Psychological groupwork with acute psychiatric inpatients

1

What patients do in hospital

Activity and inactivity, social interaction and isolation

Jonathan Radcliffe and Roger Smith

Introduction

Visitors to acute psychiatric wards and patients on their first admission are often struck by the lack of purposeful activity. Patients are mostly sitting, wandering around, or in their rooms. Sizeable proportions complain that they are bored and do not have enough to do (Sainsbury Centre, 1998, 2002; Department of Health, 2002; Sundram, 1987). In 1953 the World Health Organization named the need for activity and a proper working day for all patients as one of the constituent parts of well-managed inpatient care (WHO, 1953). The Department of Health (2002) outlines the need for the provision of social, recreational and occupational therapies and activities based on assessment of need. There are no minimum standards for this provision set by the government. The Healthcare Commission (2005) stipulated the need for a ‘fair’, ‘good’ or ‘excellent’ range of therapies and activities. The Royal College of Psychiatrists’ Centre for Quality Improvement produces a voluntary accreditation scheme, now in its third edition (2009), the Accreditation for Acute Inpatient Mental Health Service (AIMS). A number of the standards refer to activities and psychological interventions, for example each patient should be invited to therapeutic group contact with both staff and fellow patients for at least one half-hour each day and be involved in negotiating an activity and therapy programme. The AIMS accreditation scheme is an impressive attempt to improve the standard of provision. It is however voluntary and the focus is on access and provision rather than overall attendance levels. The need for such a scheme reflects the historic fact that activities are generally of lower priority on wards than practical ward management such as dealing with requests, administrative tasks and maintaining safety. Our study of a number of hospitals described below shows that activity programmes are still variable and poorly attended. Medication is seen as the most significant aspect of treatment by nurses, OTs and psychiatrists (Bowers et al, 2005) and psychological therapy is provided to a minority of patients.

An absence of engagement in meaningful activities means that there is little reason for patients to get out of bed and the normal rhythms of life are not maintained or established. Organised activities are a vehicle for social engagement. A brief period of withdrawal from social activity may be helpful for some patients in the most acute phase of their breakdown but continued withdrawal is associated with isolation, frustration, low morale, and is a wasted opportunity for meaningful activities and contact with others. The National Survey of Violence (Chaplin, 2006) found that patients named boredom as a factor that could make violent incidents more likely to occur and meaningful activities reduced their likelihood.

The problem of patient inactivity is not new and it is an international problem. In this chapter we give a historical perspective and describe more recent developments. We report on previously published research on the impact of disengagement and describe the findings from our study of 16 wards in a large London mental health trust in 2004. We conclude by discussing what types of activities are helpful and some of the practicalities of running activity programmes.

A historical perspective

The history of the treatment of patients in mental health institutions in England and other parts of the developed world has progressed through a number of stages. The first stage beginning roughly in the fourteenth century consisted of incarceration, physical restraint, and physical treatment. The second stage beginning in the second half of the eighteenth century consisted of the gradual introduction of more humane treatment and psychological explanations of mental health problems. The third stage beginning in the nineteenth century was the growth of large asylums with a variety of social, recreational and occupational activities. The fourth stage from the nineteen sixties to the present consisted of the gradual closing down of most of the large asylums and a move to care in the community and wards in local hospitals.

Early hospitals

The Priory of Saint Mary of Bethlem was confiscated by Edward III in 1375 and became a hospital for ‘lunatics’ in 1377. This made it the earliest hospital in England solely for the treatment of mental health problems. Ward activities were minimal. Patients were generally on locked wards with physical restraints for the uncontrollable patients. Patients who were permitted to leave Bethlem could be identified by their distinctive badges enabling them to be returned to the hospital should they become lost. In 1676 the new Bedlam was opened in Moorfields in a building designed by Robert Hooke and modelled on the Tuileries in Paris. Two statues by Caius Gabriel Cibber, ‘Melancholy’ and ‘Raving Madness’, were placed at the entrance to the hospital to excite the sympathy of passers-by. Patients were expected to beg from visitors or passers-by to support the operating costs of the establishment. Physical treatments such as emetics, blood-letting, hot and cold baths were common but of dubious effectiveness (Rutherford, 2008). Some importance was placed on the availability of fresh air and led to the creation of ‘airing courts’. Anyone could visit Bethlem to watch or abuse inhabitants of the asylum for a small fee. It was not until 1770 that a written permission from a hospital governor had to be produced to visit. The word ‘patient’ was not generally applied to people suffering from mental health difficulties until the eighteenth century.

