Evaluation of ‘Growing Well’- a one day a week therapeutic community

About the authorThis evaluation was written by Dr Mark Widdowson, lecturer in counselling and psy-chotherapy at the University of Salford (referred to in this report as ‘the researcher’).

Introduction

‘Growing Well is a farm based Mental Health Charity near Kendal. We provide a safe sup-portive working environment to nurture mental health recovery and welcome anyone expe-riencing depression, anxiety or more complex mental health issues.’

The project provides a one day a week therapeutic community based on the theory of transactional analysis (TA) and which incorporates horticultural activities into its pro-gramme.

Effectiveness of therapeutic communitiesResidential therapeutic communities (TC’s) are a long-established mental health interven-tion, which have demonstrated effectiveness in the treatment of personality disorder (Chiesa, Fonagy, Holmes, & Drahorad, 2004; Karterud et al., 1992; Lees et al., 1999). De-spite this, the use of residential therapeutic communities has declined. This is partly due to economic factors, but also due to changes in the needs of service users. It is also recog-nised that there is a substantial number of people who would benefit from more input than can be provided by one-weekly psychotherapy, yet who are not sufficiently impaired to re-quire residential treatment.

An evaluation of the effectiveness of one day a week therapeutic communities for people with personality disorders (PD’s) conducted by Barr, Kirkcaldy, Horne, Hodge, Hellin, Gopfert (2010) and Hodge, Barr, Gopfert, Hellin, Horne, & Kirkcaldy (2010) found that the participants (n=22) experienced improvement over a one year attendance period, although statistical significance was not achieved on some of the measures. Despite this overall im-provement, no change was reported on personality disorder diagnostic measures, indicat-ing that whilst the service had been useful, that it had not been sufficient to change estab-lished personality traits. Participants experienced improved social functioning, which is a relevant outcome to people with PD’s who tend to have poor social and interpersonal functioning. No cost-effectiveness benefit was found, although by the end of the follow-up period, it was established that the TC had ‘broken even’, in terms of net cost of service off-set against use of health services.

Haigh (1999) has suggested that there are five principal factors present in therapeutic communities which can account for much of their effectiveness. These are; attachment, containment, communication, involvement and agency. In this model, ‘the TC provides a safe environment in which individuals can be enabled to reconstruct a secure attachment from which they can start to address negative patterns of relating. Childhood feelings of pain and anger can be safely expressed and contained within the group, without fear of re-jection. Then, through the TC’s culture of open communication and involvement they can begin to engage in deeper exploration. Well-organized structures are vital to creating and sustaining this culture of communication and involvement, ensuring that everything that happens in the TC is brought into the group, to be used therapeutically’ (Hodge et al., 2010:45)

Transactional Analysis (TA)- the theoretical approach used at Growing Well- has demon-strated effectiveness for depression and anxiety (van Rijn, Wild & Moran 2011; van Rijn & Wild, 2013; and Widdowson, 2012a,b,c, 2014) and also for the treatment of personality disorders in in-patient settings ( Soteman et al., 2010; Thunnissen et al., 2008). As an ap-proach, TA can be used as a framework for psychotherapy, but also for psychoeducational purposes and to promote positive interactions and improved social functioning.

The use of horticulture as part of a psychosocial recovery programme has developed its evidence base over the past few years, and has bee recognised to have benefits for de-pressive and anxiety symptoms, psychosis and for improving social functioning (Clatwor-thy, Hinds and Camic, 2013; Diamant & Waterhouse, 2010; Sempik, Rickuss & Beeston, 2014).

Structure of the programmeThe community day begins at 9.45am when members settle and briefly ‘check in’ about how they are feeling and then engage in a planning meeting until 10am. This is then fol-lowed by a therapy group until 11am. There is a short tea break and then at 11.15 three different activity groups are convened. One group prepares lunch for the community, one group engages in horticulture activities and a third group attends to administration for the community.

The community break for lunch at 12.30 and the afternoon therapy group is from 1.15pm-2.15. This is followed by another short break and then at 2.30 there is another short ses-sion which may be a community meeting or a group activity.

Method

This report uses a mixed-methods approach, in order to gain a rounded evaluation on the Growing Well therapeutic community. Quantitative data from outcome measures was used to explore the nature and extent of community members changes, and qualitative data was used to get a fine-grained perspective on the experiences of community members. Finan-cial data has also been included in order to create a preliminary cost-effectiveness analy-sis.

