Safe and supportive

David Ahearn says that even in a busy acute admission unit, inpatient group therapy can be beneficial to clients and rewarding for staff.

We have been running inpatient group therapy sessions for about a month, although the preparation, research, training and experiential sessions for the other staff nurses in the ward took over two years to complete.

A busy 24-bed, mixed-sex acute admission ward with six "de-tox" beds is perhaps not the best environment to introduce group therapy. Certainly there is a large turnover of clients whose average stay is two weeks - so why bother?

Well, we make so many assumptions about our clients. It intrigued me that when I was looking for Bill to take a call from his relative, other clients looked quite bemused and said, "Who's Bill?" when I asked where he was. These people were eating together, socialising together, but they didn't know who Bill was. I had fallen into the assumption trap.

So why group therapy? It's simple: we grew up in groups, we are educated in groups, we work and socialise in groups. Why then is it different for inpatients? After all, we are by nature social animals.

In order to facilitate the groups on our ward we had to negotiate with other members of the interdisciplinary team. We had a series of team meetings, particularly at handover when there were more staff available for the discussions. I have previous experience of inpatient group therapy but soon realised that implementing groups would take considerable commitment from the staff. Thankfully we have a well-educated and motivated nursing team, who volunteered to carry out tasks such as drawing up information leaflets, posters and so on. A clinical supervisor has been appointed for me and we have arranged for a clinical audit of the groups every six months.

Professor Irvin Yalom's (1985) model of inpatient group therapy is specifically tailored for this type of environment as the main emphasis is on the here and now. I produced a start-up pack explaining Yalom's model and we have run a number of educational and experiential group sessions for the staff nurses. A familiar question was raised: "What's going to happen in this group?" The simple answer was that I didn't know. Professor Yalom states that "the life of a group is but a single session". All we could do was provide a safe environment in which to nurture the therapeutic group process, where everyone is treated with courtesy and respect.

Back to assumptions. It never ceases to amaze me how the most withdrawn of clients can make a meaningful contribution to the group or give support and encouragement to someone who is floundering. That's the beauty of groups, although there are obvious exclusions, such as clients who are in the early stages of withdrawal from alcohol or drugs, or whose behaviour is too disruptive. Other exclusions from short-term "open" groups include clients with organic brain damage or other type of cognitive impairment.

Group dynamics are relatively easy to learn from the many and varied books and articles on the subject, but the main thrust of inpatient group therapy is that it is largely experiential for us all.

The agenda 'go-round'
In long-term group psychotherapy the therapist has considerable information at his or her disposal about each member of the group. In the acute setting the therapist often has comparatively little. A structured "go-round" allows the therapist to scan the group quickly and adopt an overview of the group and the possible work to be done. The therapist must not allow the group to start on its own - this invariably leads to a period of confusion, ice-breaking ritualistic comments and casting about for some useful or convenient topic of conversation.

Yalom states that a highly effective way of beginning a group is to ask each client to formulate a brief personal agenda for the meeting. The agenda identifies some areas in which the client desires change. Examples that lead to useful, effective group work include:

"My problem is trust"
"I feel I'm a nuisance"
"I put up a wall around myself"

Each of these statements deals with a concern that is central to the individual speaking.

Interpersonal theory
Yalom's interpersonal theory argues that one's character structure is shaped by one's previous interpersonal relationships, and that a client's current symptoms are a manifestation of disordered interpersonal relationships. Individuals seek help with a wide array of complaints but they have a common major difficulty in establishing and maintaining gratifying and enduring relationships. Yalom's contention is that "the language of the group therapy is interpersonal".

Group therapies offer a psychotherapeutic intervention to a small group of individuals and aim to create a group climate of mutual support and understanding in which the individual feels able to offer his or her difficulties to the group for discussion. Listening to others reduces feelings of isolation and alienation, and promotes a willingness actively to consider faulty approaches to living. Problems are shared and troublesome feelings are worked through in a climate of support and encouragement. New solutions can be formulated.

So the aims of the group are:

to enable members to gain greater knowledge of their behaviour and relationships
to provide reassurance and support
to decrease members' sense of loneliness and isolation and thereby modify feelings of powerlessness and hopelessness
to facilitate the opportunity for members to try out new communication patterns
to provide a safe environment where members can share concerns and learn from the experience of others.

Because ours is an acute admission ward and the clients stay is for a relatively short time, we use an "open" group format that caters for the changing client population. Inevitably this means the group's dynamics, particularly group cohesiveness, change constantly. Each group is unique, but all therapeutic groups have certain characteristics or dynamics common to them.

Why not give it a try? It can be a rewarding experience for all concerned. My advice is to contact your managers, do the research, get all interested parties together and form a small working group to make it happen. It can be fun!

David Ahearn works on Ruthven Ward, New Craigs Hospital, Inverness