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Open Recovering Group: 2004-2006 Planning Document


1:  Purpose   ...click here for details...

Purpose: To establish a process for a new recovery group at Charlton Lane Hospital

We decided that we will go ahead with an open, dialogue based group, with significant service user facilitation, similar to the one set up by Alex Stirzaker, Tim Cuss, Keith Coupland and Gerry Holloway, at Wotton Lawn.

The purpose of the group is to increase dialogue between patients and then with the staff members and facilitators that also attend. Developing a dialogue (a meaningful conversation, directed at understanding one another) is thought to be helpful in promoting an attitude of recovering from illness.


Purposes of the Group

  1. Encourage/promote interaction and connections between persons.
  2. To understand and share ideas about wellness and recovering.
  3. To share experiences through ‘narrative’ ‘storied’ expressions of the person’s life.
  4. Building hope for being in the present and looking to the future with confidence.

All patients are invited, and staff are welcome too. Patients do not have to attend but will be actively encouraged. They may leave the meeting if they wish, at any time but we hope they will stay for the whole session. If they leave they may return at any time.

The Dialogue group began on 17th November 2004.

Times: Every Wednesday, 3 pm– 4 pm (later moved to the quiet room Charlton Lane Hospital, following the closure of Sherborne House).


2:  Ground rules of the group (developed by the working team)   ...click here for details...

All dialogue is confidential to the group but individuals may talk about their experiences of the group provided they do not talk about other people without their permission. There are no notes kept about the group by the facilitators.

  • Sharing experiences and LISTENING to others is most important.
  • Everyone has the right and opportunity to speak but NOBODY IS FORCED to speak
  • And only one person at a time to speak to avoid confusion.
  • EQUALITY and RESPECT for each other is essential.
  • NO sexism, racism, homophobia or other prejudices!
  • PLUS any other rules the group wishes to have

The purpose of the group is to understand recovery through talk about personal experiences of mental ill health or distress and to hear about how others have learned to cope with these experiences and to receive support from other group members.

The main purpose of the group is for all of us to come to terms with our mental distress and help in recovering from it.


3:  Philosophy of the group   ...click here for details...

The group is inspired by the principles of dialogue (Friedman, 2003; Isaacs, 1999) , recovering attitudes to serious mental illness (Anthony, 1993) , and the meaningfulness of the experience of psychosis to the person (Epston & White, 1989) .

The process is inspired by previous successes in group work for psychosis (Coupland, Davis, & Macdougall, 2002) , especially where dialogue and meaningful narrative (an ongoing, storied account of the psychosis) are used (Coupland, Davis, & Macdougall, 2002; O'Neil & Stockwell, 1991; Vassallo, 1998) .


4:  Evidence base for the group   ...click here for details...


See article on groupwork for psychosis

A challenge to the structured group approaches is described by O'Neil and Stockwell, focusing on collaborative dialogue between group members, that explores and re-evaluates members biographical accounts of their experiences (O'Neil & Stockwell, 1991) . A dramatic example of this re-evaluation was the renaming of the group. The eight male members had chosen the title 'the losers group' for their closed group (where new members are not admitted) but after a number of sessions renamed it 'the worthy of discussion group' (O'Neil & Stockwell, 1991) . This project was repeated and similar encouraging results were obtained with members taking responsibility for changing their view of schizophrenia from a disease with inevitable decline to an illness with recovering as a process (Vassallo, 1998) . Both these studies employed a narrative approach that encouraged group members to rewrite the dominant story, (or unitary knowledge) (Epston & White, 1989) of a medical model of schizophrenia, to another story that incorporated a new vision that the group had co-created. They called their group 'A haven for active minds' and the main therapeutic aim was to identify restrictions of mental illness, externalise these restrictions through telling their stories of their experience and then rewriting these stories using their own unrecognised successes, (subjugated knowledge) (Epston & White, 1989) . The results were that the members experienced increased confidence and self acceptance (Vassallo, 1998) .