Data CollectionThe researcher attended the community for most of one day. He was introduced to the community at the start of the day, and the purpose of the evaluation was explained to members. The researcher explained that no identifying details would be recorded and members would not be expected to provide personal or sensitive information. Members were able to choose whether or not they participated in the evaluation and an optional ac-tivity was available for anyone who might choose not to participate. After this, the commu-nity participated in their morning therapy group, which the researcher was not present at. This was to enable community members to explore their feelings about whether or not they wanted to participate in private. The researcher then conducted two separate one hour fo-cus groups with the community members before and after lunch. The therapeutic coordina-tor sat in on these focus groups with an explicit purpose to provide support for community members. The researcher spent lunch with the community and left in the afternoon to give community members time to debrief and process any issues relating to the disruption in their usual structure caused by the researcher’s presence.

In the morning, the researcher told the community members that he would be asking them to discuss the following questions in the focus groups:

• What has it been like attending Growing Well?• What were you like when you first came?• How are you now?• What changes have you experienced?• What has helped?• What has the therapy been like? • What have the therapists said or done that has been helpful?• What could be improved or made different that would help?

The community members responses from the focus groups were transcribed by the re-searcher, and a copy of the researcher’s transcription was sent to the community mem-bers for a member checking procedure to confirm the accuracy of the transcription.

The transcripts were then read several times by the researcher and then analysed themati-cally, broadly following the structure provided by Braun and Clarke (2006). This involved identifying meaning units in each utterance, and then grouping these together into identifi-able themes. The themes are discussed below and will be illustrated by quotations from the transcript.

Members have regularly completed a battery of outcome measures since joining the com-munity. Data from these outcome measures was sent to the researcher by the therapeutic coordinator. Due to the small sample size, it is not possible to generate inferential statis-tics, or to analyse for statistical significance of improvement, however, descriptive statis-tics from these outcome measures are presented below.

Analysis of outcome measures dataMembers of the community have completed a battery of outcome measures, which has in-cluded CORE-10 (which measures global functioning and distress), GAD-7 (which mea-sures anxiety symptoms) and PHQ-9 (which measures depression symptoms). Unfortu-nately, complete data sets for all community members are not available, which limits the conclusions which can be drawn from this, however, from the data which is available the following findings can be reported:

• One out of three members who regularly completed PHQ-9 has shown overall improve-ment.

• One out of three members who regularly completed GAD-7 has shown overall improve-ment.

• Three out of eight members who completed CORE-10 have shown improvement in so-cial confidence which has been sustained over a period of 91 days.

• Two out of eight members (TC) have reported an overall improvement in anxiety levels and three out of eight members have reported an improvement in depressed mood.

• Three out of eight report an increased sense of resilience, two of these members have reported an improvement in resilience which has been sustained over a period of 91 days.

• In relation to general well-being and specific symptom improvement, three out of eight community members report an improvement in the quality of their sleep, and for two of these members, this improvement has been sustained for a period of 91 days.

These measurements cover a period of nine months. Given the complexity and severity of the diagnoses of community members, any improvement at all within what is a relatively short space of time must be acknowledged.

Cost EffectivenessGrowing Well staff have recorded community members use of health services throughout the time of their membership of the community. The client services receipt inventory has been used to estimate the cost of services received by each member of the community within a three month period. The following figures were used to approximate costs:Cost of inpatient days £800Cost of outpatient appointments £100Cost of day service hours £55Cost of primary & community hours £55

It would appear that there is a general reduction in the use of health services by commu-nity members over time, although without access to medical records it is impossible to ver-ify this. From visual inspection of these figures, it would appear that participation in the community typically results in a considerable cost saving, and that the community is a cost effective intervention.

Results from qualitative dataMany of the members responses below also include material relating to themes other than those they have been ascribed to. The researcher has chosen to include the full quote where possible, instead of breaking up community members responses in order to pre-serve the integrity of the statements, and to ensure that the members voices are clear and present in this evaluation.

The experience of coming to Growing Well

Initial AnxietyWithout exception, all of the community members found their initial contact with the com-munity to be anxiety provoking and that prior to joining they community they had experi-enced incapacitating levels of social anxiety.

