, such as previous hospitalization, duration of therapy, medication, diagnosis and gender. Finally a patient’s profile is described, based on those characteristics which are the most common.

Framework and Aim of the Study

The Daily Psychotherapeutic Community constitutes a major part of the therapeutic activities of the Open Psychotherapy Centre (OPC), which is an autonomous, self-sufficient, non-profit day care unit, not financially supported by any organization inside or outside Greece, founded 25 years ago (1980)[1]. Theoretical and structural innovations have been applied since the very beginning concerning, apart from the therapeutic and training activities, the organizational structure (administrative and financial function)[2].  The therapy services provided by OPC, are adressed to individuals who face any type of psychiatric problem on the condition that they are coming on their own free will. The Therapy Department includes a great variety of activities as Assessement, Individual and Group Psychotherapy, Family and Marital Therapy, Children and Adolescents Therapy and also the autonomously functioning Psychotherapeutic Communities (Daily, Forthnight and Summer TC), each of them suitable for the various therapeutic and practical needs of our clients.

The Therapeutic Communities include sociotherapy groups, psychodrama and large groups, and their main therapeutic approach is influenced by the principles of group analysis. They constitute a new version of the democratic model, suitable for the treatment of severe psychiatric disorders (i.e. psychoses, personality disorders, mood disorders etc) which has been described by Tsegos (1982) as a Group Analytic Psychotherapeutic Community. The specific model is open, non-residential, structured, with a weakened hierarchy, along with a constant role interchange, while it is therapeutic for all its members, both clients and therapists. It aims on the restructuring of the individual’s personality and special emphasis is laid on the interchange of the multiple group activities, on the reduction of the use of interpretations, on boundaries, on the individual’s personality and on the strengthening of the healthy part of the Ego (Tsegos 1996, 1999, 2002).

More specifically, the Daily Psychotherapeutic Community’s programme includes a great variety of group activities, i.e. large and small, psychodynamic and sosiodynamic, groups conducted by the therapists and groups conducted by the clients. Along with their participation in the Community, the members may also attend any other kind of treatment, which is necessary for their specific condition, such as Dyadic Psychotherapy, Group Analysis, Medication, Couple or Family Therapy etc. Clients are referred to the Community either from the Adult Therapy Department or from all over the city via doctors or other professionals, former clients, relatives e.tc.. Before entering the Community, every client undergoes the assessment procedure[3] in the Adult Department in order to clarify his/her special therapeutic needs. The decisive factor for reference to the Community is the kind of the psychological problems and his/her availability of time. The average number of client members per month is 70-80 persons, while the staff of the Community is 20-25 persons.

Regarding the entry and incorporation procedure, the prospective member is allocated to a staff member of the TC , who acts as his/her consultant. They choose together the groups which are convenient for the initial phase (according to the client’s practical and psychological needs) and the Trial Period begins.  During this period, which lasts one month, the prospective member has the opportunity to participate in several communal activities and thus to experience the TC’s function and decide if this kind of therapy is suitable for him/her. On the other hand, the Community has also the opportunity to familiarize with the new member and evaluate his/her motivation. The kind of programme that somebody will follow is flexible (part time programme: 3-4 groups, median: 5-8 groups or full-time programme which covers the whole day five days a week).  At the end of the month the prospective member is asked if he/she is going to stay. If the answer is “yes” then he/she becomes a full member of the TC, entering the Community Meeting. If the answer is “no” or “I don’t know yet”, then he/she might repeat the trial period or stop for the time being. It is a kind of self-selected (in terms of application to join)(Lees et al, 2004) procedure.

Mode of Payment: It has been established as a principle in our centre that  no one should get anything (i.e. therapy in this case) for nothing, but at the same time nobody is turned down because he is unable to pay (Tsegos, 1982). It is the client’s responsibility to pay for his/her treatment. If he/she is not able to find resources outside, he/she may get a discount  and in return he/she is  asked to do something in the centre, for example typing or other paper work, translations e.t.c. Another way out is to conduct an existing group of the TC (50% discount) or to create an original group using his/her talents, knowledge and hobbies. If he/she succeeds to do that, then he/she pays nothing at all.  We have to stress the point that this kind of procedure serves as a superb tool for titillating the individuals motivation, which is of cource a basic prerequisite to undergo psychotherapy.