The group work for psychosis that the open recovery group uses is based on dialogical processes, where the primary aim is to repair feelings of being disconnected from other human beings (Friedman, 2003) . Such groups exist in prisons and psychiatric wings of prisons in the work of prison dialogue (www.prisondialogue.org.uk). Prison dialogue has made remarkable progress in engaging groups of prisoners to re-connect to each other.

When working with psychosis, the ability to be curious, empathise and understand the person’s psychotic experiences is an important part of helpful therapy (Mosher, 2001) . The recovery group combines the empathic curiosity of Mosher’s approach with the re-connecting through group work of prison dialogue. The emphasis is on reformulating stories of hopelessness and helplessness to ones of coping, recovering and reclaiming personal stories as journeys through difficulties rather than inevitable decline.

A major philosophical foundation of the group is an attempt to alter the power inequalities that a professional to patient relationship often

5:  Process of the group   ...click here for details...

Chris Meads (STR worker) and Steve Brookes (service user) were the lead facilitators with Keith Coupland (nurse consultant) providing support. From the beginning, the group was very successful in attracting numbers of patients who seemed to value the opportunity to talk in this group format. A large measure of credit goes to Chris Meads whose role as a support worker was designed by Denise Hall (ward manager). Chris had the remit to encourage patients to go out of the hospital on social trips, trips to the hairdresser, to home but most of all to connect to each other by being ‘thrown together’. Chris managed these situations with great skill and used the patients’ strengths as human being rather than pointing to their pathology and limitations. Chris was able to keep a dialogue running through the week that often pointed to the recovering group as a natural step in a progression towards recovery.

Chris was not overwhelmed by psychiatric interpretations of the patients’ behaviour; something Keith Coupland described as ‘therapeutic naivety!’, which meant he responded and encouraged the connective conversations of normality rather than contrived therapy. This may seem an obvious point and a goal hardly worthy of a description as a group intervention but it was a fundamental step for many of the patients, who felt so ill and disconnected from others.

The other facilitators picked up on specific areas of information when asked to do so by the patients. For example Keith may suggest an article or book that explains a certain point. A large range of articles is always available in the room where the group is held and most are written by patients or are about patients’ direct experience..

Each member of the group is welcomed and offered tea or coffee and a cake. Each session began by Steve Brookes reading the ground rules of the group. Steve is a service user with eight years experience of group work, teaching and engaging in the recovering process.

Copies of the ground rules are left on the chairs before patients arrive. The chairs are laid out in a circle and there are usually ten patients and three or four facilitators. Other staff join the group as visitors (one at a time) and the hospital chaplain has joined as the fourth facilitator.

After the ground rules are read out we go around the group saying or names. Chris Meads usually initiates the first dialogue based on an encounter he has had with one of the group members during the week. Sometimes members of the group have to be asked or given permission to speak and at other times there is a dialogue developed between several members.

Sometimes members of the group may talk about their psychotic experiences and become involved to such an extent that it seems that they are losing the thread of their story or other members are not able to follow the thread. At this point one of the facilitators intervenes to try to summarise the statement and link it to the themes that have been emerging. This is a tricky and skilful intervention because it needs to be judged so the person feels heard and understood but also ‘contained’ rather than cut off. A short summary helps the person to know they have been heard.

A similar intervention that needs careful judgement is when a person is talking about distressing ‘psychotic’ beliefs because these beliefs are often underpinned by real events. Helping the person to sift the ‘psychotic’ (unreal) from the real is very skilled, especially when the facilitator has a group of patients listening, who may not be able to make sense of the dialogue or may even be frightened and distressed by it. However, our experience is that it is worth the risks inherent in listening to these statements because of the benefits of having the beliefs heard, understood and clarified.

