VOL: 98, ISSUE: 41, PAGE NO: 33
Ian Simpson, PGCE, BA, is head of psychotherapy services, St Thomas’ Hospital, London
The most pressing need of patients with psychosis at any point in time is to ‘contain’ the illness so that it does not become overwhelming and cause serious disruption to their own or others’ lives. People experiencing psychotic episodes have periods of stability but may slowly or rapidly move into serious and severe states where they may be at risk to themselves or to others, lose all forms of self-care, be prone to ‘accidents’ and altercations, and become completely disoriented and incoherent.
Medication is the first line of treatment for psychosis because, in many cases, it quickly and markedly offers some relief for the individual and enables patients to be supported and managed more easily. However, group therapy theory and techniques, particularly in an inpatient or partial hospital setting, can also be an important basis for support and containment. A ‘holding environment’ (Winnicott, 1985) can be created by attending to institutional and staff needs as well as to the clinical aspects of patient care. To better understand this it is necessary to first focus on group theory and then on the context within which this type of work usually takes place.
Human beings are essentially social. If the individual is the basic biological unit, the basic psychological unit is the small group. In our culture the family provides this primary role. This widens to the extended family, the community and then into society as a whole. We arrive at a sense of ourselves through our interaction with others. We also derive meaning and significance from personal and social relationships. The notion of someone having a sense of themselves in isolation from others is ultimately untenable. The individual must be placed within the context of his or her natural group.
Individual psychological disturbances are always located in relation to others. An individual patient’s problems represent only one aspect of an intricate group phenomenon and patients’ difficulties are located in some aspect of their life situations and their interpersonal relationships. Group theory acknowledges this and offers a means of tackling individual problems within the context of the psychotherapy group. However, it is also important to recognise that most of us live and function in various forms of groupings in our daily lives and that psychiatric institutions themselves are composed of large and small group formations.
Group psychotherapy addresses these issues. It provides a unique situation that offers patients the opportunity to interact with others and to share and explore the conflicts and anxieties that arise in interpersonal relationships. An understanding of group dynamics can help patients and mental health workers make sense of what happens in institutions established to work with mental health patients. If patients are to feel contained, then the institution and staff members working there must be containing and feel contained themselves. If the context, or environment, feels containing then this will optimise the therapeutic potential.
The first important consideration to be faced when conducting an inpatient group in an acute setting is that it is never an independent, free-standing entity. It takes place in its own complex relationship to the wider community - the inpatient ward - as well as the wider institution in which the ward is situated. To create any form of therapeutic environment the team of staff must work together and become a cohesive group themselves. This is as true for a group as it is for an acute ward itself. The group’s effectiveness, and often its very existence, is dependent on backing and support from managers and staff.
If the ward’s consultant, its team leader and other nursing staff are not persuaded that a group therapy approach is appropriate or desirable, they are unlikely to support it. They will not facilitate its development or give it the kudos or prestige it requires. Colleagues will not make themselves available to participate or encourage patients to use the group. Managers and colleagues must be involved in, and see the benefits of, this approach for treating patients.
Therapy groups attempted where there is little support or where colleagues are not ‘on board’ are rendered ineffective. The group leaders quickly become demoralised, group meetings will often begin to be scheduled irregularly and are often disrupted by patients being called out for other things or not encouraged to attend. Also, a lack of serious commitment by staff teams or managers will make it increasingly difficult for group leaders to get the appropriate time and resources necessary to fulfil their role. Adequate supervision and training structures are unlikely to be put in place. Planning and preparation are essential. If the context is carefully prepared the chance of success for the therapy group is considerably enhanced and therapeutic outcomes are optimised.
Group work in an acute inpatient ward poses two daunting problems that must be squarely faced: the rapid change in the patient population and the wide disparity in patient psychopathology. Most wards are characterised by rapid patient turnover. The ‘revolving door’ phenomenon means that most patients will have an average stay on the ward of two to three weeks, with a small number there for lengthy periods. The composition of any group will be highly variable, with little chance of having the same participants each week. The spectrum of psychopathology represented in the group must also be considered when considering group aims, objectives and methods of working.