Moral treatment

This influential humanising liberal movement was pioneered towards the end of the eighteenth century firstly by Pinel in France and then by Tuke in England. ‘Moral’ was used in the sense of emotional or psychological and meant compassionate and understanding treatment (Bockoven, 1972). Pinel used a psychological approach to the care of mental health patients rejecting the routine chaining of patients. Pinel reported improvements in patients of the Bicêtre Hospital when they were provided with work by Paris merchants. Moral treatment usually included meaningful employment of time, outdoor exercise, a ‘family environment’ and social interaction between patients and staff. William Battie advocated good food, clean fresh air, exercise, employment and distraction from family stresses as a treatment for patients at St Luke’s Hospital and the private asylums that he ran in Britain. Structured activity was seen as having a calming influence providing a basis for relating to others, being part of a group, and providing the sense of achievement and purpose, each of which are sources of self-respect (Borthwick et al, 2001). The Retreat was built by the Quaker Tuke family in York in the 1790s and showed some of the development of Battie’s ideas about the importance of the regimen (Tuke, 1813) and on the ideas of Pinel (Berrios & Freeman, 1996). Patients were Quakers or were referred by Quakers. Medical interventions such as restraint or purging were minimised. The Tuke family used social activities such as taking tea with the superintendent, walking, talking to staff and other patients, exercise and work in the garden or on the farm. They felt that activities, especially those reflecting the Quaker life of the Tuke family, were beneficial in diverting patients from irrational thoughts (Rutherford, 2008).

Large asylums

John Conolly (cited in Morris, 2008) wrote two books in the nineteenth century which influenced the development of asylums built during the Victorian era. He emphasised the importance of activities and argued against the routine use of physical restraint. The 1845 Lunatics Act gave rise to the development of the Lunacy Commission, which issued instructions for asylum builders. The Commission insisted that land was provided for therapeutic activities such as gardening, agriculture and recreation, with views from both the grounds and wards. Buildings were modelled on grand country houses in order to have a positive effect on patients’ mood. Ornaments, lodges, fields, kitchen and flower gardens, shrubberies, walks and flower borders were all considered beneficial. Exercise through the ‘airing courts’ and exposure to fresh air were considered important. Patients were expected to take part in activities and a system of rewards was instituted, for example they were given tobacco and access to dances for work in the garden. These institutions provided shelter, food, activity and entertainment, in contrast to the workhouses and prisons, which were the alternatives for many mentally ill patients. Activities in the large asylums were more concerned with the life of the institution itself rather than being seen as of direct benefit to patients. Thus activities such as working on the farm, in the laundry, kitchens, kitchen gardens, grounds, and cleaning duties reduced the operating costs of the establishment. The small scale domestic environment of asylums such as the Retreat of the previous century was superseded by the creation of ever larger asylums such as the second Middlesex Asylum at Colney Hatch which opened in 1851 and had a main corridor that was a quarter of a mile in length.

Under-funding and the passing of the early leaders of the moral movement meant that the kindly compassionate care could not take place in the large asylums. Instead, they became large custodial centres or ‘bins’ where patients frequently became isolated and deprived of nurturing interactions. Around the same time the earlier romantic view of innocent suffering was replaced by a positivist scientific view of mental illness as a biological phenomenon that was amenable to physical treatments. There was diminishing interest in social or psychological aspects of treatment and on reintegrating patients into society. Indeed in the latter part of the nineteenth century mentally ill patients were often seen as being incapable of achieving independent living.