The group continues like this for an hour. Most patients as group members seem very pleased with the group process. The facilitators often have a range of feelings from exhaustion to despair, from hope to elation. The feelings of exhaustion and despair are often linked to the strain of trying to listen at a level that far exceeds everyday concentration. The hope is linked to feelings that the facilitators have managed to connect with a person and are beginning to understand their experiences. The feelings of elation arise when facilitators are able to draw several ‘chapters’ of the patients’ narrated experiences together and the sense of a ‘story’ is emerging. This story is often one of being a victim in a confusing world. This is often an important phase because the person may have had their ‘real’ experiences negated under the cloak of the label psychotic, whereas we now realise that many persons with psychosis have had traumatic experiences before psychosis, then found admission and treatment to be traumatic and the symptoms (hallucinations and beliefs) traumatic (John Read, Mosher, & Bentall, 2004; J. Read, Perry, Moskowitz, & Connoly, 2001) .

Feelings of elation are often experienced by facilitators because of the good humour that is often present in the group. Humour is a great curative factor in recovering from any illness but it takes considerable openness in some patients with paranoia to laugh at their situations that seem so full of fear. Facilitators often role play accepting good humour by telling parts of their own story and gentle self mocking of their own difficulties (Macdougall, 2001) .

Group members are free to leave the group at any time so if a person feels distressed and not able to deal with the feeling they can leave. In fact it is very rare for group members to leave because they are distressed.

It is more likely they will leave because they are sedated by medication or are finding it hard to concentrate for other reasons.

Some group members have attended over a long period. Despite the wards being called ‘acute’ there are a number of patient who remain on the ward for a year or more. These ‘new long-stay’ patients can lose hope as well as their skills of living independently. These patients benefit from the continuity of the group as well as the fellowship it brings. Another benefit is the group facilitators may not have seen the person during the week so they often notice small changes of improvement and are able to feed this back.

 

6:  Supervision   ...click here for details...

 Supervision has been an excellent forum for facilitators to explore the roots of their feelings about the group process. The supervisor (Hannah Steer) is a clinical psychologist working with psychosis. All facilitators have supervision and all have found it essential. Supervision was programmed each week directly after the group.

The supervision has helped us maintain our own hopefulness of the benefits of the group by sharing despairing moments and reframing them. For example a facilitator felt despair when a patient seemed so unwell despite the effort he had made to attend the group. Supervision helped to reframe this as the patient talking openly about distressing symptoms for the first time, rather than being overwhelmed by new symptoms. This was confirmed the next week when the patient made a statement confirming this and stating how helpful it had been to get this experience in the open.

As the group progressed it was clear that the group was not homogenous in any conventional way, it has members that are male, female, young, older, different ethnic groups and different diagnoses. The one thing that drew them together seemed to be the wish to connect to others.

 

7:  Conclusion   ...click here for details...

 The open recovering group has required a good deal of planning. Such an open group breaks the usual mould for groups; the power is more evenly distributed, the membership is diverse and their experiences are diverse. The group facilitators are skilled human beings rather than trained group therapists. No notes are taken so there is no written record that can be drawn on to protect against any possible allegation against the facilitators.

The facilitators, it seems, are taking as much of a therapeutic risk as the patients. No formal evaluation was done but informal evaluation from group members is that they look forward to the group and for some members it is the only time they feel heard.

 

8:  Further developments   ...click here for details...

Recovering groups have now been set up in two recovery units and a social services day centre. A new group is planned for the Low Secure Unit.

9:  Dialogue for Recovering Group   ...click here for details...

Who is it for?

It is for in-patients of Charlton Lane Centre and recently discharged patients. All patients are invited. Patients do not have to attend. They may leave the meeting if they wish, at any time but we hope they will stay for the whole session.

What is it for?

To understand and share ideas and experiences of the process of recovering from mental illness

Who helps run it?

A service user who is now a user consultant, who has used the recovering process and the patients who are present, with members of staff who have an interest in this kind of group.

When does it meet?

The group runs on Wednesdays from 3.00 until about 4.00.

Where does it meet?

In the quiet room, Charlton lane

Where can I get more information?

A leaflet with full details is available; ask your key worker or lookout for the information stand

 

10:  References:   ...click here for details...

Anthony, W. A. (1993). Recovery from mental illness: The guiding of the mental health service in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11 - 24.

