A Tea Party with the Mad Hatter: a wonderland production of the “patient”- staff   community meeting –

David Cameron and Chris Fry

Northern Ireland (NI)

* The International Society for Psychological and Social Approaches to Psychosis

Changing Realities: New developments in psychological approaches to psychosis (2nd &

3rd October, 2012

WELCOME TO WONDERLANDW H E R E

“EVERY ONE HAS WON ……. AND ALL MUST HAVE PRIZES”

Please take a seat and wait until March Hare gives you

your prize/instruction. With the prize is a very important

letter. Take a few minutes to read the letter and

carefully follow the instructions

ENJOY THE TEA PARTY

But I don't want to go among mad people.

Oh, you can't help that, we're all mad here. I'm mad. You're mad.

How do you know I'm mad?

You must be or you wouldn't have come here.

We’re all mad Here

*Historical context

*The origins of the community meeting can be traced to ancient times when the primary family or tribe came together to solve problems of common interest (Berczeller,1984).

*Henceforth, in psychiatry beginning with the seminal work of Maxwell Jones the community meeting has become the cornerstone of so-called milieu therapy.

*Founded on the premise that examining social roles, systems and processes is potentially therapeutic.

*Definitions

*“It is like a town meeting in that it is concerned with the management of the hospital - community addressing and fulfilling the numerous tasks that enable a community to work.......

*It is like a family meeting in that it addresses the issues, pleasures and conflicts, both overt and covert that arise when people live, eat and sleep under the same roof” (Rice & Rutan, 1987, p. 154)

*contd

*“ It meets for the purpose of communication, ward [community] management or psychiatric treatment. Staff are encouraged to guide patients by allowing them as much decision making authority as is clinically warranted (democratisation). Patient participation in information sharing, decision making and conflict resolution (communalism) are prominent features of milieu therapy” (Lanza, 1999).

*Contextual factors

*“Just as technically competent surgery performed in a field of pathogenic bacteria may be doomed no matter how skilled the operating team, so group therapy in a social institutional context dominated by anti-developmental dynamics is also unlikely to do more than create non-productive dissonance” (Skolnick,1999)

*Contractual agreement either explicit or implicit between hospital/organisational administration, staff and patients is essential(Rice,1993)

*The setting can range from a large institutional in-patient hospital (Berne, 1968; Furedi et al., 1974) to small community based psychiatric alternatives (Cooper, 1974)

*contd

*Frequency ranges between once a day – once a week (Ng, 1992) for a duration of between 45 – 60 minutes (Lanza, 1999).

*Ideally all staff (professional or otherwise) and all patients/residents should attend.

*Patients may be excluded- excused if they are likely to be too disruptive or unable to benefit from the meeting.

*Staff can be excused because of emergencies, illness, leave etc (Lanza, 1999)

*Function

*To share information, solve problems, resolve interpersonal and intra-psychic conflicts which enable the community to function at an optimum level.

*Develop a sense of co-operation, cohesiveness and mutual healthy dependency.

*While it is not group therapy per se there should be a clear psychotherapeutic purpose.

*Format of the meeting

*Meaning making -use of metaphors

*Theoretical orientation - psychodynamic focus

*Developmental phases

*Leadership

*Boundaries

* Meaning making and metaphor

*Town meeting; Task-management focused reflective of higher order-secondary level functioning akin to (Bion’s) “work-group” mentality.

*Family meeting; Interpersonal – relational focus on conflicts that may arise while negotiating and re-negotiating the life long tension arc between intimacy and autonomy.

*Theatre; Intra – psychic focus on theatrical projections and unconscious, preconscious conflicts, emotions and phantasies, where inevitably the leader/staff become imbued with the power to heal or destroy.

* Theoretical orientation – psychotherapeutic focus

*Considerable controversy – debate concerns the degree and depth of psychotherapeutic/psychodynamic orientation:

*Rubin (1978) foregrounds the need for structure and cautions against an intra-psychic focus.

*In contrast, Winer and Lewis (1984)encourage an insight oriented approach to promote sustainable change that will survive outside of the highly structured social system of the community/hospital.

*contd

*Arons (1982) believes the community meeting combines aspects of both small and large group dynamics which means attending to

*Small group processes such as scapegoating, authority/leadership, projective identification BA dependency, pairing and fight/flight.

