Kevin Donoghue is a community mental health nurse, Gloucester and the Forest of Dean assertive outreach team; Ken Lomax was a community staff nurse at Denmark Road Day Hospital at the time of writing; Jan Hall is a service user and group facilitator
VOL: 103, ISSUE: 19, PAGE NO: 30-31
Kevin Donoghue, BA, PGCE, RN, Dip; Ken Lomax, RN; Jan Hall
Abstract Donoghue K et al (2007) Using group work to prevent relapse in bipolar disorder. nursingtimes.net
This article outlines the principles and ideas behind a group intervention aimed at managing bipolar disorder that was run at DenmarkRoadDayHospital between October 2003 and April 2006. The article is not intended to act as a formal protocol or as an A to Z guide to running groups for bipolar disorder. Its purpose is to make the process of running a group of this type clearer and to help healthcare professionals to feel more confident about starting a group of this type.The original idea for running a relapse prevention group for bipolar disorder came about following a presentation given by Alison Perry, research assistant at the Department of Clinical Psychology at the University of Manchester (Perry et al, 1999). Perry outlined the possibility of working with people with a diagnosis of bipolar disorder to enable them to recognise relapse symptoms orÃ?Â?Ã?Â’prodromesÃ?Â?Ã?Â’ of illness. There has recently been a growing interest in the psychological management of bipolar disorder, building on the work of pioneers such as Newman (Newman and Beck, 1992). This growing interest led up to the publication last year of a randomised controlled trial which demonstrated that targeted group intervention for bipolar disorder could prevent and ameliorate both manic and depressive swings in mood in this client group (Colom et al, 2003).Morris et al (2002) remarked on the lack of a systematic approach for the management of bipolar disorder across mental health services generally and recommended that local implementation of services should seek to address this shortfall. Goodwin (2004) went a step further in criticising what he described as a ‘cyclopean modelÃ?Â?Ã?Â’ of severe mental illness that offers almost nothing to service users with a diagnosis of bipolar disorder, unless they are in crisis. In developing this groupwork approach, we were conscious that there are no services available locally that are designed to meet the specific needs of people with this diagnosis. In a review of randomised controlled trials for the psychological treatment of bipolar disorders, it was argued that a model of group psychoeducation should be part of the standard treatment package for bipolar disorder (Gutierrez and Scott, 2004).
Group designThe group was run at DenmarkRoadDayHospital in Gloucester. The day hospital provides mental health services to the whole of Gloucester city. Access to the group was available to all community mental health teams in Gloucester city. It was not possible to accept referrals from outside secondary care, although 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 (Harris et al, 2001). Locally, the benefits of working collaboratively with service users has been well demonstrated by using the experiences of service users to provide training videos (Coupland et al, 2001). Lastly, as professional mental health workers, we were keen to avoid being seen as experts in the self-management of bipolar disorder when we were in fact attempting to deliver our programme to people who had first-hand experience of dealing with the condition.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 first group was run.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 bipolar disorder.Originally it had been proposed to send out early sign scales (Birchwood et al, 1989) to prospective group participants, before they attended the group for the first time. Following discussion with Jan, however, this idea was rejected. As a service user, Jan felt that the design of the scales was off-putting and would probably have prevented her from attending any group initially. As we were not conducting an intervention that would require us to provide quantitatively measurable data, we decided instead to use the monitoring forms that we had designed specifically for the group as a means of evaluation.JanÃ?Â?Ã?Â’s involvement, as a service user, made a notable impact on the delivery of the content of the group. Livingston and Cooper (2004) cited a study which suggested that nursing students who had significant exposure to user trainers showed more empathy, used less jargon and had a more individualised approach to client care. JanÃ?Â?Ã?Â’s work with the group provided exactly this kind of focus.Group facilitatorsAll 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 mental health professionals 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. In our opinion, 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 (included in pack), to capture the salient points raised in each group session 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 on 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 Ã?Â?Ã?Â’databaseÃ?Â?Ã?Â’ of coping techniques, which make up a significant part of the package we eventually ended up with. Working in this way also generated an atmosphere of genuine collaboration within the group. Delivering the interventionDuring the first few weeks, the group went through a slow/open format Ã?Â?Ã?Â- this means facilitating people moving into the group process slowly over a number of weeks, allowing people to dip in and out at will initially. The use of this format made it necessary to repeat information and to revisit key concepts when a new member began attending. This was actually 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 (Coupland et al, 2000). Recent research also suggests that full functional recovery in bipolar disorder is unlikely (Baker, 2001), so any group education programme needs to take this into account. We were also careful to avoid introducing potentially painful topics, such as depression, too early in the group process. Mania was deliberately chosen first, as experience had 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 ensure that we 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 there was time to resolve issues within the 90 minutes allocated. Where necessary, clients were followed up individually, after the group had finished. Over the first six to eight weeks, five people became regular attenders, one person chose to drop out, one person was hospitalised (becoming too ill to continue attending) and three clients saw the group through to the end. These three consistent attendees were all women and had all had significant periods of illness, lasting around 20 to 30 years. All three had been given an Ã?