The evaluation of the activities of the OPC (therapy and training) has been from the very beginning a significant priority of the organization. Several studys have been conducted from the Training and Research  Department since 1980. The present study aims on the recording of the characteristics of all patients treated in the Daily Psychotherapeutic Community from 1980 untill 1999 (N=816) and the discussion of the parametres which, according the findings, influence the treatment outcome.

Research Method

Record of the data, derives:

• From the archives of the Therapeutic Sector of OPC (1980-1999): all those who have participated in the Daily Psychotherapeutic Community, even for one day, constitute the sample of the present study: N = 816.
• From the archives of the Community.
• From interviews with the staff of the Therapeutic Sector and the Therapeutic Community in order to fulfill the lack of data in certain cases.
• The collected data were recorded in a special protocol, made on this purpose. Additionally three psychiatrists reviewed and re-evaluated the diagnosis of each patient according to DSM-IV (American Psychiatric Association, 1994). The evaluation of the outcome was made through the clinical observation of the therapist, the opinion of the patient[4] and the findings of the psychological tests (M.M.P.I., Rorchach, Symptom Check List etc.)[5] before and after therapy (data available in the majority of patients). The outcomes were divided in four categories: (I) Recovery: those who had fully accomplished their goals showing improvement in functioning and assumed their life without symptoms, (II) Clinical Improvement: those who were improved, but still had some symptoms, (III) Non Significant Change: those who had no significant change for the better or the worse, (IV) Deteriotation: those who relapsed and (V) Reference to Other Therapy: those who were recommended to another therapy (i.e. Group Analysis, Family or Marital Therapy etc).

Sample of the Study: the total number of patients was 816.  Nobody was excluded and an effort was made to regain missing information for few patients who stayed for a very short period of time, most of them in the early years of the TC’s functioning.

Categorization and Analysis of the Data. Statistical analysis of the data was made through SPSS 8.0.The entry and analysis of the data was completed in three parts:

1. the first one had to do with the demographic characteristics: gender, age, educational level, occupation, family status, father’s occupation,
2. the second with the psychiatric/clinical characteristics: diagnosis, age of the onset of the dicease, former hospitalization, medication, duration of stay in the Daily Psychotherapeutic Community and treatment outcome,
3. the third one with the comparison/correlation between the above characteristics and with the treatment outcome.

Results

The demographic characteristics are as follows: The results show that the majority of patients were men (53,6%), 19-25 years old (35,9%) or 26-30 (24,9%), single (75,5%), graduates of Secondary School (54,3%), unemployed (24,4%) or students (23,6%) and the father’s occupation is laborers/ paeasants/craftsmen (29,4%) or merchants (21%).

The psychiatric and clinical characteristics are as follows: Diagnostically according to DSM IV, the majority of patients belong to the group of Mood Disorders (ususally Depression and Bipolar Disorders) (37,1%), followed by those who belong to the group of Schizophrenia and other Psychoses (28,5%). Additionally, 95% had no organic disease on Axis III, while the distribution of patients according to diagnosis on all Axis is: 50,4% had findings only on Axis I, 17,2% only on Axon II, 27,6% on Axis I/II, 2,9% on Axis I/II, 1,1% on Axis I/II/II and 0,8% on Axis II/III. It seems therefore that the Community is really designed for persons suffering from serious psychiatric disorders.

The majority of patients had no previous experience of hospitalization in residential psychiatric units, although a significant percentage (40%) had been hospitalized before seeking help at the OPC.  Regarding the age of onset of the disease, it is placed between 19-25 years of age for the majority of patients (41,9%). Additionally, according to findings, the vast majority (82,4%) had been or was still under medication upon entering the communal setting.

