“El Grupo”: Bringing Psychotherapy to an Underserved Population
In 2004, the Mount Sinai East Harlem Health Outreach Project (EHHOP) opened a clinic run by medical students and directed by faculty to meet the primary and preventive health care needs of uninsured members of New York's East Harlem community. The EHHOP Mental Health Program Extension was started in 2008 to complement depression screenings already included in medical visits, with on-site mental health consultations and care. It has also provided junior medical students with a hands-on exposure to psychiatric practice. Finally, it has enabled psychiatric residents from the specialized global psychiatry track at Mount Sinai to be the lead clinicians and educators for the extension clinic, by providing a domestic experience to complement their international fieldwork with underserved populations.
Over time it became evident that there was a shortage of psychotherapy options in the community to supplement the medication-focused psychiatric management in EHHOP. It was decided that an efficient approach to this service gap was to form a psychotherapy group that was support focused, and so, in January 2011, “El Grupo” was born.
El Grupo is loosely based on the dialectical behavioral therapy approach to group psychotherapy, using ideas from the Skills Training Manual for Treating Borderline Personality Disorder, by Marsha M. Linehan. The group teaches skills from this manual to help the patients target issues in their daily lives. To give structure to El Grupo, the leaders designed a six-month cycle consisting of four modules. Each module is focused on teaching essential psychosocial skills outlined in the manual: mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance. The manual was translated from English to Spanish by the primary leader of El Grupo, to accommodate the language spoken by the participants and to make the handouts more relevant for the group's members. The hour-long group sessions are held weekly. Each group starts with a mindfulness exercise, followed by sharing the experience of the exercise, reviewing homework, and openly discussing a new skills set for that week. Tools utilized, aside from the milieu itself, include role-playing exercises, chain analyses, skills handouts, and behavior modeling.
Despite the origins of dialectical behavior therapy in the treatment of borderline personality disorder, El Grupo does not restrict treatment to patients with borderline personality disorder. The participants are all of Hispanic origin, most are female, in their mid-30s to late-40s, and have disorders from the mood and anxiety spectrums. The group is led primarily by one resident, but other psychiatry residents and medical students also help to lead and model positive behaviors.
Supervision meetings are held every other week with an attending psychiatrist, who was a former resident leader of the group. During supervision, facilitators practice mindfulness, give updates on the group, address concerns, and discuss relevant articles. A senior faculty member has also been involved in the group since its inception and is available for further supervision when needed.
El Grupo has been successful in many ways. It has provided access to psychotherapy at no cost for individuals who would not otherwise have had such an opportunity. The leaders have taught coping skills to its participants, three of whom have come nearly every week over the past year. With creative teaching and repetition of skills, participants have shown improvement in their symptoms of depression and anxiety, as perceived through the examples that they discuss in group, affect of the members, and findings by their providers.
In addition, the group helps reduce social isolation for these members by providing a safe environment to learn and share from their commonalities and differences. The group leaders have also benefited, by learning what it takes to create an effective group. Also, the structure of El Grupo allows for supervision at many levels—from senior and junior psychiatry attending physicians, residents, and medical students—all of which allows for a rich learning experience.
The group's challenges lie mostly in recruitment and nonadherence. The group has been able to recruit only about four members per six-month cycle. Attendance problems have plagued each cycle, largely explained by chaotic work schedules and life stressors commonly found in this underserved population. Some leaders have likewise missed groups because of sickness, vacation, and the hectic schedules inherent in residency and medical school.
Despite some shortcomings, El Grupo has been a positive addition to the mental health extension of EHHOP, by providing free, efficient, and effective access to psychotherapy for an inner-city population and a unique learning experience for early clinicians. It is hoped that others can learn from the “win-win” experience of El Grupo by implementing a similar group psychotherapy experience into more student- and resident-run clinics for the underserved.