Milieu Therapy

The twentieth century brought a new kind of moral treatment known as milieu therapy. In Germany, Simon (1927, in Rice & Rutan, 1987, p.4) developed ‘activere behandlung’ or ‘more active therapy’ whereby patients were given tasks to perform with gradually increasing levels of difficulty, based on their previous work experience. Thomson (1986, p.35-36) described milieu therapy as a non-hierarchical environment, which can act as a supportive family. The advantages that he describes of removing patients from a home environment that may be contributing to their problems are very reminiscent of Battie’s suggestions (Morris, 2008). Milieu’s emphasis on involvement and the provision of opportunities for interaction influenced nursing in many countries during the nineteen sixties and seventies (Gunderson, 1983). More recent surveys have shown that patients value and want milieu aspects of inpatient care such as closeness with staff especially in the context of therapy (Lelliott & Quirk, 2004). Haigh (2002) makes a strong case for more emphasis on creating a therapeutic atmosphere, and the importance of human relationships as opposed to organisational arrangements.

Therapeutic Communities

The therapeutic communities movement, developed by Main (1946) and Jones (1952) amongst others, has overlapping characteristics with milieu. It emphasises egalitarianism between patients and staff with joint decisions made about many aspects of running the community. All the patient interactions that take place in the community are considered to reflect individuals’ difficulties and characteristic ways of relating and these become part of the treatment, with group meetings of various formats taking central importance. The therapeutic community ideas were influenced by work in military hospitals during World War II, where staff shortages showed how effectively these institutions could be run with the help of patients (amongst others: Bion, 1948; Foulkes, 1948). Therapeutic communities have continued to exist in their pure form in the UK in specialised units such as the Cassel Hospital and Richmond Fellowship hostels. The movement also influenced acute care in local hospitals, for example seen in the weekly ‘community’ meetings and in ideas of democratisation seen in service-user involvement and empowerment. Haigh (op cit.) outlines some of the principles of therapeutic communities. He points out that the ‘principles used successfully to understand the work in modern therapeutic communities are translatable into practice that may help thinking about solutions to the crisis in acute care’.

Anti-psychiatry

The anti-psychiatry movement of the nineteen sixties rejected hospitals and the medical approaches to mental illness. Proponents led by R.D. Laing and others believed that what patients essentially need is support, space and an absence of pressure, or medical / professional interventions. Natural healing would occur with emotional and practical support and without any form of coercion.

De-institutionalisation

The closure of the large asylums in the last decades of the twentieth century represented a major change in psychiatric care in the UK and in many other parts of the world. Patients who were formerly living in the large hospitals moved into hostels, supported accommodation and their own flats. In the last two decades in the UK there has been a huge increase in the number of mental health professionals working with patients living in the community. The local wards replacing the asylum care provide briefer admissions, and are intended to be less institutionalised. Current approaches to ward activities reflect in part a reaction against the institutionalised activities of the asylums. Many occupational therapy departments which traditionally ran activity programmes now focus more on work with individuals aimed at improving independent living skills. Occupational therapies in the large asylums such as basket-weaving became associated with ‘institutional mind-numbing’, although in fact, art activities can be valuable means of expression as well as vehicles for social interaction. Acute admissions are now far shorter than in the past, averaging two months in wards in the trust we studied (reported below). The population of patients present on the ward is constantly changing with four new patients joining a typical 18-bed ward each week. Quirk et al. (2006) have written about the permeability of acute wards compared with the previous closed institutions, with patients keeping in closer contact with friends and family who visit and by using mobile phones. When they are well enough patients are encouraged to leave the ward for periods each day to acclimatise them to life outside and build up independence. Other patients are prevented from going out. Nurses spend a great deal of time in tasks such as processing and assessing new patients, and note-keeping. The emphasis is on safe containment. There is pressure to free up beds for new admissions.