A typical contemporary inpatient psychiatric ward admits patients with a wide range of diagnoses, often including at any given time people with:
- Acute schizophrenia;
- Borderline or severe neurotic conditions;
- Dual diagnosis with substance abuse;
- Bipolar disorders;
- Major affective disorders;
- Eating disorders;
- Post-traumatic stress disorder;
- Situational or adjustment reactions.
Having a wide range of disgnoses and a changing group violates the clinical conditions that are normally deemed necessary for outpatient group therapy. It is usually vital that the membership is stable as this enables a gradual building of cohesion and containment. Care is also taken to select members with roughly similar ranges of difficulties.
How does the group therapist lead a group if some members are profoundly disturbed while others are better functioning and more integrated? It is essential that these issues are considered when preparing to establish a group.
In practical terms, the therapist needs to take an active, directive stance and the setting should be supportive. This requires therapists to speak more frequently, ask more questions and draw in members of the group more than they would in a more ‘traditional’ psychotherapy group. Therapists can use structured tasks and interventions with an emphasis on thinking or cognitive processes.
It is also important to impose structure and set limits. This includes reminding people of the ground rules such as when the group begins and ends, and what is permissable and safe. The therapist should also try to help people stay for the duration of the group. This is important to maintain cohesion and a good working group climate. However, there also needs to be a recognition of the shifting population and conflicting demands on time for some patients. Moreover, the work is likely to be more gradual than with higher functioning patients.
What is possible in group work?
What are reasonable goals in inpatient group therapy? The goal of the group is certainly not to resolve psychotic depression or anxiety or to slow down manic episodes. Nor is it to reduce delusions or hallucinations. Groups can do none of those things.
Other aspects of the ward treatment programme address these issues predominantly by using medication, but also by using psychosocial interventions in areas where nursing practice is more developed. When medications work effectively, they allow therapists to do a better job by alleviating symptoms and enabling patients to begin to come to terms with their illness and more easily face previously overwhelming issues around personal autonomy and social functioning.
Although an inpatient therapy group cannot do much to change deeper problems, it still has much to offer in terms of helping improve interpersonal interactions among patients, and between patients and staff. It also enables patients to make more sense of their current difficulties in the ward setting and in their lives in the outside community.
Yalom (1983; 1985) has written extensively on this subject. He suggests that there are six basic and achievable goals for inpatient therapy groups. These are:
Engaging patients in the therapeutic process
Inpatient psychotherapy experience may be the first or only exposure to therapy for many patients. If it is sufficiently positive, supportive and engaging, it can become an important affirmation of the benefits of therapy and will be something that the patient will be encouraged to continue after discharge. In my own experience, I have found that group therapy is a powerful and effective aftercare treatment, which works to keep group members out of hospital. Aftercare groups can work effectively on issues of medication concordance, advice and support, maintenance and the management of illness, while facilitating the exploration of relationships with fellow patients and with mental health professionals and institutions.
Communication and sharing
A group can help members understand that they do not have to struggle desperately in an attempt to contain their difficulties (see Box 1).
Talking to others, sharing feelings, listening and being listened to are good ways of getting some relief from disabling and distressing pain, through acceptance and mutual understanding. Recognition that you are not alone or the only one suffering is immensely important and the empathic and sympathetic understanding and support of others is positive and affirming.
Exploring difficulties and the recognition of problems
Group therapy is probably the best format for participants to learn about their maladaptive interpersonal behaviour, as it takes place in a context with other people, many of whom will have had similar experiences. In this way patients can begin to understand how their behaviour affects others and why people may respond to them negatively. Patients can begin to recognise and acknowledge why they find it difficult to be with other people and why their behaviour can be self-destructive and self-defeating.
A group helps individuals share experiences with one another and permits them to get feedback about how others perceive them.
Through this kind of feedback they discover areas of misunderstanding and misinterpretation, when their intentions did not seem to match their expectations, particularly in relation to other people.
Although the therapy experience is brief, the links and understanding gained there can be used to do further work during the remainder of patients’ hospital stay. They can also be used when patients return to the wider community, particularly in an appropriate aftercare structure.
One valuable aspect of inpatient hospitalisation is the help and support that patients can get from their relationships with other patients. In this context, reducing isolation between group members has two main benefits. First, if isolation is decreased it becomes evident in a patient’s behaviour on the ward. The less frequently that patients are isolated or withdrawn, the more they are able to use the therapy resources available. As communication improves, patients are able to make good use of their relationships with other patients, counteracting isolation or withdrawal.
