Recovery Group for Distressing Psychotic Experiences

1. "Recovery Group" Venue: Anita House, North Hackney CMHT Duration : 8 sessions (24.10.08 – 12.12.08) Group facilitators: Gulsen Huseyin, Clinical Psychologist Martin Rodriguez-Tellez, Employment Coach Kerine Robertson, ST4 Psychiatrist Michael Kabia, CPN

2. Who is the Group for? Those who have distressing psychotic experiences, particularly those who hear voices. Aclosed group comprised of service-users referred from the North and South Hackney Continuing Care CMHTs. Service-users who are not likely to feel too uncomfortable in a group setting, and feel able to actively contribute to group discussion. Service-users who are currently able to attend and listen to other group members, and think openly and flexibly about mental health issues.

3. What does Recovery mean? • The concept of recovery has been introduced primarily by people who have recovered from mental health experiences, rather than by mental health professionals. It means different things to different people and definitions of recovery are multiple. • Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential. National consensus statement on mental health recovery, December 2004, US Dept of Health and Human Sciences • “…a personal process or tackling the adverse impacts of experiencing mental health problems, despite their continuing or long-term presence. It involves personal development and change.” Leading mental health charity Rethink (Frak, 2005)

4. In line with; • Recommendations from the Alternative Pathways project, where service users emphasised the importance of recovery (Sandhu, 2007). • The DoH (2008) asks services and practitioners to work according to the values and principles of a recovery approach. Numerous other policy statements and documents across the disciplines also call for mental health practitioners to promote recovery in all aspects of mental health care. • NHS mental health Trust and NICE Guideline targets to promote recovery, empowerment, social inclusion and a user-centred service (NIMHE guiding statement on recovery, 2005)

5. 10 Fundamental Components of Recovery: • Self-direction • Individualised and Person-Centred • Empowerment • Holistic • Non-linear • Strengths-based • Peer support • Respect • Responsibility • Hope

6. Aims of the Group To promote recovery from psychosis-related mental health problems by: • Creating a safe and supportive space, and a common language within which mental health experiences can be shared and understood • Sharing knowledge about how perceptual experiences can cause distress • Sharing skills, or strategies that have helped others to cope with distressing perceptual experiences • Introduce group members to written materials and other resources developed by those with similar experiences • Create a sense of belonging and connection with others, in realising you are not alone • Empower group members to facilitate their own recovery by taking an ‘expert position’ in their own lives • Promote mental health awareness and communication between; those in the group, and between users and workers within mental health services

7. Narrative Therapy • Draws on aspects of Narrative Therapy (Michael White and David Epston, 1990s) • Aims to be non or anti-pathologising. No position held on the causes of problems, instead the focus is on ‘unique outcomes’ and ‘what works’. • Options are made invisible by the ‘dominant narrative’, and therefore need to be made visible by developing and re-constructing a preferred, more freeing narrative. • Undermines sense of failure and paves the way for co-operation in struggle against an external problem (the problem, not the person is the problem). • Promoting recovery using Narrative Therapy “One aspect of facilitating recovery may involve hearing the stories people have to tell and accepting their own words and terminology, thus creating a space for dialogue and exploration that can further understanding”. (Dillon and May, 2002)

8. Referral Pathways • North and South CMHT meetings • Caseload reviews with Care Co-ordinators • Service-User leaflet and self-referrals • Group Protocol for professionals Referrals No. referrals = 10 (8 NHCMHT, 2 SHCMHT) • 4 (CP), 3 (Psychiatrist), 2 (CMHN), 1 (Employment coach), 0 (self-referral) • 5 attended initial screening appt out of 7 invited to attend, 3 declined, 2 DNA

9. Resources needed • Service User authored article • Power to Our Journeys. An Exploration of an alternative community mental health project. Dulwich Centre Newsletter, 1997 No. 1 • Flipchart board with A1 poster paper and mixture of chunky and thin felt pens for group/poster exercises • Copies of Mindfulness of Breath exercise

10. Structure of the eight week Group:

11. Structure of each session ‘Session plan’ sheets were provided for all participants at the beginning of each session: • Review ground rules e.g. Confidentiality, respect time to talk • Feedback from last session • Read and discuss article (with trigger questions) • 15 minute break • Flipchart exercise • Most Important Event Question • Mindfulness of Breath exercise