Following deinstitutionalisation, a major influence on government mental health policy has been public safety concerns. High profile media coverage of murders by patients led to fears of insufficient monitoring and control of potentially violent patients. The UK government response has been to propose more powers to detain and treat patients. Against this has emerged a large and effective coalition (Mental Health Alliance) opposing such coercive powers (Pilgrim, 2007), and the service-user movement has become an active and influential force. At the same time consumer choice has become a key organising principle of healthcare policy, imported from America (Pilgrim, op. cit.) based on the principle that allowing patients to choose hospitals and treatments will drive up quality. This has yet to have a major impact on psychiatric care in the UK. However there are increasing expectations for professionals to discuss options with patients and involve them in decisions. This occurs against a backdrop of a tightening of control over health-care professionals and the treatments they deliver, linked to the increasing primacy of evidence-based treatment. Treatment is increasingly determined by National Institute for Health and Clinical Excellence (NICE) guidelines based on medical diagnoses with evidence derived from randomised controlled trials. These have promoted cognitive behavioural therapy, although anecdotal evidence suggests that the NICE recommendations for psychological therapy are not being implemented on wards to the same extent as in the community. Not providing psychological therapies for inpatients denies the most severely ill patients therapies of proven effectiveness that are recommended by NICE. Having said this, the NICE recommendations can undermine other approaches which lack the evidence of efficacy provided by randomised controlled studies.

Competing influences on inpatient care

As has been seen, there are numerous ideologies and political influences affecting inpatient care. The biological view is that medication is the essence of treatment and other activities should be subordinate to it. Moral treatment with its kindly, humane care in a family atmosphere emphasises the benefits of purposeful activity. Milieu varies according to different writers, with some emphasising the importance of therapeutic programmes whilst others de-emphasise them in favour of relations with individual staff. The influence of the large asylums is largely in the reaction against them; anti-institutionalisation sees less demanding occupational groupwork as being irrelevant to the knowledge and skills needed for independent living. One consequence of government moves to detain and control potentially dangerous patients combined with the service user movement is that coercion in detaining patients may be accompanied by staff being reluctant to impose attendance at activities even when this may be in patients’ interests. Anti-psychiatry, the user-involvement movement and the patient-as-customer approach all emphasise choice and lack of strictures and prescription, but this can lead to a laissez-faire approach. Inpatient group therapy has waned in recent years and psychologists and group therapy practitioners have tended to put their efforts into working with outpatients where the ability to select committed patients and work with them longer leads to more satisfying results. Finally, positivist approaches to psychological therapy emphasise the need for research evidence for treatment, which can lead to a devaluing of approaches that do not have sufficient empirical evidence of efficacy.

Activity and social interaction

The beneficial relationship between activity and mood has been long known. Seneca, writing in about 44 AD, advocated activity as an antidote to despair and grief (Seneca, 44/1996). Much of modern cognitive behavioural therapy (CBT) can be traced back to tenets of Stoic philosophy, of which Seneca was a proponent. Activity (sometimes called behavioural activation or activity scheduling) has an important role in the treatment of mood disorders such as depression (Fennell, 1989; Fennell et al, 2004) in combination with the cognitive aspects of CBT. There is evidence that inactivity is a risk factor for depression (Farmer et al., 1988) and that physical exercise can improve mood (Dimeo et al., 2001).

Although surveys show that many patients are dissatisfied with the sparseness of activity programmes, health managers often want more than evidence of improved patient satisfaction in order to justify spending money on activity programmes. Unfortunately demonstrating that high quality organised activity programmes lead to better mental health outcomes is not straightforward. The fact that active patients recover more quickly than less active patients does not prove causality, as the healthier patients are likely to be the ones who are more active and energetic. Comparing outcome between wards with and without activity programmes is problematic as wards vary on numerous dimensions and patient populations also vary between wards.

