Stability in Variability, about the Importance of the Setting in Group Therapy for Adolescents in a Psychiatry Ward

Introduction

Adolescents face a huge challenge while searching for themselves in situations where they often have to contradict, or at least start a dynamic discourse with, values or beliefs that previously seemed obvious. This may cause discomfort or even be a factor contributing to the occurrence of adjustment disorders. Therefore, it is important for the environment to not only be stable enough for adolescents to have support in the chaos of their experiences, but also not limit the important processes of separation and intimidation [1, 2, 3, 4, 5].

Hospitalization during adolescence overlaps with the crisis associated with puberty. It is therefore important that the stay in the ward does not inhibit the constructive solution of naturally occurring dilemmas. Therapeutic interactions in psychiatric wards should be stable and clearly defined, so as to build a sense of security and be open enough to support the processes of separation and self-discovery by adolescents [1, 6, 7, 8, 9, 10, 11].

Almost from the very beginning of its operation, the Department Of Psychiatry has had a therapeutic group, introduced by the Department’s founder, Prof. M Orwid [7, 8]. Currently, despite many changes, the group is one of the most important therapeutic forms in the adolescence ward [1].

The group is run based on the psychodynamic model, so the therapists leave a great deal of space for participants to speak freely, do not impose topics, but try to listen to the members’ statements, looking for common or frequently occurring themes [1].

Method

Three periods of the therapeutic group’s work were analyzed (August-October 2021, March-May 2022, and September-October 2023). The notes made by the interns who observed the course of the sessions were analyzed. These periods were selected due to the completeness and accuracy of records of group sessions, taking into account the most recent session records.

Results And Discussion

The study analyzed 55 group therapy sessions. The majority of group participants in the studied periods were girls, with boys constituting about 10% (Table 1). The average number of group members is 9 people. The minimum group size during the study was 4 individuals, representing a single case, while the maximum group size was 12 individuals.

The gender distribution most likely influences the dynamics of group work. Girls may be less inclined to overtly violate group rules and norms, demonstrating a greater willingness to discuss various issues rather than engage in actions [2, 12].

Virtually all groups were led by two therapists. It is extremely rare for a group to be led by one therapist, but occasionally it happens as a result of a therapist’s illness or a sudden event leading to the absence of one of the therapists.

The analyzed groups were led by 6 interchanging therapists (3 being specialists in clinical psychology; 3 specialists in child and adolescent psychotherapy, and one a resident doctor; with the therapeutic experience of 4 therapists exceeding 15 years). The group was conducted in various arrangements, by a male and female therapist, two male therapists, or two female therapists.

According to the psychodynamic model of work, therapist activity is limited and closely tied to the group’s activity, providing material for transference and counter- transference analysis. Facilitators can analyze both the personal statements of specific individuals (referred to as individual therapy within the group context) and the group as a whole [13, 14, 15, 16].

The therapeutic principles and framework are presented and agreed upon by both participants and therapists. Over the last few years, the group of therapists in the ward managed to establish the basic conditions and rules of participation in the group. On the other hand, groups at different stages of work sometimes introduce their own rules for organizing group work.

Over the years, the principles of group work have evolved significantly. Initially, there were no consequences for absences (participants were not suspended), and new participants were introduced every day of the week, impacting the sense of security within the group. The lack of consequences for leaving the group or being absent did not serve as a corrective measure for acting out behaviors, especially in individuals with maladaptive personality development.

The rules are presented when a new participant joins the group. Since 2018, new people are introduced to the group on one specific day. Thanks to this, participants, even though the group is semi-open, can feel safe because there is at least partial predictability of the group structure.

Therapists introduced rules regarding the group working time, number of sessions per week, consequences of absence from the group, including periodic suspension from participation, issues of eating and drinking, and invitation to the group (Table 2).

Participants most often introduced rules related to the inability to leave the group, introducing the order of statements, giving the floor, the starting round, and topics brought to the group forum (Table 2).

An important element of the therapeutic process is also a group of interns supporting the therapeutic process from behind the glass, keeping records of therapy sessions. These co-therapists also begin observing the group process on a selected day so that the group can, if they want, get to know the people behind the glass.

Currently, both new people and co-therapists/interns are invited to the group on Mondays. In most cases, participants willingly indicate their readiness to meet co- therapists/interns behind the glass (Table 3). There is a visible willingness for the same participant to present the rules from week to week, so it is not always the person who starts the group’s work.

In the analyzed periods, breaches of group rules were observed relatively rarely. The most frequently violated rule was punctuality (the maximum delay was 10 minutes) and the ban introduced by the participants related to leaving the group. On several occasions, the group decided not to allow a person who was late into the session because a process had already started and was ongoing. Once, one person brought cookies to the session. People fed with a tube were invited to the sessions twice, but the tubes did not work during the group’s work periods. During the session, there were doubts about the limits of group work, they were encouraged by the therapists to express their feelings and views, and present their ideas about the consequences of breaking the rules. The participants did not attempt to attack or break the rules of the therapeutic group.

The therapeutic group is supervised regularly (once a week). During the supervision, issues related to the introduction of norms and rules of group work, as well as all cases of breaking them, are discussed. Supervision also enables therapists to reflect on their own counter- transference reactions, allowing for deep consideration of therapist reactions or feelings, which may sometimes lead to a desire to tighten rules or, conversely, to abandon settings or reluctance to enforce consequences for boundary violations.

Conclusions

Introducing clear boundaries in group therapy is extremely important. Boundaries in working with adolescent groups must be clearly defined, and changes in group work rules should be introduced after careful consideration and reflection, taking into account suggestions arising from the supervisory relationship. Introducing a clear structure, while leaving ample room for freedom within the group, can positively impact the reduction of acting out behaviors, especially in youth groups where girls dominate. Clear rules and predictability are significant factors influencing the sense of security within the group. Therapists should not be afraid of an emerging adolescent discourse questioning the meaning and sense of the group’s principles. Adolescents should even be encouraged to introduce changes that do not contradict the basic principles and could help build a sense of security. The small number of boys in the analyzed therapeutic groups (which, however, corresponds to their total number in the ward) may have a significant impact on the acceptance and way of experiencing boundaries, which should be taken into account when using the conclusions resulting from the data contained in the article.