Â?Ã?Â?Ã?Â?Ã?Â’officialÃ?Â?Ã?Â?Ã?Â?Ã?Â’ diagnosis of bipolar disorder following the births of their first children, although at least two of the three group members identified hormonal change in puberty as the first time they could clearly identify what they now believe to be the onset of the disorderÃ?Â?Ã?Â’s 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 clients receiving as many as three or four misdiagnoses before an accurate recognition of the condition is made by an appropriate clinician (Mynatt et al, 2002). 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 half and half, with two male and two female facilitators. One of the group members 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. Group dynamicsThe early sessions of the group were largely facilitator-led. In fact, on reflection, we were able to identify a process that took place within the group, which involved a change in the way that the intervention was delivered, as the group 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 members. Yalom (1983), in his work on group processes, described what he calls Ã?Â?Ã?Â’universalityÃ?Â?Ã?Â’, where the knowledge that other people share similar problems helps to further psychological improvements. Over the course of the group, 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 membersÃ?Â?Ã?Â’ experiences were elicited and paid attention to. The work was linked back in to frameworks such as the stress/vulnerability model, which were already familiar to the group members. The group sessions reflect this structure and for future groups we intend to close the group to new members after session eight. This was the point at which it seemed the structure and dynamic of the group moved decisively away from being didactic and facilitator-led, to 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 counterproductive to introduce new members. Another feature of the group was the emphasis on what time of year the group was run. In discussion, the group facilitators recognised a shared anecdotal evidence base (from working with individuals with bipolar 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 proposal to run through the winter in the expectation that a subset of individuals would be able to attend the group through the course of an episode. Mixed affective statesMost of the group members found the monitoring forms useful. However, as we worked through the group process, 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 bipolar disorder, so we attempted to work on this within the group on a Ã?Â?Ã?Â’here and nowÃ?Â?Ã?Â’ basis. One group member described this state as Ã?Â?Ã?Â’non-linear: in the mixed state, awareness seems to hop from a sense of elation to a sense of depression Ã?Â?Ã?Â- following the experience rather than being part of itÃ?Â?Ã?Â’. 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, flipcharts were used to brainstorm ideas for coping with mixed states, and they are included as part of the coping strategies generated by the group. A number of the group members have also modified their own action planning charts to include mixed signs as a separate mood state to plan for, alongside highs and lows. Relatives and carersThe 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 has emphasised the importance of including relatives and carers as part of any management package for the treatment of bipolar disorder. A survey for the Sainsbury Centre for Mental Health (Hill et al, 1998) concludes that specific intervention packages for the families and carers of people with bipolar disorder are long overdue. A randomised study by Miklowitz et al (2003) demonstrated that targeted carer and family support and education can lead to a reduction in symptom prevalence and longer relapse-free intervals. Lastly, a study of coping and caregiving by Chakrabarti and Gill (2002) concluded that education of carers of clients with bipolar disorder can lead to the adoption of more adaptive coping styles. 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 well-being to ignore. It is unlikely that we will ever run a long relapse prevention group for bipolar disorder 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 the decision was taken 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; Department of Health, 1999). Plans for the futureFuture groups may include more of an emphasis on dual diagnosis issues (alcohol and substance misuse). Previous studies suggest that as many as 60% of people with a bipolar disorder diagnosis also have problems with alcohol and substance use (Regier et al, 1990). Although we were aware of the significance of substance and alcohol use for people with bipolar disorder, the group attenders at Denmark Road did not have ongoing or historical problems with this particular aspect of their illness management. Future groups may include inviting outside speakers to the group with local expertise in dual diagnosis issues or signposting group members to relevant organisations, such as Gloucestershire Drug and Alcohol Services. They could also include the use of a problem-solving approach to drugs and alcohol within the context of a stress/vulnerability model of serious mental illness generally (Zubin and Spring, 1977). We would also like to be able to catch people as early as possible in the pathway of their disorder, although we acknowledge that a group approach may be harder to implement for people in the earlier stages of their illness. This may be especially difficult in view of the experiences of our group attenders, who sometimes waited for as long as a decade before being given a possible diagnosis. 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. It is hoped the next phase of development of the group will be to try to promote the delivery of relapse prevention groups for bipolar disorder on a countywide basis. Whether this will happen remains to be seen. We have run a very successful inpatient group along the same principles but with some modifications. There is a precedent for this in the published literature (Pollack, 1990) and it is envisaged that we will be able to use the inpatient group as a Ã?Â?Ã?Â’feederÃ?Â?Ã?Â’ group for community relapse prevention groups for manic bipolar disorder.