Conclusions can be drawn from large-scale comparisons although due to the pace of change care must be taken when making comparisons with today’s wards. A large-scale study was carried out by Collins et al (1985) on 79 wards in America, where 4589 patients were assessed on admission and three months after discharge. Pre and post-measures were carried out using four patient questionnaires plus questionnaires completed by relatives. 191 ward characteristics were compared with patient outcome, 11 of which were significantly correlated to positive outcomes on both sources of outcome measure. The overall picture was that wards with more interactions of a positive nature were associated with better outcome and wards with more social passivity had poorer outcome. Eight of the 11 factors related to ward attributes including orderliness and good organisation, nurses sticking to regular shift patterns and informal relations between patients and staff. Social passivity was measured by periodic observer ratings of the percentages of patients deemed socially passive, e.g. watching TV, watching other people or engaged in self-care e.g. doing the laundry. Wards with higher percentages of socially passive patients were found to have poorer outcomes. Three other characteristics indicated that positively engaged relationships were associated with better outcome; wards where patients called staff by their first names, wards where there were fewer negative feelings expressed by patients and staff in response to a questionnaire, e.g. ‘patients often gripe’, and wards where chairs were arranged so that patients interacted rather than watching TV. It is possible that some of these characteristics were markers for well-run wards rather than being significant themselves. However, the overall picture was clear; ward regime clearly makes a difference to recovery.

The findings of a recent study on the perceived effectiveness of scheduled activity were that scheduled activities had a beneficial effect on the mood of depressed inpatients (Iqbal & Bassett, 2008). Most patients also reported increased satisfaction and pleasure in taking part in the activities. Staff attitudes were a mixture of feeling that they did not have time to undertake such activities or uncertainty about the benefits. This may partly explain the lack of activities or staff enthusiasm in delivering them as reported elsewhere in this discussion.

STUDY: Patient activity and social engagement

Our study was carried out on 16 adult acute locality wards in six hospitals in a large inner city mental health trust in 2005 (Radcliffe & Smith, 2007). Firstly, we observed what each patient was doing during the day, focussing on activity and social interaction. Secondly, we audited attendance at organised activities.

Ward context

The number of beds on each ward was between 13 and 25 with a median of 18. Mean bed occupancy rates were 118% including patients sleeping at home on leave (range 96%-150%) and 95% excluding patients on leave (range 80% - 120%). The average length of stay was 60 days. There were on average four new patients admitted or transferred to each ward each week (range 8-26) with the concomitant load placed on staff to assess and process these patients.

Social engagement

Each ward was observed three times a day over the course of a 9 a.m. to 5 p.m. week excluding lunchtimes and weekends. Timings were randomly determined and the observer followed a set route around the ward, categorising each patient’s behaviour in one of ten categories (Table 1). Reliability was found to be good, with intra-class coefficients of between 0.60 and 0.93 during piloting for two observers carrying out observations simultaneously. Across 16 wards, 4103 individual patient observations were made, equating to an average of 17 patients per ward visit. An identical patient group was not necessarily seen on each ward observation due to patient turnover and because some patients would have been off the ward on leave when we visited.

Table 1

Percentages of patients observed in different activities

Table 2

Categories of activity

Type 1: Talking groups

Ward community meeting, psychodynamic, depression-management, anxiety-management, coping with psychosis, hearing voices, substance misuse, pre-discharge.

Type 2: Non-verbal therapies

Music therapy, art therapy, drama therapy.

Type 3: Creative/expressive

Arts and craft, woodwork, pottery, creative writing, drumming.

Type 4: Skills and information

Cooking, careers advice, local college education advice, outings to local resources e.g. mental health community resource centres.

Type 5: Physical/Relaxation

Aerobics, gym, yoga, walking group, relaxation, meditation.

Type 6: Recreational

Videos, table tennis, pool competitions, table football, music appreciation, leisure outings.

