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A relapse prevention group for bipolar disorder

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A 'Managing Manic Depression? group intervention was run at DenmarkRoadDayHospital between October 2003 and April 2006.

A 'Managing Manic Depression? group intervention was run at DenmarkRoadDayHospital between October 2003 and April 2006.

This article is not intended as a formal protocol or as an A-Z guide to running groups for manic depression. Instead, its purpose is to make the process of running a group of this type clearer and it is could help service users and professionals to feel more confident about starting a similar group.

The original idea for running a relapse prevention group for bipolar disorder came about following a presentation given by Alison Perry, in which she outlined the possibility of working with people with a diagnosis of manic depression or bipolar disorder to enable them to recognise relapse symptoms or 'prodromes? of illness.

Last year a randomised controlled trial demonstrated that targeted group intervention for bipolar disorder could prevent and ameliorate both manic and depressive swings in mood in this patient group (Colom et al, 2003).

The group was run at DenmarkRoadDayHospital in Gloucester. Denmark Road provides mental health services to the whole of Gloucester city. Access to the group was available to all community mental health teams in the city.

It was not possible to accept referrals from outside the secondary mental health system, though this has been suggested as a possible option for future groups.

The original proposal was to run the group with a service user as co-facilitator. This decision was taken for a number of reasons. First, it was felt to be good practice. The Manic Depression Fellowship has run self-management courses for a number of years, with service users alone providing the training.

More locally, the benefits of working collaboratively with service users have been well demonstrated by the work done through the local Thorn Initiative in using the experiences of service users to provide training videos.

Finally, as professional mental health workers, we were keen to avoid being seen as 'experts? in the self-management of manic depression when we were in fact dealing with people who had much more first-hand experience of dealing with the illness.

Having taken this decision, we approached a local service user, Jan Hall, following discussion with her CPN, who had initially suggested that she might be interested. Once Jan had agreed to participate and the process had been explained to her, she was also involved in the planning that took place before the group was run for the first time.

The group attenders were identified by their respective keyworkers. A standard letter was sent and interested service users were invited to discuss the group with the facilitators at Denmark Road. The only condition for group attendance was a primary diagnosis of schizoaffective disorder or manic depression.

Originally it had been proposed to send out Early Sign Scales to prospective group attenders before they attended the group for the first time. However, following discussion with Jan this idea was shelved.

She felt the design of the scales was off-putting and would probably have prevented her from attending the group. As we were not conducting an intervention that would require us to provide quantitatively measurable data, we decided instead to use the ongoing monitoring forms that we had designed specifically for the group as a means of evaluation.

Jan?s involvement made a notable impact on the delivery of the content of the group. For example, she stopped the two male facilitators from using any kind of jargon-heavy language, which can put users off.

All three facilitators (other than Jan) were mental health nurses. This is purely coincidental. There were no professional criteria used to select facilitators. We eventually ended up with facilitators who were particularly interested in this intervention, and who were prepared and able to use their professional time to do it.

The model for the future is likely to be two 'professional? facilitators, plus a service user. In this way, there is always likely to be at least two facilitators each week. Our experience of running this group would suggest that a single facilitator would not be adequate.

The group could be run by mental health workers from any professional background. It could also be run by service users, with no professional facilitators, although the current arrangements for service user participation within Gloucestershire Partnership NHS Trust would make this difficult to implement.

In other areas, such as Exeter, the local mental health services have collaborated with the Manic Depression Fellowship to support the running of self-management groups by service users.

At the end of each session the four group facilitators met to review and debrief for an hour. Jan was offered access to an independent clinical supervisor (a clinical psychologist), which she chose not to take up.

We were unable to pay Jan for her work with the group but this is a situation that we believe will be addressed when the group starts up again. Also, it is proposed that we use a debriefing form to capture the salient points raised in each group in a more comprehensive fashion.

One of the other significant features of the group was the use of flipcharts to capture discussion within the group. This was particularly useful during sessions based around recognising the early warning signs of illness and coping strategies.

Permission was sought from the group members to use the ideas and suggestions they came up with to build up a database of coping techniques, which make up a significant part of the package we ended up with. Working in this way also enabled us to generate an atmosphere of genuine collaboration within the group.

During the first few weeks the group went through a slow/open format. The use of this format made it necessary to repeat information and to revisit key concepts when a new member started.

This was welcomed by the other group members and fits in with the suggestion that people with serious mental illness can have difficulty processing information, so the pace of material delivery is particularly important.

We were also careful to avoid introducing potentially painful topics such as depression too early in to the group process. We deliberately chose to deal with mania first, as our experience suggested that talking and thinking about depression was often very difficult and would need to be done when the group members had established trust and confidence in themselves and the group process.

We also tried to make sure that we pre-warned people if a painful topic was coming up, and we never began talking about something new in the last 30 minutes of the group, so that we had time to resolve issues within the 90 minutes allocated. Where necessary, we would follow people up individually after the group had finished.

In the first 6-8 weeks five people became regular attenders, one person chose to drop out, one person was hospitalised and three people saw the group through to the end. These three were all women and had all had significant periods of illness, lasting around 20-30 years. All three had been given an 'official? diagnosis of manic depression following the births of their first children, though at least two of the three group attenders identified hormonal change in puberty as being the first time they could clearly identify what they now believe to be the onset of manic depressive symptoms.