The average duration of stay in the Psychotherapeutic Community is 14,4 months. 26,9% stays for 2-6 months, followed by those who stay for 7-12 months (16,9%) and 1 month (16,8%) (Min: one, Max: 55 months). Finally, regarding the treatment outcome, the majority of patients had shown clinical improvement (38,7%), while a significant percentage had fully recovered (27,5%). However, a relatively large percentage of patients showed no significant change (24,7%), while only 5,7% had shown signs of deterioration of some kind. If we take away from our sample those patients who stayed only for one month[6] (16,8%), the outcome of therapy is as follows:

In an effort to find possible correlations among our data, we examined several pairs of the above characteristics, in order to find the statistically significant differences and the significant correlations. There was no apparent significant correlation between the duration of stay and the data regarding: gender, age, educational level, occupation, family status, father’s occupation, age of onset and diagnosis. Furthermore, no significant correlation was found between the outcome of therapy and the findings concerning: age, educational level, occupation, family status, father’s occupation and age of onset. Likewise, the gender is not significantly correlated to prior hospitalization, multiaxial evaluation or medication. This possibly means that the above factors have little prognostic value. On the other hand, there is significant correlation, and therefore possible interaction, between the following factors: Clinical Improvement (46,7%), Recovery (31,4%), No Significant Change (13,9%).

Duration of Stay in the TC and Prior Hospitalization (P< 0,001 – df 6):

The largest percentage of patients who discontinued their therapy within the first month, had been hospitalized in the past. On the contrary, among the patients who stayed in the Community more than 2 years, a small percentage (19,3%) had the experience of a hospitalization, while 80,7% had not been hospitalized.

Duration of Stay and Medication (P< 0,001 – df 6):

The longer the patients stay in the Community the less becomes the percentage of those who receive medication, with the exception of those who stayed over 37 months.

Therapy Outcome and Former Hospitalization (P< 0,001 – df 4):

The overwhelming majority of patients who had  fully recovered, had no prior experience of hospitalization in a psychiatric unit. However, this difference is reduced in the category of improvement, since among those who showed improvement at the termination of therapy a percentage of 44,2% had been hospitalized in the past, while 55,8% had no experience of prior hospitalization. Furthermore, the vast majority of patients who showed signs of deterioration of any kind, had at least one experience of a former hospitalization.  Consequently, 58,3% of the patients who had been hospitalized in the past, fully recovered or showed improvement at the termination of therapy, while among those who had not been hospitalized, the percentage in the same categories is increasing to 75,1%.

Therapy Outcome and Medication (P< 0,001 – df  4):

It seems that medication affects the outcome of therapy  positively, since the majority of patients who showed recovery or improvement, receives medication.

Therapy Outcome and Diagnosis (Multiaxial Evaluation) (P< 0,001 – df 8):

It seems that there is a good prognosis regarding the outcome of therapy for patients who suffered from disorders on Axis I, on Axis II and on the combination of Axes I and II (recovery and improvement: 62,5% on Axis I, 78,6% on Axis II and 70, 3% on the combination of Axes I and II). However, patients who showed signs of deterioration of some kind or remained stagnant, suffered mainly from Disorders on Axis I.

Therapy Outcome and Disorders of Axis I (P< 0,001 – df 16) :

Findings indicate that there is good prognosis regarding Schizophrenia and other psychotic disorders (recovery or clinical improvement of 57,5%), as well as Mood Disorders (recovery or improvement 68%). Still, in the category of Schizophrenia or other Psychoses, improvement prevailed, while in the category of deterioration (as outcome), Schizophrenia (as diagnosis) also prevailed. We must also mention that, in the category of deterioration (as outcome), Anxiety Disorders do not appear at all.