‘My CPN suggested I attend here. I was quite anxious at first but then realised that this was a good opportunity for me. My individual therapy had come to an end and I realised that I still needed more therapy.’

‘When I first came I experienced a lot of ‘triggering’ from conversations. I found it ex-tremely difficult as we didn’t know each other. It took a while for us to get to know each other and to get used to each other’s ‘triggers’

‘I was in hospital for a while before coming here and I felt institutionalised. I started out by feeling very different from other people in the group. I was really shy of talking, but I’ve got better at it.’

All community members identified a number of benefits that they felt they had experienced as a direct result of attending Growing well.

StructureThe frequency and regularity of the TC has provided community members with a much-needed sense of structure and routine which has helped members to experience a feeling of normality and has also promoted social contact.

‘Coming here has been a really important structure. I was in hospital before I came here and this has helped me to get back into normal life. I have really relied on this project and it has given me structure and focus.’

‘I like that it is regular and it stops me being so reclusive. I normally avoid social situations so coming here has pushed me to be around people. Also the frequency of it has given me a sense of stability.’

‘Being involved in the structure and being part of a normal environment where you do things with other people (has helped). Like having lunch together and being around other people definitely helps. It gets me out and doing stuff which I wouldn’t do otherwise.’

Mutuality and connectionThe community members described a sense of mutuality and connection to other mem-bers which has reduced their sense of isolation.The process of empathising with others and receiving empathy also appears to have had a beneficial impact in reducing the expe-rience of loneliness which can be a part of living with mental illness. Furthermore, as part of the mutuality community members have shared coping strategies with each other.

‘Getting to know everyone and listening to other people’s stories and symptoms has really helped me to not feel so alone. It has helped me to understand where other people are coming from. I’ve also learned some useful coping strategies and I’ve enjoyed the sense of sharing and co-operation. Coming here has also helped me to learn more about myself.’

‘I feel less alone and more understood. I’ve started saying what’s going on for me instead of it all going round and round in my head. Although we’ve all had different life journeys, i can talk here. I couldn’t even talk to my husband about the things i speak about here.’

‘The group activities have been really good. Witnessing and being with each other’s pain has also helped. There is something about sharing and being in a consistent group that has been good.’

The consistency and regularity has encouraged community members to form friendships and social networks, which in turn has reduced their sense of isolation and improved their social anxiety.

‘I’ve always had problems making and keeping friends. Coming here every week helped and after a while we started to exchange numbers so we could keep in contact with each other between sessions. Because I’ve been coming every week it has made me confront issues that would normally make me dump a friendship. Whenever I’ve experienced someone as caring in the past it has given me a ‘red flag’ and I’ve backed off. I haven’t been able to do that in the same way here and it has really helped.’

The sense of mutuality has enabled community members to re-think their attitudes towards mental illness. This appears to have had a de-stigmatising effect which has reduced the group member’s sense of shame and isolation about their distress, which in itself has been therapeutic.

‘What’s changed for me is my perceptions of other people. I’ve realised that labels don’t matter. We’ve all got problems that interfere with our lives. I’ve appreciated that no matter what the label, its the problems that have the impact. We are all equal. There’s no differ-ence between us, regardless of if you have one, two or three diagnoses. Mental illness is subjective to the person. There’s no hierarchy here- we’re all equal.’

In with the sense of mutuality is a feeling of mutual accountability that several members of the community commented on. In addition to promoting their sense of belonging, this strengthens their sense of responsibility for their actions and for their behaviour towards others. This is clearly done from a position of care and respect for each other, which sug-gests improvements in self-esteem and interpersonal relatedness.

Changes

It is notable that the primary changes that community members reported were largely con-nected to their interpersonal functioning.

Interpersonal changes:• Reduction in social anxiety• Less isolated• Greater acceptance of self and others• Increased capacity for empathy• Increased sense of connection• Increased capacity for managing and resolving conflict

‘One thing that has definitely helped has been addressing difficulties in relationships and managing difficult situations. I’ve gained a lot from that.’

Reduction in social anxiety‘When i first came i didn’t want to talk to other people or socialise. I didn’t want to do any-thing. Now I feel comfortable talking and eating in front of the group. I actually want to come here and I’m not as scared as I was. I’m still scared in general, but not about coming here. That’s the first time I’ve experienced that.’