We found that across 16 wards on average 84% of patients were socially disengaged at any one time. The other 16% were mostly interacting informally and a small number were engaged in an organised activity. ‘Socially disengaged’ consisted of being alone in the bedroom (46%), walking around or sitting in a communal area, predominantly passively (34%) or engaged in self-care such as washing or making tea (4%; see Table 1). The percentage of socially disengaged patients was consistent across the six hospitals with a variation of three percentage points between the highest and lowest, which is not statistically significant (χ²=1.42, d.f. =5, p>.05). A logistic regression analysis showed that there were significant differences between wards within hospitals for three out of the five hospitals with more than one ward (χ²= 5.46, p<0.05 d.f.=2; χ²=6.13, p<.05, d.f.=1; χ²=40.6, p<.0001). The highest and lowest levels of social disengagement across the trust were found in two wards in the same hospital (91% and 75%).

Table 3

Number and types of organised activities provided on each ward

Organised activities

We audited attendance registers over three-week periods, again focussing on the Monday to Friday working week. We looked at how many activities were offered, their take-up, type, who ran them and how the programme was organised. We placed each activity into one of six categories (Table 2).

The number of weekly activities on each ward varied from four to 15 with an average of ten (Table 3). Between one and three activities were timetabled each day although sometimes these were cancelled. Attendance registers are the most reliable method of showing whether groups take place and for how long. These showed that take-up was low; the average patient spent 90 minutes each week in organised activities, equating to 4% of the 9-5 working week. On one ward the proportion was 2% whilst the highest was 7.5%.

Table 4 shows variation between hospitals. These averages hide wide differences in attendance by patients on the same wards. A minority of patients on each ward attended several activities each week. Detailed audits of three wards showed that 28% of patients attended no activity each week, 25% attended one activity (generally the community meeting), 20% attended two, and 27% attended three or more groups per week.

Table 4

Patients’ time spent in organised activities each working week

There was wide variation in provision of the different types of activity on different wards (Table 3). Talking groups were poorly provided. These mainly consisted of the ward community meeting held weekly and in one case daily. Eleven out of the 16 wards had no other talking group. Two wards had groups run by clinical psychologists. There were no other psychological therapy groups and no groups run by psychiatrists at that time. The other types of talking group were women’s groups run on two wards and discharge planning meetings also run on two wards, and a problem-solving group. Seven wards had art, music or drama therapy run by peripatetic professionals. Creative-expressive activities such as art or creative writing were better provided. These were run by nurses or occupational technicians (OT techs) working on the wards. Although all the wards had access to gyms, typically only two or three patients used them once or twice a week.

A range of workers including OTs and psychologists, qualified and unqualified, and peripatetic staff members such as a relaxation therapist and a music therapist delivered activities (Table 5). The largest group delivering activities unsurprisingly were OTs. However, four wards had no OT groups. A key factor was the time-allocation of professionals from local occupational therapy and psychology departments and this varied. Some OT departments concentrated more on patients living in the community whilst others provided a traditional ward OT programme. One hospital had a centrally provided OT service, but not all wards accessed this, and patients were referred individually to the service rather than it being offered to all patients on the wards. Eight wards had no psychologist, one ward had a full-time psychologist and the remainder had one and a half days of psychologist’s time. Ward OTs or psychologists decided departmentally or individually how to spend their allocated ward time; some ran groups whilst others concentrated on individual work. Most wards had some peripatetic run activities such as music therapy or relaxation therapy. This was determined by the budget and the priorities of the budget holder, for example the ward manager. In one hospital a decision had been made some years previously to have no art therapy.

Eight wards employed a full-time staff member employed to organise and deliver activities. These wards had a better range and take-up of activities. These were OT technicians (see Table 4, Hospitals A and B and two wards from E), or nursing assistants (Hospital D). Hospital D had previously been audited and improved since nursing assistants were appointed to run activities a few months earlier. This had led to a marked increase in patient activities, albeit largely recreational activities such as karaoke, as well as some arts and crafts and escorting patients to the gym. The OT technicians had art backgrounds and provided art activities as well as organising guest speakers and outings. They individually assessed and reviewed each patient’s engagement with the programme, an important aspect of good practice. Psychology assistants ran talking groups under supervision of qualified psychologists as well as seeing individual patients (Hospital C). Eight wards had no worker dedicated to organising and delivering activities. These wards had fewer activities and lower attendance rates. Although regular shift nurses helped run groups, on most wards they did not run other groups other than the community meeting.

