July 11July 11thth, 2007, 2007

Group Psychotherapy in Group Psychotherapy in the Contemporary the Contemporary Psychiatric WardPsychiatric Ward

““From Obstacles to Stepping Stones”From Obstacles to Stepping Stones”

Background: Background: Safety, Privacy and DignitySafety, Privacy and Dignity..

Post of Group Therapy Development Post of Group Therapy Development OfficerOfficer

2001 Scottish Executive Audit : 2001 Scottish Executive Audit : Safety, Safety, Privacy and DignityPrivacy and Dignity

Psychotherapy Dept consulted 2004Psychotherapy Dept consulted 2004Job description agreed and post appointed Job description agreed and post appointed

October 2005October 2005Post activated in Feb 2006.Post activated in Feb 2006.

Key Elements of PostKey Elements of Post

“ …“ ….to facilitate the development of group .to facilitate the development of group therapy and reflective practice……in the therapy and reflective practice……in the five acute admission wards, in the first five acute admission wards, in the first instance.”instance.”

““To lead the development of this new To lead the development of this new clinical service via service provision, clinical service via service provision, training, supervision and reflection in five training, supervision and reflection in five teams.”teams.”

““Rights, Relationships and Recovery”Rights, Relationships and Recovery”

““Recovery is often described as a long-term Recovery is often described as a long-term process or “journey” and is not simply the process or “journey” and is not simply the absence of symptoms. It is based on absence of symptoms. It is based on hope, hope, involvement, participation, inclusion, meaninginvolvement, participation, inclusion, meaning,,

purpose, control and self-management and purpose, control and self-management and emphasises the importance of emphasises the importance of peer supportpeer support, , meaningful activitymeaningful activity, employment, maintaining , employment, maintaining social networks and activities when distressed social networks and activities when distressed and having and having the chance to contribute, or the chance to contribute, or giveback, in some waygiveback, in some way.” ( p18,RRR).” ( p18,RRR)

““Rights, Relationships and Recovery.”Rights, Relationships and Recovery.”

““Acute inpatient care is an area in which mental Acute inpatient care is an area in which mental health nurses sometimes feel compromised in health nurses sometimes feel compromised in their ability to deliver rights, principles and their ability to deliver rights, principles and recovery-focused care.” ( p24, recovery-focused care.” ( p24, RRRRRR))

“…“…inpatient care is struggling against a culture inpatient care is struggling against a culture of risk-averse, defensive practices……..serves of risk-averse, defensive practices……..serves to stifle some aspects of practice development to stifle some aspects of practice development and undermines efforts to meaningfully engage and undermines efforts to meaningfully engage with service users and carers.” ( p24 with service users and carers.” ( p24 RRRRRR) )

The First YearThe First Year

Who?..What?...Why?...How?Who?..What?...Why?...How? ““Who am I and what am I doing here?”Who am I and what am I doing here?”

““Who are you and what do you do here?”Who are you and what do you do here?”

““What is your experience of here?”What is your experience of here?”

“ “ Why are you / they doing that?”Why are you / they doing that?”

““How might we improve your experience?”How might we improve your experience?”

““Hello, my name is…….”Hello, my name is…….”

““My Early Countertransference……..”My Early Countertransference……..”

LostLost

AfraidAfraid

Bewildered…..and tiredBewildered…..and tired

I think I was beginning to really understand I think I was beginning to really understand the experience of both the service user the experience of both the service user and the staff member.and the staff member.

Many service users had told me of feeling Many service users had told me of feeling lost, afraid and bored.lost, afraid and bored.

Many staff had described bewilderment, Many staff had described bewilderment, fatigue and frustration. fatigue and frustration.

A Paradigm Shift?A Paradigm Shift?CountertansferenceCountertansference

ResonanceResonance

Heinz Kohut’s emphasis on “ experience Heinz Kohut’s emphasis on “ experience near” subjectivity and empathy. near” subjectivity and empathy.

A more systemic approach?A more systemic approach?

Preliminary WorkPreliminary WorkCoping with Change, Loss and LocationCoping with Change, Loss and LocationAsking and listeningAsking and listeningDiscussionsDiscussionsConsultationsConsultationsTrainingTraining ImplementationImplementationPsychotherapy DeptPsychotherapy Dept

The Challenges…………………..The Challenges…………………..

SpaceSpace

““Busy…busy….busy….”Busy…busy….busy….”

Academia !!!Academia !!!

The Debating SocietyThe Debating Society

The Fears : FightingThe Fears : Fighting

The Fears : Despair and ParanoiaThe Fears : Despair and Paranoia

The fears : Distress and….The fears : Distress and….

……..and hugging...and hugging.

The HopesThe Hopes ““There needs to be greater valuing of and There needs to be greater valuing of and

support for the highly skilled nature of support for the highly skilled nature of working with people with acute mental working with people with acute mental health problems.” ( p25, health problems.” ( p25, RRRRRR))

TrainingTraining SupportSupport Supervision / Reflective PracticeSupervision / Reflective Practice Protected timeProtected time Role extensionRole extension

HopesHopesNurses need to and Nurses need to and wantwant to.. “maximise to.. “maximise

time to build time to build RelationshipsRelationships.....based on.....based on principles in legislation, safeguards and principles in legislation, safeguards and codes of conductcodes of conduct ( Rights ( Rights)….to listen to)….to listen to what people say….to see the whole what people say….to see the whole person and not just his/her symptoms person and not just his/her symptoms

( ( RespectRespect)…..and to promote )…..and to promote RecoveryRecovery and inspire hope.” ( p14and inspire hope.” ( p14, RRR), RRR)

Tell me what to do and how to Tell me what to do and how to think.think.