Therapy Outcome and Duration of Stay in the TC (P< 0,001 – df 24) :

The duration of therapy in the Therapeutic Community is positively related to the outcome of therapy. It seems that, 2-3 years of stay in the Community, were required for full recovery. However, 6-12 months were sufficient for improvement. Yet, it is important to mention that the category Non Significant Change did not appear at all among the patients who stayed in the Community more than 18 months, while for those who stayed in the Community more than 12 months, the possibility of deterioration of some kind was gradually reduced.

Therapy Outcome and Gender (P< 0,005 – df 4):

Generally, it seems that women showed better results in therapy than men. Men also showed signs of deterioration of some kind more often, compared to women. On the contrary to that, women were referred to another therapeutic scheme within the OPC more often than men.

Diagnosis on Axis I and Gender (P< 0,001 – df 4):

Schizophrenia or Other Psychoses appeared more often among men, while the Mood Disorders appeared more often among women.

Conclusions and Implications

According to the above results the statistical profile of the patients treated in the Daily Psychotherapeutic Community between 1980 and 1999 is formulated as follows:

Man (53%),  19-30 years old (60,8%), single (75,5%), with secondary education (54,3%), unemploeyd or student (48%) and the father’s occupation is laborer/peasant/craftsman or merchant (50,4%). He enters the Community without the experience of a former hospitalization in a residential psychiatric unit (60%), the age of the onset of the dicease is untill the 25th year (69,6%), he is under medication (82,4%) and the diagnosis is mood disorder, schizophrenia or other psychotic disorder (65,6%). The average duration of therapy in the Community is 14,4 months and the outcom, if he stays over one month is either clinical improvement (46,7%) or recovery (31,4%).

Commenting on the above profile, we should underline that, even though the majority of the patients are of low economic status, young and unemployed they stay for a considerably long time in therapy. So, it becomes of great importance that they are not only willing to pay for their therapy but also that they (and their families) actually manage to afford the cost of communal therapy for a long period of time. Thus the myth of expensive psychotherapy is disproved. According to Polyzos et al (2004) communal therapy is proved to be the less expensive therapy for both the patients and the providing organization: OPC’s pricing policy favors treatment in groups. As we go through from individual (35 euro/per hour) to group psychotherapy (Group Analysis: 18,33 euro / per hour and TC: 5,08 euro / per hour), prices are getting much lower (Polyzos et al, 2004, p.179). Furthermore, according to the cost-effectiveness analysis for all group psychotherapies (Daily and Fortnight Psychotherapeutic Community, Psychodrama and Group Analysis) of the year 1999, conducted by Vylliotou Delikonstantinou (2004) the average cost of  recovery/ improvement without symptoms is 3.050 euro (average stay: 26 months), for clinical improvement is 2.650 euro (average stay: 22,6 months), for non significant change is 755 euro (average stay: 6,4 months) and for deteriotation is 660 euro (average stay: 5,6 months).

The statistical analysis and the correlations between the recorded characteristics,  showed that:

• The duration and outcome of therapy in the Community depend on the experience of previous therapeutic schemes. More specifically, we observe that the duration is longer and the outcome is better for those who had the communal approach as their first therapeutic experience, in contrast to those who have the experience of a former hospitalization in a residential psychiatric unit. Generally, it is a common belief that therapy within a residential psychiatric unit “immobilizes” the patient, since mental illness is considered mainly in its biological dimension, the focus is on medication and eventually the patient feels weak to influence his/her symptoms. On the contrary, therapy in a daily communal setting aims on the mobilization of the healthy part of the ego and considers the patient-member as an active partner in therapy: a) mobilization through sociodynamic and psychodynamic groups, b) not isolating him/her from the family and social enviroment, c) focusing on the change of the way of relating to reality, others and the self.
• The duration and outcome of therapy depend on medication. Despite the fact thet the longer a patient stays in the Community, the less medication he/she receives, medication seems to be necessary for a successful outcome. In this way it is asserted that the therapy of mental illness is more effective when a conjoined or multifactorial approach is applied.
• Communal therapy is proved to be efficient for Mood and Psychotic Disosrders or, in other words, the above diagnostic categories have a good prognosis when treated in a multifactorial communal setting.
• The outcome depends on the duration of therapy. Approximately 1,5 year is enough for clinical improvement, while 2-3 years are necessary for total recovery.
• Women show better results in therapy than Men. Additionally gender influences the diagnosis and the onset of the disease, i.e. Mood Disorders are more common in women, while Psychotic Disorders in men, where the onset of the disease is at a younger age in relation to women.