Summary of findings

Consistent with findings from patient surveys, our study showed that most patients were socially disengaged and inactive most of the time and took part in few organised activities. Levels of social disengagement were strikingly similar between hospitals although there were differences between wards. There was a marked variation in organised activity provision between wards including those in the same hospital, with some programmes having twice the patient engagement rates as others, as well as considerable variation as to the types of group activities provided. Over half of a sub-sample of patients attended one or no activity each week. The results are consistent with the findings from patient surveys in the UK and elsewhere. The range and quality of activity programmes reflects the priority placed on this as well as resourcing and local OT and psychology department provision. The patchiness of provision suggests that a wider organisational response is needed at trust and national level.

Engaging patients in activity programmes

Who should provide activities?

In terms of costs and benefits, unqualified staff can provide a significant proportion of what is needed if the structure and support is in place. Our study revealed that the fullest programmes were led by an OT technician who delivered activities and over-saw the programme, supervised by a qualified OT. Art, music and drama therapists have much to contribute. There were no psychotherapists running patients groups that we were aware of at that time, and we believe that they would have much to offer especially those with group training. The core inpatient professions of nursing, social work, OT, psychology, psychiatry each potentially have valuable knowledge and skills that can be delivered to patients in groups. The last three professions often combine ward work with community work and have limited time for ward work. Psychiatric registrars routinely ran groups in the same trust ten years earlier (Robertson & Davison, 1997) but we found that consultant psychiatrists and specialist registrars were not running groups. If representative nationally, this situation will lead to a generational gap in psychiatrists’ experience of running groups. OTs may get some experience of inpatient groupwork during their training but this is not guaranteed nor necessarily taught on the OT training. Psychologists and psychiatrists are unlikely to have specific training in running inpatient groups.

Table 5

Numbers of timetabled ward-based groups run by profession

Nurses are by far the largest group of staff. There are many demands on nurses’ time that take them away from direct patient care, including practical tasks, note-keeping and dealing with enquiries. In general nurses tended not to run groups apart from the community meeting. The authors’ clinical experience is that nurses can play a key part in supporting patients attending groups run with other professionals, forming a communication bridge between the group and the ward. There is clearly a tension between the demands of containing and managing patients and taking time out to run groups. Sustained contact with disturbed patients also creates anxiety and institutions and individuals develop defences to reduce the intensity of the emotional contact (Menzies Lyth, 1959). Workers who are not based on the ward full-time may find it easier to deal with the feelings stirred up by running difficult groups as they can escape afterwards. This makes the specific role of running groups more manageable although they are less integrated into the ward system and do not know the patients as well. For nurses to run therapeutic groups both training and support would be needed as well as supervision and sufficient time for debriefing after the group. A specialist psychological group intervention role with specific training in different types of groups may be one way forward.

The group programme

As Parahoo et al. (1995) point out, it is not just the number of activities and attendance levels but also their nature and quality. Staffing levels, training and skills, group protocols, support and supervision all affect the quantity and quality of what is offered. Without proper funding, programmes will not meet the needs of most patients. The ideal is for patients to attend an activity after breakfast to give them a reason to get up and another in the afternoon. A lesson from institutionalisation is that activity should not be for activity’s sake or a substitute for thought and reflection.