12. Flipchart Exercises Advantages and disadvantages of: • Sharing with others • Stepping outside of the expectations of others

13. Attendance The table below shows the number of clients who attended the group each week:

14. Recovery Group Outcomes Mental Health Recovery Measure (MHRM): (Young & Bullock, 2003) Total score = 120, Average score = 80 (SD = 20)

15. MHRM Conceptual Scores • Eight conceptual model-based subscales of the MHRM are as follows: • Overcoming Stuckness (OS) • Self-Empowerment (SE) • Learning and Self-Redefinition (L&SR) • Basic Functioning (BF) • Overall Well-Being (OWB) • New Potentials (NP) • Advocacy/Enrichment (A&E) • Also the role of ‘Spirituality’ in the recovery process (S) • (* denotes an increase in scores)

16. Qualitative Outcome Data

17. Thematic Analysis of Post-group facilitator notes

18. Disconnection and Loss

19. Solidarity, connection and sense of belonging

20. Causal and maintenance factors of mental health problems

21. Ways of coping with mental health problems and voices

22. Sharing

23. Recovery

24. Relationship with NHS mental health services

25. Promoting empowerment

26. Boundaries

27. Safety

28. Coping in a group

29. Most Important Event Question: Of the events that occurred this session, which one do you think was the most important for you personally? Why was it so important for you?

30. The table below lists the most important events chosen by group members: *Therapeutic group factor (Bloch et al., 1979)

31. Most Important Event (M.I.E.) Bloch et al (1979) Taking all the qualitative data analysis into account, the group was most notably observed to fulfil at least 7/10 group therapeutic factors classified. Namely; • Self-disclosure (The act of revealing personal information to the group) • Learning from interpersonal actions (The attempt to relate constructively and adaptively within the group) • Universality (Perceiving others as having similar problems and feelings, therefore reducing own sense of uniqueness) • Acceptance (Sense of belonging, being supported, cared for and valued by others unconditionally) • Altruism (Feeling better about oneself/learning something positive through helping other group members) • Guidance (Receiving useful information and advice about problems from others) • Self-understanding (Learning something important about behaviour, thoughts etc through feedback or interpretation by the group) • The remaining 3, which were not so obviously observed, were: • Instillation of hope • Catharsis • Vicarious learning

32. What came after… • Therapeutic letters (a therapeutic document) • A document of knowledge and affirmation • Helpful when people are in danger of losing their preferred identities (consolidating the subjugated narrative they have developed) • Useful in stressful situations when people are most likely to forget the knowledge and skills that they have acquired • Follow-up appointments to develop a recovery plan

33. Summary of Evaluation • Q. What do the outcomes tell us about the extent to which we have met the group aims? The main aims were to promote recovery from psychosis-related mental health problems by:

35. Recommendations • More referrals for bigger groups • Use non-verbal materials produced by service-users e.g. DVDs. Art, photos to tap into peoples’ different strengths. • Ensure goodness of fit between materials and group members i.e. level of educational attainment, concentration and attention • Move beyond psychosis to include recovery from other severe and enduring mental health problems e.g. those diagnosed with BPAD • Promoting wider use of a ‘recovery-based’ approach by continually involving non-psychologists as co-facilitators. Ideally these should be permanent CMHT workers so that the skills and knowledge stay within the service.

36. Future Possibilities… • Recruit service-users as paid co-facilitators • Possible funding via the ‘Florid’ Organisation? • Increase access to the recovery group for others, including; • Non-English speaking service-users and other ethnic minority groups (in line with the Delivering Race Equality initiative in mental health care; DRE, DoH, 2005). • Those in other Hackney mental health services e.g. AOS, Rehab & Recovery Team? Voluntary Sector services? • Open up to other boroughs within the trust? February 2009

37. Members Said… • By sharing our experiences we gain knowledge of our conditions • Contact with mental health staff is useful but it must be ‘professionally’ handled • To understand and make time to find out about a person’s background and history • Team work, positive sharing, positive outcome • Bridging the gap between mental health professionals and people’s understanding of mental health experiences and problems • Being aware of sources of support, overcoming fear, and finding confidence to access support

38. Contact gulsen.huseyin@eastlondon.nhs.uk martin.rodriguez-tellez@eastlondon.nhs.uk