One community member felt that she had not experienced an improvement in her interper-sonal functioning, but had found that she was now able to eat in front of other people.

‘I don’t think I’ve changed socially. I’m still reclusive. I don’t do anything or don’t go any-where- I just hide. I can sometimes eat in front of other people now, but I don’t feel that I’m improving much’

It would appear that this is the exception, as all other group members reported a reduction in their social anxiety and in particular, an improvement in their ability to speak to other people. Members of the community typically reported high levels of social anxiety.

‘This is the only useful therapy I’ve had. Its taken me a long time to get comfortable here but now I’ve started to speak about things that I haven’t spoken about before.Because I dissociate, I spend a lot of time needing to get grounded. I still struggle with self—harm, cleaning the house and relationships and usually don’t feel safe. This has become a safe space for me. In terms of changes, i now feel able to speak in a group which is really big for me. I can feel vulnerable and fragile and i know I’d be safe and treated kindly and com-passionately by others. Everyone is so kind and understanding.’

What has helped

Being with other group members and starting to get an understanding of each other has helped. The help from the therapists has given me more understanding of how the mind works and why we do things. The therapy has helped me to deal with the trauma of (a be-reavement). Through the talking therapy and feedback from the group has helped me to see through the fog. I couldn’t do that before.

Acceptance and equality‘It specifically helps me that this is a group. That helps me more than if it were individual therapy. The ‘witnessing’ part of things is important. I can speak and other people don’t run out of the room. Its not just the insightful things that people say that helps, its that they stay and support and give feedback about how what we said affected them. When people are sharing it causes you to reflect on your own life and gain empathy for others. We are a group of people who are committed to caring and its consistent. I like the ‘radical accep-tance’. Its unconditional, and non judgmental and there’s a clear structure.’Here we see that the sense of acceptance that the community member has experienced has also increased their sense of empathy and connection to others. This was echoed by another community member who described a process of greater acceptance of self and others and clear sense of equality:

‘What’s changed for me is my perceptions of other people. I’ve realised that labels don’t matter. We’ve all got problems that interfere with our lives. I’ve appreciated that no matter what the label, its the problems that have the impact. We are all equal. There’s no differ-ence between us, regardless of if you have one, two or three diagnoses. Mental illness is subjective to the person. There’s no hierarchy here- we’re all equal.’

The atmosphere of acceptance has clearly been supported and modelled throughout by the therapists. All community members felt that the therapists maintained a non-judgmen-tal approach. The following responses were fairly typical of community member’s percep-tions of the acceptance they experienced from therapists and the overall collaborative ap-proach to the therapy:

‘The therapists have been completely non-judgmental and you never feel like you’re being assessed. I too get that feeling of equality and respect.

‘The therapists are like guides and are willing to walk alongside you. In the past I’ve expe-rienced therapists who take an ‘expert’ stance and you don’t feel that its a joint effort. Here the therapists are more equal and collaborative.’

HopeOne member of the community occupies a combined service user/ staff role. Drawing on her experiences as a service user has given community members a sense of hope about their own capacity for recovery.‘Having (service user representative- name removed) role is really useful and helps be-cause we can draw on her experience and that normalises things. She gives us confi-dence and hope because she has ‘been there’ and we can see how far she has gone in her own recovery. ‘

Reduction in Self-HarmSeveral community members reported a reduction in their self-harming behaviour since joining the community, although frequency of self-harming behaviours was not recorded prior to joining, or during membership of the community. Due to this absent data, it is not possible to form conclusions about any beneficial impact that Growing Well might have on self-harming behaviour although further research is warranted. ‘I’ve gained a new understanding of my previous suicide attempts- I wanted to escape from the pain and to take the guilt away.’

Creative and expressive therapy interventions

One community member who experiences dissociative symptoms described how creative interventions from the therapists have been beneficial.

‘I often feel silenced until a part of me comes back that can talk. I started writing and showed it to the therapists. They are willing to try alternative ways of working and go into uncharted waters. They accepted that I could only write and not talk at times. When I started writing I felt so supported in a way that I’ve never felt before. Also there’s a flexibil-ity and you get some individual attention.I wanted to to release some anger in a safe way so we went into a field and threw rocks. Just being in a field helped- I could go out and shout and no one would hear. I haven’t needed to go to hospital since coming here and it stops the need for self harm. Digging things and the horticulture helps. I’m learning new things and doing something physical which is really good.’