The present study, as every research study, arises new questions and further examination is required, in order to alocate other factors which may affect the present findings and, beyond that, there are certain limitations we should have in mind, such as:

·         Treatment outcome was evaluated through multiple assessments: clinical observation of the therapist, the opinion of the patient and the findings of the psychological tests (M.M.P.I., Rorchach, Symptom Check List etc.) before and after therapy. Even though the above synthetic evaluation might offer more reliable results, it does not provide comparative evidence for corellation with other research studies. Thus a “psychological oriented study” (Lees, 1999) would be useful in this direction, measuring for example only the changes on the MMPI or Symptom Check List scales. This was not applicable for the whole sample of the present study, due to missing relevant evidence of the early years.

·         Our clinical practice all these years has proved that the Multifactorial Approach[7] is more effective for the so-called “difficult patients”. The sample of the present study includes patients who, apart from Therapeutic Community, have also attended other therapeutic activities for a short or a long period of time. The question arises “which combination of therapeutic activities is the best?” (if there is only one). This is a complex question to answer if we also consider that the communal approach itself is multi-dimensional – in other words, the therapeutic community treatment consists of a great many ‘molecular’ (i.e. single small unit) variables, which interact in a complex way, so that any one, or combination of them, might contribute to outcome (Lees, 1999, p.213).

In conclusion, based on the existing data, in this first attempt to record the characteristics of patients and the treatment outcome in the Daily Psychotherapeutic Community from 1980 until 1999, we could say that the ambitious goal “about open treatment of individuals suffering from serious psychiatric disorders”, which was set in the institutive declaration of the OPC, seems to have been accomplished. Beyond that, the present study offers data relating to the type of patients who seek therapy in a day care unit as well as for the effectiveness of their therapy, based on a quite large sample.

 References

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders. DSM-IV. 4th Ed. Washington, DC: American Psychiatric Association.

Lees J. (1999) Research. The Importance of Asking Questions. In: Campling P.,  Haigh R. (eds): Therapeutic Communities. Past, Present and Future. Jessica Kingsley Publishers, London and Philadelphia, p.p.207-222.

Lees J., Manning N., Rawlings B. (2004) A Culture of Enquiry: Research Evidence and the Therapeutic Community. Psychiatric Quarterly, Vol. 75 (3), p.p. 279-289.

Madianos M., Zacharakis C., Tsitsa C., Stefanis C. (1999) The Mental Health Care Delivery System in Greece: Regional Variation and Socioeconomic Correlates. Journal of Mental Health Policy Economics, 2, p.p. 169-176.

Polyzos Ν., Bardis V., Bartzokas D., Pierrakos G., Pantelaki K., Kostopoulos Ch. (2004) The Cost of Psychotherapy. Economical and Functional Evaluation of a Day Psychotherapy Unit (Open Psychotherapy Centre). Preface:I.K.Tsegos, Discussion-Conclusions:N.Karapostoli.  Enallaktikes Ekdoseis: Athens .

Stefanis C., Madianos M. (1981) Mental Health Care Delivery System in Greece: A Critical Overview. In: Christodoulou G. (ed.) (1981) Aspects of Preventive Psychiatry, p.p. 78-83. Basel: Karger.

Tsegos, I.K. (1982) A Psychotherapeutic Comunity in Athens. Paper Presented at the Vth Windsor Conference, Windsor, 1982.

Tsegos, I.K. (1985) The Impact of the Institutional Background in the Matrix and the Transference in a Group Analytic Group (The Case of the OPC). Paper presented at the 3rd Group Analytic Symposium in Heidelberg, Heidelberg, 1985.