At least one of the group members believes it was about 10 years before she was accurately diagnosed. Again, this is a common experience for people with this particular disorder, with most people receiving as many as three or four misdiagnoses before an accurate recognition of the disorder is made by an appropriate clinician.

It may also have been significant that all of the group attenders were women. The literature suggests that women are often more readily diagnosed with affective disorders than men. It may also reflect a 'traditional? readiness on the part of women to engage with the idea of talking about their emotions. We would recommend that there is a balance of genders in the group facilitators. For this group, the balance was split 50/50, with two male and two female facilitators.

One of the group attenders chose to manage her illness without medication. The other group attenders used a combination of maintenance medication and targeted medication during periods of high pressure or early relapse. During the sessions that dealt specifically with medication this group member chose not to attend. A local pharmacist with specialist knowledge of mental health provided two guest sessions on medication. This also gave the group members the opportunity to get specific feedback about the medication they were taking.

The early sessions were largely facilitator led. We were able to identify a change in the way the group was delivered as it became more cohesive.

This involved a move from earlier sessions, which were largely facilitator led and focused around explanation and categorisation of symptoms and experience, towards a group dynamic in the latter stages, which was largely group member led and concentrated more on comprehension of the experience of the group members.

As the members became more comfortable with sharing their experiences there was very little need to structure the group sessions very closely. Instead, topics such as loss were introduced and group members experiences were elicited and paid attention to, while linking the work back in to frameworks, such as the stress/vulnerability model which were already familiar to the group members .

The group sessions reflected this structure and for future groups we intend to close the group to new members after session 8, feeling this was the point at which the structure and dynamic of the group moved decisively away from being didactic and facilitator led into a more personally focused group. This was also reflected in the level of self disclosure that took place, by both group facilitators and group attenders, and it was felt that at this stage in the group process it would have been counter productive to introduce new members.

Another feature of the group was the emphasis on what time of year it was run. In discussion, the group facilitators recognised a shared anecdotal evidence base from working with individuals with Bi-Polar disorder in a variety of settings,that indicated a marked seasonal component to the experience of the disorder for many people. It became a reasonable proposition to run through the winter in the expectation that a sub-set of individuals would be able to attend the group through the course of an episode.

Most of the group members found the process forms useful. However, as we worked through the group, it became clear that we had paid very little attention to dealing with mixed affective states. There is almost no published literature on working psychologically with this aspect of manic depression, so we attempted to work with this within the group on a 'here and now? basis. One group member described this state as 'non-linear; in the mixed state, awareness seems to hop from sense of elation to sense of depression - following the experience rather than being part of it?. Other group members referred to a sense of unreality and gave evidence of dissociation.

In follow up work on an individual basis it has been helpful to discuss experiences of derealisation, depersonalisation or dissociation and to notice these as early warning signs of mixed affective state, using mindfulness and grounding techniques as intervention.

Working within the group, we used flipcharts to brainstorm ideas for coping with mixed states, and have included them as part of the coping strategies generated by the group. A number of the group attenders have also modified their own action planning charts to include mixed signs as a separate mood state to plan for alongside highs and lows.

The group also included an evening session for relatives and carers. This was done at the request of the group members and their relatives. Although we were only too happy to accede to this request, we were also aware that recent literature emphasises the importance of including relatives and carers as part of any 'management? package for the treatment of manic depression.

From examining the themes which cropped up in the group each week, it was clear that the relationships the group members had with their partners, relatives and other significant people in their lives were too important a factor in their overall wellbeing to ignore. It is unlikely that we will ever run a long relapse prevention group for manic depression without including at least one session with relatives and carers, and it is recommended that this is adopted as part of the overall group process.

Although we took the decision to eschew traditional, qualitative evaluation methods, the principles underpinning the overall approach, and the content of the group itself, are well supported by evidence based practice guidelines (Goodwin, 2003 and the National Service Framework for Mental Health).

Overall, as facilitators we believe this process has enormous value and could easily be adopted and run in both statutory and non-statutory mental health settings. The next phase of development of the group (it is hoped) will be to try and promote the delivery of relapse prevention groups for manic depression on a countywide basis. Whether this will happen, remains to be seen.

It is also proposed that we run an adapted version of the group for the local inpatient population and it is envisaged that we will be able to use the inpatient group as a feeder group for community relapse prevention groups for manic depression.

References

Colom, F., Vieta, E., Martinez Aran, A., Reinares, M., Goikulea, JM., Benebarre, A., Torrent, C., Comes, M., Ciorbella, B., Parramon, G., Corominas, J. (2003). A randomised controlled trial of the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Archives of General Psychiatry, 60 402-407.

Department of Health. (1999). National Service Framework for Mental Health : Modern Standards and Service Models. HMSO Publications, London.

Goodwin, GM, (2003), Evidence based guidelines for treating bipolar disorder: Recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 17 (2), 149-173.

Zubin, J. Spring, B. (1977). Vulnerability : A new view of Schizophrenia. Journal of Abnormal Psychology. 86, 103 - 126.

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