We now have the whole relapse prevention package available as a package on a CD-ROM. Over the next few months, my colleagues and I are working on developing a training programme for the rest of the TrustÃ?Â?Ã?Â’s mental health staff, so that the relapse prevention work can be delivered on a countywide basis. If anyone is interested in having a copy of the package they can contact me at Kevin.firstname.lastname@example.orgReferencesBaker, J.A.(2001) Bipolar disorders: An overview of current literature. Journal of Psychiatric and Mental Health Nursing;8: 437Ã?Â?Ã?Â?Ã?Â?Ã?Â-441. Birchwood, M. et al(1989) Predicting relapse in schizophrenia: the development and implementation of an early signs monitoring system using patients and families as observers. A preliminary investigation. Psychological Medicine; 19: 3, 649Ã?Â?Ã?Â?Ã?Â?Ã?Â-56. Chakrabarti, S., Gill S.(2002) Coping and its correlates among caregivers of patients with bipolar disorder: a preliminary study. Bipolar Disorder; 4: 50-60. Colom, F. et al(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. Coupland, K. et al(2001) Learning from life. Mental Health Care; 4: 5, 166-169. Coupland, K. et al(2000) Groupwork with people with psychosis who hear voices: A preliminary evaluation.(Unpublished paper). Department of Health(1999) National Service Framework for Mental Health: Modern Standards and Service Models.London: HMSO. Goodwin, G.(2004) Interview with Amanda Harris. Pendulum;20: 3, 10-11. Goodwin, G.M.(2003) Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology; 17: 2, 149-173. Gutierrez, M.J., Scott, J.(2004) Psychological treatment for bipolar disorders: a review of randomised controlled trials. European Archives of Psychiatry;254: 92-98. Harris, A. et al(2001) Evaluation of the effectiveness of self-management in Bipolar Affective Disorder. Self-Management Training Team, Manic Depression Fellowship .Hill, R.G. et al(1998) In sickness and in health: The experiences of friends and relatives caring for people with manic depression. Journal of Mental Health;7: 6, 611-620 .Livingston, G., Cooper, C.(2004) User and carer involvement in mental health training. Advances in Psychiatric Treatment; 10: 85-92. Miklowitz, D.J. et al(2003) A randomised study of family focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry;60: 904Ã?Â?Ã?Â?Ã?Â?Ã?Â-912. Morris, R. et al(2002) Bipolar affective disorder: left out in the cold. British Medical Journal; 324: 61-62. Mynatt, S. et al(2002) Identify bipolar spectrum disorders. The Nurse Practitioner;27: 6, 15Ã?Â?Ã?Â?Ã?Â?Ã?Â-29. Newman, CF., Beck, A.(1992) Cognitive Therapy of Rapid Cycling Bipolar Affective Disorder: Treatment Manual.(Unpublished manuscript.) Perry, A. et al(1999) Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. British Medical Journal;318: 149Ã?Â?Ã?Â?Ã?Â?Ã?Â-153. Pollack, L.(1990) Improving relationships: groups for inpatients with bipolar disorder. Journal of Psychosocial Nursing; 28: 5, 17-22. Regier, DA. et al(1990) Comorbidity of mental disorders with alcohol and other drug abuse. Journal of the American Medical Association; 264: 2511-2518. Yalom, I.D. (1983) Inpatient Group Psychotherapy.New York: Basic Books. Zubin, J., Spring, B.(1977) Vulnerability: a new view of schizophrenia. Journal of Abnormal Psychology;86: 103Ã?Â?Ã?Â?Ã?Â?Ã?Â-126. Further informationManic Depression Fellowship www.mdf.org.uk