Staff were keen to have Staff were keen to have a theorya theory

Theories are not hardened truths, rather shared Theories are not hardened truths, rather shared interactive constructions which emerge and have utility in interactive constructions which emerge and have utility in certain situationscertain situations

Theory helps therapist and the group contain and modify Theory helps therapist and the group contain and modify powerful and chaotic affectspowerful and chaotic affects

Key concept in group analysis is a communications Key concept in group analysis is a communications networknetwork

Yalom’s Therapeutic Factors, particularly:Yalom’s Therapeutic Factors, particularly:

Yalom’s Therapeutic FactorsYalom’s Therapeutic Factors Instillation of HopeInstillation of Hope UniversalityUniversality Imparting InformationImparting Information AltruismAltruism The corrective recapitulaltion of the primary family groupThe corrective recapitulaltion of the primary family group Development of socialising techniquesDevelopment of socialising techniques Imitative behaviourImitative behaviour Interpersonal LearningInterpersonal Learning Group CohesivenessGroup Cohesiveness CatharsisCatharsis Existential FactorsExistential Factors

Setting Realistic GoalsSetting Realistic Goals

Largely driven by patientsLargely driven by patientsContextContextComposition DifficultiesComposition DifficultiesPrevious ExperiencePrevious ExperienceStaff Hopes and FearsStaff Hopes and FearsEncouraging staff to be realisticEncouraging staff to be realistic

Some numbers….Some numbers…. Ward Ward AA has had has had 5555 from a possible from a possible 7373 groups groups This equates to This equates to 75.3%75.3% Average number of attendees per group was Average number of attendees per group was 44 Highest number of attendees wasHighest number of attendees was 6 6 Lowest number wasLowest number was 2, 2, not technically a group not technically a group

but often time well spent.but often time well spent. Over six months Over six months 242242 possible attendees ( from possible attendees ( from

people assessed as able to attend)people assessed as able to attend) Actual attendees was Actual attendees was 175175 This equates to This equates to 72.31%72.31%

““The Leap of Hope”The Leap of Hope”

More numbers…..More numbers….. Ward Ward BB has had a more difficult start. has had a more difficult start. Of a possible Of a possible 5151 groups there have been groups there have been 3333 This equates to This equates to 64.7%64.7% Average number of attendees is Average number of attendees is 3.53.5 Highest number of attendees is Highest number of attendees is 66 Lowest number of attendees Lowest number of attendees 22 Over 5 months possible attendees was Over 5 months possible attendees was 186186 Actual number of attendees Actual number of attendees 116116

Fresh numbers…..Fresh numbers….. Ward Ward CC recently commenced, on recently commenced, on June 12June 12thth.. Of a possible Of a possible 9 9 groups there have been groups there have been 99

groups, this equals groups, this equals 100%100% Possible number of attendees was Possible number of attendees was 5050 Actual number of attendees was Actual number of attendees was 4343 Average number of attendees per group was Average number of attendees per group was 4.64.6 Highest number was Highest number was 66 Lowest number was Lowest number was 44

SnapshotsSnapshots ““How come I’m allowed to talk now?”How come I’m allowed to talk now?” ““Can you hear my voices?”Can you hear my voices?” ““Is it o.k to talk about voices?”Is it o.k to talk about voices?” ““I’m not leaving…….”I’m not leaving…….” ““I never thought I would share that….”I never thought I would share that….” ““I don’t think I’ll be able to reveal anything about myself I don’t think I’ll be able to reveal anything about myself

as I’m scared it won’t be confidential.”as I’m scared it won’t be confidential.” ““Oh God that’s just like me.”Oh God that’s just like me.” “ ““ “How would you like it?”How would you like it?” ““What the xxxx would you know?”What the xxxx would you know?” ““Thank you”Thank you”

Common Themes…..Common Themes…..

Power and ControlPower and ControlThe “Patient” experienceThe “Patient” experienceMedication, side-effectsMedication, side-effectsLossLossPersonal relationshipsPersonal relationshipsWard RelationshipsWard RelationshipsFacing the futureFacing the future

Common Concerns….Common Concerns….

Managing diversityManaging diversitySmall numbersSmall numbersManaging anxiety and silenceManaging anxiety and silenceThe MonopoliserThe MonopoliserThe IntrudersThe IntrudersStaff rotasStaff rotasChallenging themesChallenging themes

Countertransference……Countertransference……

AnxietyAnxietyHopeHopeFearFearExcitementExcitementParanoiaParanoiaNumbNumbFrustrationFrustration

Presently…….Presently……. Groups, groups, groups…… Groups, groups, groups…… Yes, but….Yes, but…. TrainingTraining DataData CollaborationsCollaborations Supervision GroupsSupervision Groups Reflective Practice GroupReflective Practice Group PresentationsPresentations Alternative and additional GroupsAlternative and additional Groups

Stepping StonesStepping Stones Early patient and Staff Early patient and Staff

FeedbackFeedback

New wards coming on New wards coming on boardboard

““Would you like to…..?”Would you like to…..?”

““What do you think…..?”What do you think…..?”

PresentationsPresentations