Tsegos, I.K. (1996) Fifty Years of an Amateur Enthusiasm (On the Avoidance of Training and of Professional Identity in TC). International Journal of Therapeutic Communities, 17(3),159-165.

Tsegos, I.K. (1999) Training. Establishing a Professional Identity. In: Campling P.,  Haigh R. (eds): Therapeutic Communities. Past, Present and Future. Jessica Kingsley Publishers, London and Philadelphia, p.p.189-206.

Tsegos, I.K. (2002) The Disguises of the Psychotherapist.  Stigmi: Athens.

Tziotziou, A. (2002) Study of the Characteristics of the Patients in a Psychotherapeutic Community. Diploma Thesis. Institute of Psychodrama and Sociotherapy, OPC, Athens.

Vylliotou Delikonstantinou, V. (2004) Cost – Effectiveness Analysis of the Therapeutic Activities of the Open Psychotherapy Centre. Short paper for the Institute of Psychodrama and Sociotherapy, OPC, Athens.

Anna Tziotziou is a Psychologist, Psychodramatist -Sociotherapist and Family Therapist.

Ioanna Katsouri is an Occupational Therapist, Psychodramatist- Sociotherapist, Family Therapist and current Leader of the Fortnight Psychotherapeutic Community.

Dimitris Livas is a Psychiatrist and Group Analyst.

Natassa Karapostoli is is an Occupational Therapist, Psychodramatist-Sociotherapist and Family Therapist.

Ioannis K. Tsegos is a Psychiatrist, Group Analyst , President of the Administration Board of the OPC and Chairman of the Institute of Group Analysis, Athens.

Adress for correspondence: Open Psychotherapy Centre, S.Haralambi 1 & Mavromihali, 114 72 Athens, GREECE, E-mail: igaa-opc@otenet.gr

[1] OPC does not belong either to the public nor the private (profit making) sector. “In Greece, the functional capacity of the mental health care system until 1980, was totally inadequate to meet the increasing mental health needs of the population and to provide efficient and community-based services” (Madianos et al, 1999). “Psychiatric care until 1980 was based on nine overcrowed anachronistic public mental hospitals and 40 private ones, both categories of settings inadequately staffed with lack of rehabilitation programmes” (Stefanis et al, 1981).

[2] The basic characteristics of the organization are: the administration is group-centered, the operation is based on the open systems, where the small and large group meetings are utilized, and role interchange is frequent (the conductor of each department changes every two years).  In communal approach, as this kind of structure is called small and large group meetings are officially functioning in order to provide the proper space for the personnel to discuss face-to-face thoughts, emotions and disagreements, while at the same time everyone is aware of the whole organizational function (Tsegos, 1985, 2002).

[3] The assessment period serves for the formation of an intergrated diagnostic evaluation and for the formulation of the therapeutic proposal. It includes: Psychiatric Evaluation, Psychological Assessment (M.M.P.I, Rorchach, W.A.I.S. etc) and Family Assessment.

[4] It is a common practice in OPC since 1980 that the clinical evaluation of the therapist and the patient’s opinion is recorded immediately after the termination of therapy in a protocol, kept in the archives of the Therapy Department. This protocol consists of several categories such as Outcome of Therapy (Recovery, Clinical Improvement, Non Significant Change, Deteriotation, Reference), Way of Termination (Disapear, Fairwell Procedure etc), Reasons that the patient declares for the termination (Practical, he/she does not require more therapy, family reasons etc) etc.

[5] It is also a common practice in OPC that everyone goes through a Psychological Assessement (M.M.P.I., Rorchach, Symptom Check List etc.) before and after his/her therapy.

[6] The first month of participation in the Psychotherapeutic Community is considered as the Trial Period.

[7] Patients may attend several kinds of therapies depending on their psychological and practical needs, such as Group Analysis, Therapeutic Community, Dyadic Psychotherapy, Drug Therapy, Family or Marital Therapy.