The purposes of activities can be categorised in various ways, for example: meaningful occupation to prevent demoralisation and institutionalisation; exercise which is mentally and physically health giving; the acquisition of new skills to help the person manage socially and with employment outside hospital; rehabilitation to reacquire lost skills; and psychological therapy to address psychological difficulties. Both normalising and rehabilitating activities are needed as well as psychotherapeutic groups and expressive activities (art, music, and drama); broad-based talking groups as well as theory-based therapy groups. Activity programmes need to cater for patients who are functioning at a higher and lower levels. Having a range of groups provides a variety of contexts for interacting and learning as well as meeting the needs of patients with different types of problem. Schwartzberg et al (1980) compared three formats of groups facilitating social interaction and found that the quantity and type of interaction varied according to format. They concluded that patients learn skills in one format and then practice them elsewhere. Innovative practice such as parallel groups in hospital and in the community can provide continuity across the boundary. As a minimum, physical exercise should be available for physically active patients and exercise classes for all should be considered. As a rule, recreational activities should be provided at evenings and weekends and not during the working day.

The paucity of talking therapy groups found in our study is a concern. The commonest talking group was the ward community meeting. Anecdotal evidence suggests that these vary in quality, and that they have become nurse and patient only business-type meetings where practical information is communicated such as information and complaints. Potentially these meetings can form a valuable integrating function, spanning both the practical aspects of ward life as well as social and emotional issues (see Klein, 1981; Russakoff & Oldham, 1982). Community meetings are an area for staff development and could be extended to daily or twice weekly, as was the case on two of the wards.

A key issue is many inpatients’ reluctance to engage in organised activities. A minority are too unwell to attend, whilst others are anxious and demoralised. Many are resentful about being in hospital and may be less likely to cooperate with non-essential aspects of treatment. Psychiatric breakdowns are by their nature traumatic and leave patients feeling vulnerable. Withdrawal can be seen as a defence against excessive stimulation when personal resources are needed to deal with an internal crisis. Staff cannot force patients to take part against their will, but they need to work together to create a group culture where attendance is the norm. Patients need support and care but also to re-engage socially and engage with their problems in order to help them to regain their independent functioning. We believe that respecting patients’ wishes to remain withdrawn for too long may be unhelpful. Whilst it is widely believed that engaging in meaningful activities and with others is empowering, the culture of many or most patients opting-out makes it very difficult for staff to establish ambitious programmes of activity. An active approach of organising leave around an individual timetable of activity is one way of dealing with poor attendance.

Sundram (1987) writes:

The type of assertive clinical judgement that has led psychiatrists to challenge a patient’s refusal to take psychotropic medication should carry over to dealing with other aspects of treatment including a patient’s refusal to participating in therapeutic activities … If the programs and activities offered challenge the human spirit, harness human potential and restore human dignity, there would not be any sizable problem of refusal to participate.. the reality is that some patients will refuse participation in all forms of treatment.. (Our) job is to raise expectations, to open new horizons to which we should collectively aspire.. existing standards or expectations should be viewed as evolving standards of decency that mark the progress of a maturing society … a concerted array of options in therapeutic programs and skill building activities … (are needed, which) will require a critical re-examination of staffing levels and types of staff available.

Conclusions

Admissions are a chance for patients to learn knowledge, skills and behaviour and they are an opportunity for professionals to deliver therapy to patients who would not normally attend groups. Groups allow learning to take place alongside others in the same situation. Our study showed that this opportunity was not being taken up for most patients. The reasons include the view that medication is the primary treatment, the lack of consensus about what constitutes therapeutic activities and the view that patients essentially need time and space to recover. Professionals may take a user-empowerment view that patients know what is best and should not be pressured into attending activities. This leads to patchy attendance, lack of continuity and lowered expectations and sets up a negative cycle. Resourcing, ward culture and lack of staff skills also contribute. Managers are often more concerned with other issues such as safety and the ward environment. Assertive strategies with support at all levels of the service are needed to create a culture of participation. Becoming ill affords a necessary respite from demands. In the case of mental health problems after a suitable pause for dealing with the trauma of the breakdown, the work of recovery needs to begin. This should be an active process of re-engaging with the world. Inpatient care needs to extend beyond looking after patients, keeping them safe and giving them medication, to the psychological work of recovery, of which passivity and isolation are enemies. If the task of engaging with the problems that caused the breakdown is started, with good follow-up care, change and growth is possible.

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