Buccheri, R., Trygstad, L., Kanas, N., & Dowling, G. (1997). Symptom management of auditory hallucinations in schizophrenia: Results of 1 year follow up. Journal of Psychosocial Nursing, 35, 20 - 28.

Buccheri, R., Trygstad, L., Kanas, N., Waldron, B., & Dowling, G. (1996). Auditory hallucinations in schizophrenia: Group experience in examining symptom management and behavioural strategies. Journal of Psychosocial Nursing, 34, 12 - 25.

Coupland, K., Davis, E., & Macdougall, V. (2002). Group work for psychosis; a values led evidence based approach. Mental Health Nursing, 22, 6 - 9.

Downs, J. (2001). Starting and Supporting Hearing Voices Groups. Manchester: Hearing Voices Network Publications.

Epston, D., & White, M. (1989). Literate means to therapeutic ends. Adelaide: Dulwich Centre.

Friedman, M. S. (2003). Martin Buber and dialogical psychotherapy. In R. Frie (Ed.), Understanding experience: Psychotherapy and postmodernism. London: Routledge.

Hall, P., L, & Tarrier, N. (2004). Short term durability of a cognitive behavioural intervention in psychosis: effects from a pilot study. Behavioural and Cognitive Psychotherapy, 32, 117 - 121.

Halperin, S., Nathan, P., Drummond, P., & Castle, D. (2000). A cognitive-behavioural, group-based intervention for social anxiety in schizophrenia. Australian and New Zealand Journal of Psychiatry, 34, 809 - 813.

Isaacs, W. (1999). Dialogue and the art of thinking together. New York: Currency.

James, A. (2001). Raising our voices; an account of the hearing voices movement. Gloucester: Handsell.

Kanas, N. (1988). Therapy groups for schizophrenic patients on acute care units. Hospital and Community Psychiatry, 39, 546 - 549.

Kanas, N. (1996). Group Therapy for Schizophrenic Patients. Washington DC: American Psychiatric Association.

Kanas, N. (1999). Group therapy with schizophrenic and bipolar patients. In Group psychotherapy of the psychoses: Concepts, interventions and contexts (pp. 129 - 147). London: Jessica Kingsley.

Macdougall, V. (2001). The use of a humorous approach to assessing voices in group work for psychosis (pp. 10): Gloucestershire County Council.

Mosher, L. R. (2001). Treating madness without hospitals: Soteria and its successors. In K. J. Schneider, J. F. T. Bugental & J. F. Pierson (Eds.), The handbook of humanistic psychology: Leading edges in theory, research and practice (pp. 389 - 402). Thousand Oaks: CA: Sage.

O'Neil, M., & Stockwell, G. (1991). Worthy of discussion; Collaborative group therapy. Australian and New Zealand Journal of Family Therapy, 12(4), 201 - 206.

Read, J., Mosher, L. R., & Bentall, R. P. (2004). Models of madness : psychological, social and biological approaches to schizophrenia. Hove: Brunner-Routledge.

Read, J., Perry, B. D., Moskowitz, A., & Connoly, J. (2001). The contribution of early traumatic events to schizophrenia in some patients: a traumagenic neurodevelopmental model. Psychiatry: Interpersonal and Biological Processes, 64, 319 - 345.

Smith, J. (1999). Five questions about group therapy in long-term schizophrenia. Group Analysis, 32(515 - 524).

Tarrier, N., Haddock, G., Barrowclough, C., & Wykes, T. (2002). Are all psychological treatments for psychosis equal? The need for CBT in the treatment of psychosis and not for psychodynamic psychotherapy. Psychol Psychother, 75(Pt 4), 365-374; discussion 375-369.

Vassallo, T. (1998). Narrative group therapy with the seriously mentally ill: A case study. Australian and New Zealand Journal of Family Therapy, 19(1), 15 - 26.

Wykes, T., Parr, A., & Landau, S. (1999). Group treatment of auditory hallucinations. British Journal of Psychiatry, 175, 180-185.

Yalom, I. (1983). In-patient Group Psychotherapy. New York: Basic Books.