Another community member describes a collaborative experience with the therapy team to devise creative ways for the member to express her needs.

‘I was really anxious about coming to Growing Well. I don’t remember the exact process, but I know I was angry at the beginning. I’d been in other groups before which were really structured and I couldn’t find my own space in them and I struggled to find my own space here at first. After a while, it became easier. I talked to therapy team who helped me to create visual cues that I could use to help me speak out- like putting a hanky on my knee to let others know I wanted to speak. I was so frightened that if I spoke I’d be interrupting others. It was really good that other people started picking up when I wanted to speak and although it wasn’t easy. I now can find a space. We did some contracting in the group for sharing time which made it easier.’

Use of Psychoeducation and Transactional AnalysisThe community members have found the use of transactional analysis theory for psychoe-ducational purposes to be particularly helpful. For example, the theory of ego states has

been used to help members understand their internal reactions to situations and also their different ‘parts of self’.

‘I’ve found that learning about TA has been really useful in helping me and others to un-derstand what’s happening and to make sense of experiences.’

‘I’ve learnt a lot about my different ‘parts’ which has been really helpful.’

The theory has been used by members to gain new insights and understandings into their internal experiences and their behaviours as well as ways to improve how they relate to other people.

‘I’ve gained a new understanding of my previous suicide attempts- I wanted to escape from the pain and to take the guilt away. Everyone in the group has given me comforting words to help me deal with what happened. I’ve learned a lot about other people and I’m beginning to accept myself and others more. I’ve also began to realise more about the role I normally take of helping and looking after people and where that comes from. ‘

‘When I first came here I was in a huge emotional mess. I had lots of questions about why I was acting like I was- taking overdoses and so on. I’ve got an awful lot from listening to others and from the teaching and learning about TA. I also liked the fried egg diagram. The yolk is your personality and the white is the outside influences. It’s helped me to make sense of things and feel better about myself. I’m not totally scrambled! I’ve learnt a lot about understanding emotions and different parts of my mind. I can honestly say its been really beneficial and I do hope there is opportunity to continue. My psychiatrist has said I can halve one of my medications, which to me is a big thing and shows I’m definitely get-ting better.’

‘I liked learning about “rupture and repair” and how to solve problems.’

What could be different or improved?RecommendationsThe author recommends that the service be continued, and ideally, extended. The cost ef-fectiveness of the service appears to be compelling evidence in support of the continuation of the service.On the whole, community members appeared to have a general trend to-wards symptomatic improvement, although the service appears to be particularly helpful at improving interpersonal functioning, and specifically reducing social anxiety.

The community members were in unanimous agreement that the service could be im-proved by increasing the length of the community day and by adding extra days.

‘I think I could get better but there’s not enough time. It’s only one day a week and I think if we came here for more days I would definitely notice a difference. It just feels too re-strained at the moment and doesn’t feel enough.’

‘I feel I could make much more progress if it was more often.’

‘I really wish there were more time. I feel a sense of anxiety about the prospect that the project could suddenly end and I’d be without a valuable service. There’s a long waiting list for 8 weeks of therapy. I’m not well enough to manage that.’

There was a general sense amongst community members that some kind of structured in-duction programme would have been beneficial.

‘Also, rules might have helped at the beginning. Whilst the flexibility has been important and we developed our own rules, a few to start with (such as no relationships) would have been helpful.’

‘Maybe some kind of structured introduction process when people start would help to get to know each other’s problems’

‘People are committed here. Some kind of induction about the importance of attendance and also how to manage the anxiety of starting would be helpful.’

In light of how helpful community members have found the TA based psychoeducational aspects of the programme, it would be helpful to add in an additional 20-30 minute psy-choeducational slot into each community day. This would mean extending the length of the community day, which has obvious resource implications, however it would seem that this would increase the effectiveness of the programme and promote a sense of self-efficacy and agency amongst members.

It would be helpful if community members were encouraged to complete outcome mea-sures on a monthly basis, in order to increase the amount of data available to assess the effectiveness of the project for symptomatic improvement.

Some community members suggested that they had experienced a reduction in self-harm-ing behaviours, although there is no data available to verify this. It would be desirable if the project found some way to record frequency of self-harming behaviours amongst commu-nity members to explore the impact that participation in the community has on self-harm.

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