*Large group processes such as sub-groups, identity, integrity and perceived attacks on identity and integrity.

*contd*Foulkes (1974) advocates for the use of psychotherapy

but with certain caveats.

*Because staff are the primary containers for projected hostility and rage individual or “lofty interpretations” about the group will merely heighten persecutory anxiety.

*Staff should avoid placatory or patronising statements to avoid the patients anger and hostility if and when it does emerge.

*Interpretations should be ordinary, focus on the “here and now” and acknowledge patient’s possible fear of expressing their implicit-unspoken attitudes towards staff.

*Minor everyday complaints may possibly represent “expressions of [unspeakable] group transferences”

*Developmental Phases*To a greater or lesser degree all groups have inter-

related and dynamic (Rice, 1993) beginning, middle and ending phases (Mann, 1973).

*The structure should not be overly rigid nor impermeable to preclude or avoid emotionally laden unconscious communications nor so loose that the passions of the theatre overwhelm or override order and the capacity for critical reflection.

*Facilitators should track and be attuned to the dynamic movement and or at times lack-off or “stuckness” of the group, balancing and attending to the various, task, inter-personal and intra-psychic aspects as they emerge naturally in the development of the meeting.

*Leadership

*The dialectical debate between autocratic (Wilmes, 1958) and democratic (Jones, 1952) leadership styles is longstanding.

*A strong robust style can contain phantasies of collapse but equally can accentuate persecutory phantasies of retaliation.

*An open, non-directive style can sensitively uncover and making meaning of material which, alludes to but is not about staff to identify maladaptive relational patterns even if the patient remains unaware of their origins.

*Maintaining boundaries

*Irrespective of leadership style the importance of attending to clearly and consistently defined boundaries is essential including membership, role and task (Lewis, 1999).

*Boundaries define what is in and what is not in, distinguishing between and amongst members as well as between patients and staff (Rice, 1993).

*Leaders define and regulate both internal (e.g., how work, tasks and roles are defined) and external boundaries (e.g., who can attend, time and frequency).

*In a more transient setting with a rapidly changing membership, boundaries rest primarily with the leader whereas in a more stable (e.g., TC ) environment the leader may work towards enabling and empowering members to establish their own boundaries fostering cohesiveness .

* An Integrative needs adapted framework - psychosis

SAFETY is paramount, achieved by establishing a “therapeutic alliance through being unequivocally helpful, tolerating incoherence, tolerating not understanding[knowing], and being realistically optimistic” (Karon, 2008, p. 4).The therapeutic alliance, therefore, is not merely a means to an end

but an end in itself (Kanter, 2000).

The moment you decide “not to run screaming from the room you are doing good psychotherapy, even if you have no idea what is going on” (Karon, 2001, p. 17)

The holding of group work with psychotic patients resides with the capacity to tolerate-integrate dialectical yet nebulous states of mind in an ordinary and “authentic” way (Karon, 2008).

* Contd

The blank screen inevitably becomes a monster, the facilitator, therefore, must “turn up” (Bollas, 1987) and pro actively map out an unambiguous course that promotes “cohesiveness” (Kapur et al., 1988).

Work in the “here and now” to promote interpersonal relatedness, mastery and control (Rice & Rutan, 1987).

Benign human contact is more important than psycho-technological correctness; avoid defensive “aloof” intellectualisation.

be willing to think the unthinkable.

tolerate the uncertainty of not knowing and of making mistakes (Karon, 2001, 2008).

* Contd

Meaning making;Willingly collaborate with experiential worlds that

may disconcert your own (Chandler & Hayward, 2009).

Value and validate subjective, individually generated non-consensual experiences (Atwood et al., 2002; Dilks et al., 2010).

Draw out themes which connect group members at an interpersonal level.

Construct a coherent and cohesive narrative by linking the subjective experience of psychosis with the interpersonal experiences of the group in an ordinary way (Kapur, 1999; Dilks et al., 2010).

*Contd

Be attuned to and tolerate uncensored and intense counter-transference feelings of helplessness, despair, hate, anger, anxiety-terror and deadening depression (Winnicott,1958; Karon, 2001).

Hold and instil hope (but not false hope) an empirically derived factor in recovery from psychosis (Garcia – Cabeza & Gonzalez de Chavez, 2009).

patient progress is inevitably slow and hard-earned!