Second, improved communication skills will help patients in their relationships with other people inside and outside the hospital. Most patients who are admitted in crisis to an inpatient ward suffer from some form of breakdown or an absence of important supportive relationships. If these patients can begin to transfer what they have learned in the group to their lives outside, then the group will have fulfilled an important function.
One of the most important aspects of group therapy for participants is the way that their self-esteem and self-confidence can be enhanced by the contribution they make for others. A group experience enables them to participate actively in the process in a way that individual therapy does not.
Yalom (1985) states: ‘If patients are helped by other patients, then they are also helped by the knowledge that they themselves have been useful to others. Patients generally enter psychiatric hospitals in a state of profound demoralisation. They feel that not only have they no way of helping themselves but that they have nothing to offer others. The experience of being valuable to other ward members is enormously confirming to one’s sense of self-worth.’
A group can enable members to contribute actively to the common endeavour towards better psychological health by increasing each member’s self-worth. It can also work against the often restrictive dichotomy of ‘active, expert professional’ and ‘passive patient’ by encouraging group members to value themselves as they see that they too can have a positive impact upon the lives of others. Even within the rather limited possibilities of an inpatient group, this can be extremely valuable and life enhancing.
Alleviation of anxiety
Admission to an acute ward generates considerable anxiety. Although some relief may be experienced by the initial sense of containment, a new patient has to come to terms with what can be a frightening, chaotic and often bizarre environment. In addition to this there is likely to be some sense of failure or shame because of stigmatisation or the effects that hospitalisation may have on the perceptions of family, friends or colleagues. Discussing and exploring these issues in a therapy group can be reassuring because worries and concerns are shared with others who are in a similar situation. Airing these immediate issues helps patients come to terms with their new circumstances by examining problems and difficulties together in a common endeavour.
Containing the staff
It is important when considering group therapy in an acute setting to accept that objectives must be limited by necessity. The patient group can have great difficulties with even rudimentary socialisation processes. Nurses must recognise their own limitations with such patients and accept that there will inevitably be ‘failures’ in containing some of them and that they will need to deal with what this brings up for them. Realistic aspirations of what is possible are required and it is essential that nurses meet regularly to discuss and explore the impact that working in such a setting can have on them and on their colleagues.
Powerful and disturbing feelings can be evoked in nurses and other staff members by individuals with psychosis, especially in group situations including on the ward itself. These feelings can lead to interpersonal difficulties such as burnout, psychosomatic disorders and stress-related problems if they are not processed.
Such difficulties can lead to unauthorised absences or leaving the unit altogether, which would inevitably necessitate the use of agency staff and result in considerable disruption to the continuity and consistency of approach.
The best strategies and techniques for patient care are likely to founder if they are applied without attention to the staff’s own needs, feelings and conflicts as they are aroused in the treatment process. Therefore it is essential that adequate training and supervision structures are put in place. Nurses involved in facilitating inpatient groups should have some grounding in their theory and practice.
This is a sound investment for trusts to make, given that such skills will be applied to large numbers of patients. Regular and structured supervision from someone trained in this vital support for the facilitators will help prevent problems with the overall functioning of the group. It is also important that the entire team of staff have a forum where they can discuss the impact of the group on their work and on their care for individual patients.
Powerful feelings of being overwhelmed and ‘uncontained’ are common. Staff need regular support to manage these feelings if patients are to experience some degree of success as they try to ‘contain the uncontainable.’
Inpatient group therapy offers a unique forum for nurses to work closely with patients to look at interpersonal relationships, the anxieties and conflicts that arise out of them, and explore issues about the ways in which individuals interact with, and within, their environment. It requires a supportive and containing environment for staff as they attempt to provide that for the patient group.
Groups will not resolve all the issues that brought the patient into hospital and are not without potential difficulties. However, they do offer a wide range of healthy outcomes as well as embodying an intrinsically humane and optimistic therapeutic approach.
Unlike long-term, outpatient groups, inpatient groups require the nurses or therapists involved to adopt a far more active and directive stance, intervening more and emphasising cognitive processes. Moreover, they can offer nurses a clear therapeutic role and help create a safe and containing environment on an acute inpatient ward.
- World Mental Health Day is on October 10
- Visit the mental health charity Mind on: www.mind.org.uk